Treatment of Excessive Interpersonal Dependency: A Cognitive-Behavioral Model

Clients with excessive dependency often seek treatment for an Axis I anxiety or mood disorder. Simply providing treatment for the Axis I disorder may fail to address the long-standing personality factors that may underlie the acute anxiety and depression. A four-stage model has been proposed for the treatment of excessive interpersonal dependency. This model describes strategic ways therapy content and style should change over the course of treatment. Despite the apparent utility of the four-stage treatment model, it may be difficult to apply in many sites that now emphasize short-term approaches to treatment. In many cases, therapy can be designed to address themes that are relevant to both dependency and the Axis I syndrome. Therapy can be focused around helping clients make improvements in stabilizing emotional reactions, enhancing views of the self, and improving social functioning. Treatment focused on stabilizing emotional reactions can help clients confront and develop tolerance for feelings of depression and anxiety. Treatment focused on enhancing views of the self can help clients improve their self-esteem, self-reinforcement and reduce self-criticism. Treatment focused on improving social functioning can enhance social skills, reduce social anxiety and challenge feelings of loneliness. In addition, treatment can focus on reducing specific aspects of interpersonal dependency and confronting developmental antecedents that may underlie the dependency.     

The assessment of personality characteristics in depressed and dependent psychiatric inpatients

The diagnosis and treatment of depression may be complicated by the presence of excessive dependency needs. Previous research has found stable personality traits useful in identifying depressive subtypes. This study was designed to assess the personality characteristics of 106 psychiatric inpatients. Subjects were grouped according to the presence or absence of two primary dimensions: depression and dependency. Results indicated that both depression and dependency were significantly related to various indices of psychopathology. Main effects were more useful than interactions, implying that depression and dependency both affect symptomology directly rather than interactively. Although the assessment of personality traits may be complicated by the presence of a major psychiatric disorder, results from our study suggest that the assessment of both Axis I and Axis II variables can be useful in understanding the current clinical picture.     

The relation of neediness and Axis II pathology

Neediness, as a maladaptive form of interpersonal dependency, has been implicated in a range of psychopathology, most commonly mood and personality disorders. In light of the literature's sparse and inconsistent findings, Bornstein, Hilsenroth, Padawer, and Fowler (2000) have called for a systematic evaluation of dependency's role across the spectrum of Axis II disorders. The current study of individuals without current or past Axis I diagnoses found that Neediness was significantly related to dimensions of dependent, borderline, and histrionic personality disorders. Implications for the assessment of interpersonal dependency and issues in need of further clarification are highlighted.     

Treatment outcomes for female offenders: relationship to number of Axis I diagnoses

This article describes a study that examined the relationship between multiple Axis I mental health diagnoses and treatment outcomes for female offenders in prison substance abuse treatment programs. Preliminary findings of the effectiveness of therapeutic community (TC) treatment, modified for female offenders, relative to a control cognitive behavioral treatment condition, are presented. The hypothesis--that participants who fit into multiple diagnostic categories have more dysfunctional symptoms and behaviors at baseline--was confirmed; however, a hypothesized relationship between the number of Axis I diagnoses and 6 month treatment outcomes across five domains (mental health, trauma exposure, substance use, HIV needle risk behaviors, and HIV sexual risk) was not supported. Across all Axis I mental health groups, TC treatment was significantly more effective than the control condition overall, as well as on measures of mental health symptoms and HIV sexual risk. These findings suggest that this TC treatment program, as modified, is an effective model for women with varied diagnoses and diagnostic complexities.     

Interpersonal dependency and personality pathology: variations in Rorschach Oral Dependency scores across Axis II diagnoses

Although several investigations have examined the relationship of Rorschach Oral Dependency (ROD; Masling, Rabie, & Blondheim, 1967) scores to Axis I diagnosis, there has been very little research assessing variations in ROD scores across Axis II personality disorders (PDs). In this study, ROD scores were compared in 5 PD groups (borderline PD inpatients, borderline PD outpatients, avoidant-dependent PD outpatients, narcissistic PD outpatients, and antisocial PD outpatients), and 2 non-PD comparison groups (psychotic disorder inpatients and college students). Borderline PD inpatients had significantly higher ROD scores than borderline PD outpatients, antisocial PD outpatients, and college students; no other between-group differences were found. We discuss implications of these results for research on dependency and Axis II psychopathology and offer suggestions for future studies.     

Social phobia: Axis I and II correlates

The presence of Axis I and Axis II disorders in 71 social phobic patients was examined. Generalized anxiety disorder was the most common secondary Axis I disorder, followed by simple phobia. Avoidant personality disorder and obsessive-compulsive personality disorder were the most common Axis II diagnoses, and 88% of the sample exhibited features of these 2 personality styles. Subjects with additional Axis I diagnoses were more anxious and depressed than those with no additional Axis I disorder. Social phobics with additional Axis II disorders were more depressed but not more anxious than those with no Axis II diagnosis. Furthermore, those with an additional Axis I disorder had higher scores on measures of neuroticism, interpersonal sensitivity, and agoraphobia. The prevalence and impact of additional Axis I and II disorders on the etiology, maintenance, and treatment outcome for persons with social phobia are discussed.     

An evaluation of evaluative personality terms: a comparison of the big seven and five-factor model in predicting psychopathology

Two personality models are compared regarding their relationship with personality disorder (PD) symptom counts and with lifetime Axis I diagnoses. These models share 5 similar domains, and the Big 7 model also includes 2 domains assessing self-evaluation: positive and negative valence. The Big 7 model accounted for more variance in PDs than the 5-factor model, primarily because of the association of negative valence with most PDs. Although low-positive valence was associated with most Axis I diagnoses, the 5-factor model generally accounted for more variance in Axis I diagnoses than the Big 7 model. Some predicted associations between self-evaluation and psychopathology were not found, and unanticipated associations emerged. These findings are discussed regarding the utility of evaluative terms in clinical assessment.     

Use of Bowen Theory

A theory-based approach to treatment of co-dependency is missing in both fields of chemical dependency and traditional mental health. Bowen family systems therapy is presented as a foundation and framework for treatment goals and interventions. Similarities between the characteristics of low levels of differentiation of self and co-dependency are illustrated.     

Diagnostic profiles of offenders in substance abuse treatment programs

This study examined the association of Axis I and Axis II disorders among offenders who were in prison-based substance abuse treatment in a national multi-site study. Participants (N = 280) received a psychosocial assessment and a structured diagnostic interview in two separate sessions. Logistic regression models examined the association between lifetime mood and anxiety disorders with two personality disorders, and the relationship of Axis I and Axis II disorders (alone and in combination) to pre-treatment psychosocial functioning. Over two-thirds of the sample met criteria for at least one mental disorder. Borderline personality disorder was strongly associated with having a lifetime mood disorder (odds ratio = 7.5) or lifetime anxiety disorder (odds ratio = 8.7). Individuals with only an Axis II disorder, or who had both Axis I and Axis II disorders, had more severe problems in psychosocial functioning than those without any disorder. Clinical treatment approaches need to address this heterogeneity in diagnostic profiles, symptom severity, and psychosocial functioning.     

Family approval as a constraint in dependency regulation: Evidence from Australia and Indonesia

Murray and colleagues’ dependency regulation model suggests that individuals in romantic relationships permit themselves to be emotionally dependent on a romantic partner only when they are certain they are valued by their partners. We argue that in cultures where family has a role in mate selection, family approval of the relationship provides an additional constraint on emotional dependence. Reports of relationship perceptions were collected from Australian and Indonesian individuals in dating relationships. The traditional dependency regulation model was affirmed for the Australian sample, but regulation of emotional dependence was best accounted for by both feelings of security in a partner’s affections and perceptions of approval from the partner’s family for the Indonesian sample.     

The burden of disease among adolescents with personality pathology: quality of life and costs

In adults, personality disorders are associated with a low quality of life and high societal costs. To explore whether these findings also apply to adolescents, 131 adolescent patients were recruited from a mental health care institute in The Netherlands. Axis I and Axis II disorders were diagnosed using semi-structured interviews. The EuroQol EQ-5D was used to measure quality of life and costs were measured by the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness. The mean EQ-5D index value was 0.55. The mean direct medical cost in the year prior to treatment was €14,032 per patient. The co-occurrence of Axis I and Axis II disorders was a significant predictor of a low quality of life. Direct medical costs were higher for the depressive personality disorder. This study shows that the burden of disease among adolescents with personality pathology is high. This high burden provides evidence to suggest that further research and development of (cost-)effective treatment strategies for this population may be worthwhile.     

Chronic suicidality and borderline personality

Suicidal ideation is a complex clinical event. In this article, acute suicidal ideation is compared with chronic suicidal ideation, specifically their different meanings, relationships with Axis I and Axis II disorders, intrapsychic functions, approaches to assessment, and interventions. The potential risks of acute hospitalization of the chronically suicidal borderline personality disorder patient are discussed as well as a longitudinal, multidimensional treatment strategy for the chronically suicidal individual.     

Borderline personality disorder features and utilization of treatment over two years

This study assessed the relationship between borderline personality disorder (BPD) features and treatment utilization over a 2-year time period. Participants included 349 18-year-old nonclinical young adults, approximately one-half of whom endorsed significant borderline features. The laboratory phase of the study involved the administration of self-report and interview-based assessments of BPD psychopathology at Wave 1, as well as interviews targeting Axis I psychopathology and treatment utilization history at Wave 2 (2 years later). Results indicated that borderline features prospectively predicted utilization of psychopharmacological treatment above and beyond what was accounted for by gender, lifetime Axis I psychopathology, and nonBPD Axis II psychopathology. The borderline feature most strongly associated with treatment utilization was affective instability.     

The effect of Axis II disorders on the outcome of treatment of anxiety and unipolar depressive disorders: a review

Psychiatric and other clinicians have often speculated on whether the presence of a personality disorder would indicate a poorer course of treatment for an Axis I disorder. Starting around 1990, the standardized criteria of the DSM increased interest in examining this area empirically. This report updates my previous reviews and examines other writing in this area. There is still a considerable body of evidence indicating that personality may cause a poorer treatment outcome of an Axis I disorder; however, there are also intriguing new developments. The introduction of new drug treatments that may be helpful with some dysfunctional personality traits changes some of the findings and may suggest that there may be preferential treatments for some Axis I patients with certain comorbid personality traits. (In certain cases this may apply to some specific psychotherapy techniques as well.) In addition, at times, personality traits may predict a positive outcome to treatment. This review is an attempt to bring together this diverse area and suggest where fruitful areas of research and intervention may possibly be found.     

Rates of personality disorders in substance abusers: a comparison between DSM-III-R and DSM-IV

The publication of the DSM-IV represents the first revision in 7 years to the DSM-III-R diagnostic criteria. The purpose of the current study is to evaluate the impact of changes to the Axis II criteria on diagnostic rates in a substance abusing population. We interviewed 370 patients entering treatment using a modified version of the SCID-II, which allowed for the diagnosis of both DSM-III-R and DSM-IV Axis II diagnoses. Prevalence rates for each Axis II disorder are given, as well as kappa statistics showing diagnostic agreement between the two systems. The results of this study indicate good rates of diagnostic agreement between the two systems with a few notable exceptions. Poor rates of diagnostic agreement were obtained for the histrionic and dependent diagnostic categories. No single diagnostic change appears to be responsible for the prevalence rate differences between the two systems.     

The Role of Sexual Trauma in the Treatment of Chemically Dependent Women: Addressing the Relapse Issue

A review of the literature indicates a high incidence of sexual trauma among women who seek treatment for substance abuse. Additionally, clients who have experienced sexual trauma appear to be more susceptible to relapse, the return to substance abuse. This article explores issues surrounding sexual trauma and chemical dependency. It aims to provide direction for relapse prevention with a relapse-prone population. Application of traditional milieu substance abuse treatment for sexual trauma survivors is explored. Recommendations for working with sexual trauma survivors who are also substance abusers are presented, as are suggestions for research.     

Examining Subtypes of Behavior Problems among 3-Year-Old Children,Part II: Investigating Differences in Parent Psychopathology,Couple Conflict,and Other Family Stressors

This study examined family stressors among 3-year-old children who were classified as hyperactive (HYP), hyperactive and oppositional defiant (HYP/OD), and non-problem based on mothers' reports of behavior. Children with HYP/OD were found to experience higher levels of family stressors than non-problem children on almost every family stressor variable. Compared to children with HYP, families of children with HYP/OD also tended to report more Axis II maternal psychopathology, Axis I paternal psychopathology, and high intensity couple conflict tactics. However, the HYP and HYP/OD group did not significantly differ on maternal Axis I psychopathology, paternal Axis II psychopathology, parental marital status, negative life events, frequency of couple conflict, or use of lower intensity couple conflict tactics. Parents of children with HYP and HYP/OD reported more negative life events, more maternal adult ADHD symptoms, and more maternal avoidance and verbal aggression during marital conflict than parents of non-problem children. Implications for treatment and etiology are discussed.     

The joint structure of DSM-IV Axis I and Axis II disorders

The Diagnostic and Statistical Manual (4th ed. [DSM-IV]; American Psychiatric Association, 1994) distinction between clinical disorders on Axis I and personality disorders on Axis II has become increasingly controversial. Although substantial comorbidity between axes has been demonstrated, the structure of the liability factors underlying these two groups of disorders is poorly understood. The aim of this study was to determine the latent factor structure of a broad set of common Axis I disorders and all Axis II personality disorders and thereby to identify clusters of disorders and account for comorbidity within and between axes. Data were collected in Norway, through a population-based interview study (N = 2,794 young adult twins). Axis I and Axis II disorders were assessed with the Composite International Diagnostic Interview (CIDI) and the Structured Interview for DSM-IV Personality (SIDP-IV), respectively. Exploratory and confirmatory factor analyses were used to investigate the underlying structure of 25 disorders. A four-factor model fit the data well, suggesting a distinction between clinical and personality disorders as well as a distinction between broad groups of internalizing and externalizing disorders. The location of some disorders was not consistent with the DSM-IV classification; antisocial personality disorder belonged primarily to the Axis I externalizing spectrum, dysthymia appeared as a personality disorder, and borderline personality disorder appeared in an interspectral position. The findings have implications for a meta-structure for the DSM.