A Patient With Panic Disorder Abetted by a Dependent Personality

By the time I interviewed Robyn in the emergency room, her panic attack had all but passed. But this 21-year-old woman was still shaken and tearful. This was her first panic attack, and she did not know what hit her. She thought she was having a heart attack.

Robyn had gone out the evening before-a Saturday evening-drank four or five mixed drinks and returned home around 6:30 a.m. After two hours of sleep, she awoke with a tight feeling in her chest, hyperventilating. Her fingers and feet were numb and tingling. She experienced what she called a "closing in feeling." Robyn thought she was going to die. These symptoms disappeared, but she had another similar episode later that day. Her father brought her to the emergency room.

Robyn's appetite had increased recently, and she was eating more and gaining weight. She was also awakening in the middle of the night. Her friends interested her less. She acknowledged a certain dysphoria, but she denied being seriously depressed or feeling hopeless. Robyn also denied having any thought or plan to hurt herself, or making any prior attempts to do so. "I'm afraid of dying," she assured me, recalling how hard it was to breathe during her recent panic attacks.

Robyn acknowledged being a social drinker but did not feel she abused alcohol. (One could wonder about the "four or five" mixed drinks she had the night before she came to the ER.) She had been using marijuana on and off for several months.

I had seen Robyn in the ER before, five months earlier. "I hate myself and I'm very angry," she told me at the top of that interview. Her anger was diffusely focused, which probably explained why so much of it was directed toward herself-she had been throwing herself against the wall at home. Her mother, who brought her to the ER, was present during the interview and volunteered that her daughter had bruises all over her body. Robyn was also pulling out her hair. "Everything is my fault," she said, as if convinced.

During that first interview, Robyn's speech was tearful and plaintive. Her affect was restricted, although not flat. She looked away as she spoke to me, often staring at the floor. When I asked her about this, she said she frequently avoided eye contact while talking to people and thought that low self-esteem was the reason.

Robyn had felt well until three weeks before. But then she became depressed, could not enjoy what she usually enjoyed, had problems concentrating and took several days off from her assembly-line job at a factory. She felt hopeless and had thoughts about dying, but she had no intention or plan to harm herself. Robyn was sleeping only three to four hours a night, instead of the usual eight. She denied any psychotic symptoms, and I saw no evidence of psychosis during the interview. The diagnosis for this first ER visit was adjustment disorder with anxiety and depressed mood.

Robyn had no psychiatric history or significant medical problems. She took naproxen (Naprosyn) for menstrual pains and had been on the appetite suppressant phentermine (Fastin) for two months (she was slightly overweight). She reported using marijuana for the first time about a week earlier and had smoked eight to 10 joints since then. Her toxicology screen was positive for cannabinoids and amphetamines due to the phentermine.

Robyn told me her father had verbally abused her since she was a child. They had a serious disagreement the week before at a family outing. Also, she had just broken up with her boyfriend of three years, Erik. He was a heavy drug user and sold drugs. "He's not good for me," she said. "He's ruined his life, and now he's ruining mine." Still, Robyn could not let go of Erik emotionally. "I still love him, but I don't like the person he is," she reported, as if the contradiction could not be resolved. This young man insisted she pay for everything when they were out together and often played her off against other women.

Clearly, what Robyn needed was intensive work with an outpatient psychotherapist. This she got from me, first weekly, then biweekly, for two months. Her physician prescribed sertraline (Zoloft) 50 mg and lorazepam (Ativan) 0.5 mg prn. A psychiatrist she saw later switched her to fluoxetine (Prozac). Although she had no side effects, Robyn stopped the fluoxetine after two days, but she continued taking lorazepam for several weeks. It seemed ironic that someone so dependent on others for her most basic needs would defy a doctor's medication order. This 21-year-old woman did not have a driver's license and had never tried to get one. Her mother drove her to my office for our sessions.

We quickly identified the issues that made Robyn so vulnerable to anxiety and depression. Her story was redolent of Axis II. DSM-IV defines this pathology as "a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior." Five of the following eight criteria are required for diagnosis:

• Difficulty making everyday decisions without an excessive amount of advice and reassurance from others;
• Needs others to assume responsibility for most major life areas;
• Difficulty expressing disagreement with others because of fear of loss of support or approval;
• Difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy);
• Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant;
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself;
• Urgently seeks another relationship as a source of care and support when a close relationship ends; and
• Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Robyn met all eight criteria, although some more strikingly than others. In addition, her Millon Clinical Multiaxial Inventory-II (a test for personality disorders) showed very high scores on the avoidant, dependent, passive-aggressive and self-defeating scales, as well as a very high score on the debasement scale (she was bruised from throwing herself against the wall) (Millon, 1987).

Someone with these personality structures and associated dynamics would be expected to have a fragile identity. Faced with recent negative experiences, it seemed likely that Robyn's brittle self-another way of expressing the notion of fragile identity-might have been sufficiently challenged to produce symptoms of anxiety and depression. In the parlance of DSM-IV, this could be thought of as Axis II pathology driving Axis I pathology.

In our sessions, we clarified how Robyn's response to, or more specifically, her acceptance of, her father's lifelong verbal and emotional abuse predisposed her to dependent and abusive involvements with others, including Erik. "My father treated me this way," she said, "and I guess I expected other people to act that way."

Robyn made rapid and steady progress. At what turned out to be our last session, she said, "There's a piece of me that fights back [now]. I feel alive. Before, I felt like I was dead." Robyn did not keep her next scheduled appointment. When I called, she said she thought we had done as much work as we needed to. "I'm fine, real good," she insisted. "Everything is fine." I had my doubts about how long things would stay "fine," and told her to call me if she felt she needed further help.

I did not see or hear from Robyn until that Sunday evening, three months later, when she reappeared in the ER, frightened in the aftermath of her first panic attack. It did not take long to identify the reasons for her severe anxiety.

Three weeks earlier, Robyn had resumed her sexual relationship with Erik. "He was nice at first," she said. "Then he was like he was before...It should not have happened. But I was in more control than before...I recognized what I was doing. I didn't deny it." Robyn told me she would rather be hurt by someone whose pattern of abuse she knew than take a chance on being hurt by someone else.

Robyn had worked in a factory for several years until two weeks before this second hospital visit. During a discussion about her work with two supervisors, she became argumentative and slapped them both in the face-another ironic act for someone with a dependent personality. She was unceremoniously fired. Unemployed now, her bills were piling up. She was spending money she did not have, maxing out a $500 Montgomery Ward card and an $800 Sears card, buying presents for herself and others. Her attitude about money had changed drastically. "I've been working since I was 15," she said. "I've always had money." Now she didn't, and she was accumulating debt.

Robyn's grandmother was in the hospital recuperating from hip replacement surgery. Robyn had lived with her grandmother for some time and looked to this strong woman for emotional support and affirmation. Although she got along well with her mother, Robyn had left home to get away from her emotionally abusive father and did not feel comfortable there. Her grandfather had died five years earlier from cancer. "He held everything together," she said with urgency. "He brought a lot of love to us. He was the first person I ever lost. I could never accept the fact that he was gone. I'm coming to terms..."

These new developments seemed likely reasons for Robyn's severe anxiety, and the breakthrough of that anxiety manifested as panic attacks. The renewal of a relationship with an abusive man, being unemployed and having financial trouble for the first time, and seeing her grandmother laid up in the hospital (which almost surely reactivated unresolved feelings for her dead grandfather) must have threatened much of what this young woman had felt was stable and worthwhile in her life. With her dependent personality, how could Robyn's world still seem even a minimally familiar or safe place?

We resumed therapy. Robyn's physician started her again on sertraline 50 mg/day and lorazepam 0.5 mg prn. Robyn had several more panic attacks (a sufficient number to make the diagnosis of panic disorder), but none as severe as the episode that brought her to the ER. She described one attack this way: "I felt like my whole body was on fire...I was in a whole different world."

I tried to get Robyn to focus on what she was getting from her involvement with Erik. At first, she insisted that she wasn't getting anything positive and was just being hurt. After I challenged her denial, she came up with this: "I gave Erik so much of myself, I felt I had to get him back to get myself back." A classic answer from a classic dependent personality, I thought.

What was Robyn getting from this entirely inappropriate man? Most obviously, companionship, a twisted kind of affirmation and sex. I helped her acknowledge that her involvement with Erik had not been just a passive acceptance of the little he was doling out to her, but an ongoing choice she made day by day.

All through our second attempt at therapy, Robyn kept insisting things were not as bad for her as when we had worked together the first time. She showed what seemed like real improvement after about a month. She made a clean break with Erik, although she still thought about him a good deal, even after he was jailed for drug charges and theft. She found a part-time job as a cashier. Her physician increased the dose of sertraline to 100 mg/day, and Robyn took herself off lorazepam because she felt she did not need it.

I encouraged Robyn to elaborate on her feelings about the abusive man with whom she had just broken up. Comments like "bad news," "no future" and "the lowest person in the world" rang true, which is to say she seemed behind her words. "My investment in him was counterfeit...I went bankrupt." But she made it clear that although she knew Erik was wrong for her, she still had strong feelings for him. "Erik cared about me once," she maintained, probably recalling the brief periods when he had been nice-which he no doubt was, when he was setting her up.

Robyn still clung to the affirmation she felt during those times and to the person who offered it. Gradually, she came to see what this had cost her. The dependent person gladly pays a heavy price for a little affirmation, up to a point. Robyn was starting to get beyond that point now. "Erik was the best thing that happened to me this year; he was the worst thing," she said, convincing me she was beginning to recognize her ambivalence about this man. It seemed she was just where she needed to be to work through the painful dilemma of loving someone who did not deserve love and could not return it.

The full-blown panic attacks stopped, followed by the chest pain and shortness of breath, which were the last somatic conversion symptoms of her anxiety. Robyn's sleep, fitful and interrupted since her first panic attack, increased to six hours a night. She looked and sounded better.

She also met a new man. He was 26, had an infant son and was getting a divorce. She talked as though this relationship might have some future. "I'm giving, and I'm getting," she told me. "I'm smiling and being smiled back at."

Our second round of therapy lasted two months, as had the first. Again, Robyn did not keep her last appointment. She called the office and left a message that she was doing well. I was more persuaded this time, although I knew her personality must still be dominated by the structure and dynamics of dependence.

How far Robyn goes beyond this pathological state will depend, in part, on how vigorously she rejects that mode as a way of life and on what kind of luck she has finding other people-particularly men-who will treat her fairly. Of course, even the fairest of relationships eventually becomes conflicted (and less fair), and during these times it will be very hard for Robyn to hold on to her sense of self-worth and act with autonomy. She will always live with a certain deficit of self that leaves her feeling that she is not worthy of the best this world has to offer.

References:

References

1.

American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association.

2.

Millon T (1987), Millon Clinical Multiaxial Inventory-II. Minneapolis: National Computer Systems Inc.