Co-dependency: when caring becomes a disease

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Co-dependencywhen caring becomes a disease

• Yana M. Van Arsdale, MD, PhD

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Clinical case ID

• 48 y/o SCM
• Hx Adult ADHD, treated sporadically
• Self referred to out-Pt Psychiatry clinic at
  MSU/KCMS after episode of violent behavior and
  suicide attempt
• CC I have to learn how to manage my anger

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HPI

• The patient suffers from significant difficulties
  to sustain attention, concentrate, read, follow
  directions
• He is restless and fidgety all the time, with
  prominent rocking movements
• He fails to complete tasks
• Symptoms re-appeared since the Pt did not take
  Adderall for the last week, run off medication

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HPI cont.

• The Pt reported lost trust in all people after
  his fiancee of four years denied his rights
  towards any community property,
• feeling like a failure
• feeling confused about who he is and where is he
  going with his life
• feeling hurt b/c others did not recognize his
  efforts to do more than his share

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HPI cont.

• The patient described himself as giving, caring
  and loving person,
• who usually avoids arguments and keeps quiet
• cares about his partners lives more than they
  care about him
• does his best to hold on to a relationship
• ...feels inferior towards others

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HPI cont.

• The Pt doubted his ability to be who he wants to
  be
• He reported difficulties expressing his true
  feelings to others, including anger
• difficulties adjusting to change
• difficulties to make decisions and to move on
• always worrying about others opinions of him

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HPI cont.

• The Pt reported trouble saying no when asked
  for help
• feeling overwhelmed b/c so many things going at
  once
• feeling guilty and ashamed most of the time
• fear of others anger
• trying to make others happy but not getting much
  in return

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Psychiatric Hx

• Since early childhood hyperactivity, attention
  deficit, impulsivity
• Neglect by biological parents
• Emotional and physical abuse by step father, who
  suffered from alcohol abuse
• 10 y/o sexual abuse by uncle
• 38 y/o first Dx ADHD by PCP, various
  medications trials. Good response only to
  Adderall 180 mg/day.
• 42 y/o first in-Pt Tx for a week at 1N at
  Borgess after wife had a miscarriage and asked
  for divorce. Cried all the time, was depressed,
  suicidal. No medications.

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Psych. Hx cont.

• F/u with Pine Rest Clinic, trials of medications
  others than Adderall with no improvement
• 46 y/o in-Pt Tx at KPH after episode of
  violence towards fiancee and suicide attempt to
  shoot himself with a gun. Admission Dx Bipolar
  DO, hypomanic episode. D/ch Dx Dysthymic DO
• F/u admission to Hope Center. Dx Adult ADHD.
  Adjustment DO. R/o Dysthymic DO. Cluster C
  personality DO (dependency, avoidance features).
  Adderall re-started. F/u with PCP.

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Medical Hx

• Obesity
• Hypertension
• Hyperlipidemia
• Hx kidney stones and lithotripsy
• Hx IBS
• NKDA

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Addiction Hx

• Alcohol on rare social occasions. The Pt
  reports being very sensitive to alcohol even in
  low doses.
• Marijuana Hx until 30 y/o, helped with anxiety.
  Sober now.
• Nicotine 1/3 pack/ day until recently.
• Caffeine 1-3 cups cause sedation, after 5th
  cup attention and concentration improve.
• Denies illicit drugs abuse.

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Family Hx

• Mother attempted suicide through OD medications.
  Quiet, emotionally unavailable person. Tolerated
  physical and emotional abuse from Pts
  stepfather.
• Father suffered from Alcohol Dependency, died
  young. Emotionally unavailable, unassertive.
• Sister attempted suicide, suffers from Bipolar DO
• Majority of relatives suffer from Alcohol
  Addiction

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Social Hx

• Lives with his mother and sister
• Drummer in a nightclub music band until recently
• Employed in flooring business, part-time
• Helps to restore old collectable cars, for cash
• Helps relatives in construction work, on occasions

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Social Hx cont.

• Worked as a musician since age 13, just like his
  father and brothers
• 9 grades of educations, poor academic performance
• Never had any professional license, despite
  several vocational skills
• Was deceived by other construction workers on
  several occasions, working under their license

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Social Hx cont.

• 15 y/o left his family. Lived with a women 10
  years older. Supportive passionate relationship
• 25 y/o marriage of three months mistake
• 34 y/o marriage of eight years. Wife was
  emotionally distant. She completed a masters
  degree in psychology during marriage. Suddenly
  divorced the Pt after having miscarriage.

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Social Hx cont.

• 40 y/o severe distress over older brothers
  death from DM complications. Brother was the
  closest friend/relative, parental figure and role
  model
• Separation with each women especially ex-wife and
  fiancee was experienced as severe emotional
  trauma
• Never had children, always wanted them
• Difficulty with social contacts with strangers or
  maintaining superficial relationships
• All close relationship with deep emotional
  involvement and attachment

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Social Hx cont.

• 42 y/o living together with J. for four years
  intent to marry. She was passionate, took
  initiative in relationship, helped with grief
  over divorce and fetal demise
• She completed her masters degree in psychology,
  as well, while the Pt built their house.
• They bought a few pieces of land together,
  however the Pt did not complete any documents,
  stating that he trusts her b/c of love

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Social Hx cont.

• 46 y/o J. denied the Pts right toward any
  community property, including the house the Pt
  built from scratch and land
• The Pt was very angry and became violent, driven
  by impulses
• He was arrested after staying 7 days barricaded
  in his bedroom with a gun in his mouth

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Legal Hx

• Probation for domestic violence with J.
• No previous Hx. Have never been violent before

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Medications

• Adderall 60 mg PO at morning, 40 mg PO at noon,
  at 3 p.m. and at 6 p.m.
• Norvasc 15 mg PO BID. Samples given at church. No
  PCP

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Developmental Hx

• 2 y/o earliest memory about divorce and
  fighting between parents
• 10 y/o did not disclose episode of sexual abuse
• Since 4 y/o emotionally traumatized by
  stepfather abusing mother. Did not voice
  objections, considered that violence might become
  even worse, kept walking away

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Develop. Hx cont.

• Was restless, hyperactive, anxious child, with
  difficulty sustaining attention, easily upset
• All 11 siblings were emotionally close
• 15 y/o could not tolerate parents abusive
  relationship moved out

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MSE

• Pleasant, engaging, cooperative, articulate
• Soft spoken
• Listens attentively but effortful
• Restless, fidgety, rocking in the chair, shaking
  legs
• Looks sad, but denies feeling depressed
• Affect constricted

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MSE cont.

• Immature statements, low self esteem
• Good insight
• No signs of depression or psychosis
• Transient anxiety

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Course of Tx

• Within 2 months ADHD symptoms improved
  significantly cont. Adderall 180 mg/day
• Individual Psychotherapy supportive, CBT,
  psychodynamic for 15 months
• Group therapy denied by insurance company
• Current GAF 70, overall improved relationships
• Does not feel ready yet for meaningful intimate
  relationship, wants to work harder in
  psychotherapy

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Definitions

• Co-dependency / codependence
• Dependency
• Interdependency

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Codependency, original concept

• Behaviors people develop from living with a
  substance abuser
• The term was developed in the late 1970s
• Addiction literature referring to the wives of
  men who abuse alcohol

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Codependency, more recent concept

• Dysfunctional style of relating to others (Irwin,
  1995)
• Extreme focus on relationships, caused by a
  stressful family background, like alcoholism,
  mental or physical chronic illness in parent
  (Fisher, Spann Crawford, 1991
• Personality trait found within members of
  chemically dependent families, that creates
  sufficient dysfunction to warrant the diagnosis
  of Mixed Personality Disorder (Cermak, 1986)

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Codependency, modern concepts

• Progressive disease manifested as an unconscious
  effort to keep repressed pain at bay,
• brought by child abuse/neglect
• caretaking through keeping the loved one
  addicted in order to gain a sense of self worth
  (Westermeyer, 2005)

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Codependency, modern concepts

• Emotional and behavioral condition that affects
  an individuals ability to have a healthy,
  mutually satisfying relationship (National Mental
  Health Association, 2005)
• Relationship Addiction, one-sided, emotionally
  destructive and/or abusive relationship
• Behavior learned by watching and imitating other
  family members who display codependency

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Codependency, modern concept

• A set of maladaptive, compulsive behaviors
  learned by family members in order to survive in
  a family which is experiencing great emotional
  pain and distress (www, 2005)

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Sources of great emotional pain

• Chemical dependency
• Chronic mental / physical illness
• Physical / emotional / sexual abuse
• Divorce / separation / death of loved one
• Hypercritical / non-loving environment

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Codependency features

• Tendency to get involved in relationships with
  unreliable, needy, emotionally unavailable
  partner
• Attraction to persons who want to have power over
  another people (chemistry)
• Attempts to control relationship without
  addressing own needs or desires
• Chronic unfulfillment
• People with healthy boundaries are not likely to
  be involved with codependent person

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Codependency signs symptoms

• Controlling behavior towards oneself and others
• Caretaking behavior, boundary distortions
• Avoidance of feelings
• Intimacy problems
• Hypervigilence, mistrust
• Depression, anxiety
• Denial, projection, projective identification,
  rationalization, supression
• Somatoform symptoms, compulsive behavior

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Dramatic outbursts

• Constriction of undesirable emotions
• Depersonalization or dissociation
• Unexperienced feelings are build up over time
• Any incident can trigger an explosion
• Inappropriately intense compulsive exposure of
  feelings

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Interdependency

• Natural and healthy behaviors that are mutual,
  fulfilling and unrelated to addiction or abuse
• Socially acceptable and encouraged
• Sense of self remains relatively unaffected
• Examples gender distributed roles in a family
  between parents

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Dependency (pathological)

• Excessive need to be taken care of
• that leads to submissive and clinging behavior
• and fear of separation
• Quick and indiscriminative attachment to another
  person
• Passivity, allowing others to take initiative and
  take responsibility

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Treatment approach / goals

• Team work
• Boundary setting
• Learning assertiveness, listening, and
  communications
• Breaking denial system
• Awareness of non-helpful actions / behaviors
• Uncovering feelings and covering them again
• Developing new healthier coping skills

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Tx modalities

• Individual therapy
• Family therapy
• Group therapy
• Psychopharmacotherapy
• Education
• Self-help groups (CODA, ACA)

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Can you care too muchand be happier than you
are now?
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Maybe its okay to care too much?

• 50-80 mental health providers have not addressed
  their own codependency issues (NMHA, 2005
  Driscoll, 2004)

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