What treatment approach is recommended for an adult male patient with insecure attachment, anxiety, and depression, who exhibits demand-making behavior due to insecurity?

Treatment Approach for Adult Male with Insecure Attachment, Anxiety, and Depression Manifesting as Demand-Making Behavior

Cognitive Behavioral Therapy (CBT) delivered by a licensed mental health professional is the first-line treatment for this patient, as it directly addresses the maladaptive cognitive schemas, information-processing errors, and interpersonal patterns that link insecure attachment to both anxiety and depression. 1, 2, 3

Initial Safety and Severity Assessment

• Immediately assess for risk of self-harm or harm to others given the combination of depression and demand-making behavior driven by insecurity, referring for emergency psychiatric evaluation if present 2
• Quantify symptom severity using standardized instruments: PHQ-9 for depression and GAD-7 for anxiety to guide treatment intensity 1, 2
• Screen for substance use, as this complicates both diagnosis and treatment in patients with anxiety and depression 3

Understanding the Clinical Formulation

The demand-making behavior stems from insecure attachment as a psychological vulnerability, which research demonstrates prospectively predicts both interpersonal stress generation and symptoms of depression and anxiety 1. Specifically:

• Anxious/preoccupied attachment styles are associated with excessive reassurance-seeking and dependency, which generate interpersonal stress through demanding behaviors in relationships 1
• This attachment pattern predicts higher levels of both depressive and anxious symptoms, particularly when experiencing interpersonal stressors 4, 5, 6
• Dismissing and preoccupied attachment styles prospectively predict social and interpersonal stressful events, creating a cycle where insecurity drives demands, which generate relationship conflict, perpetuating symptoms 1

Treatment Algorithm Based on Severity

Moderate Symptoms (PHQ-9: 10-14, GAD-7: 10-14)

• Start with CBT monotherapy delivered by a licensed mental health professional using manualized protocols that include cognitive restructuring, behavioral activation, and interpersonal effectiveness skills 2, 3
• CBT demonstrates significant reductions in both depressive and anxiety symptoms with benefits maintained in short and medium term 3
• Target the attachment-related mechanisms: dysfunctional attitudes and low self-esteem, which mediate the relationship between anxious attachment and internalizing symptoms 4, 7

Severe Symptoms (PHQ-9: ≥15, GAD-7: ≥15)

• Initiate combination treatment with CBT plus SSRI from the outset 2, 3
• First-line SSRI: Sertraline 50 mg once daily (morning or evening), which can be increased to 200 mg/day based on response 8
• Alternative SSRI: Fluoxetine 20 mg/day (morning), which can be increased to 60-80 mg/day if needed 9

Specific CBT Components for Insecure Attachment

The CBT protocol must address:

• Maladaptive cognitive schemas derived from insecure attachment, including negative self-evaluations and information-processing errors that drive demand-making behavior 1
• Interpersonal problem-solving skills, as poor problem-solving predicts interpersonal stress generation 1
• Emotion regulation strategies to address the instability of affect management characteristic of insecure attachment 1
• Behavioral experiments to test beliefs about relationships and reduce excessive reassurance-seeking 1

Treatment Monitoring and Adjustment

• Assess treatment response at 4 weeks and 8 weeks using PHQ-9 and GAD-7 2, 3
• If symptoms are stable or worsening after 8 weeks despite good adherence, immediately adjust the regimen: 2, 3
  • Add pharmacotherapy to CBT or vice versa
  • Change the specific SSRI (e.g., switch from sertraline to fluoxetine or to an SNRI like venlafaxine)
  • Switch from group to individual therapy format
• Do not wait beyond 8 weeks to adjust ineffective treatment, as prolonged inadequate response worsens outcomes and increases chronicity 3

Adjunctive Interventions

• Structured physical activity/exercise provides moderate to large reductions in depression and may reduce anxiety 2, 3
• Mindfulness-Based Stress Reduction (MBSR) demonstrates statistically significant improvements in both depression and anxiety, and may serve a protective role in the relationship between insecure attachment and depression 2, 3, 7
• Psychoeducation for patient and family about how insecure attachment drives demand-making behavior through excessive reassurance-seeking and dependency, and how this perpetuates interpersonal stress 1, 2

Critical Pitfalls to Avoid

• Do not use benzodiazepines as routine treatment for anxiety management due to risks of cognitive impairment, dependence, and abuse potential, particularly given the interpersonal stress generation pattern 10
• Do not neglect to evaluate follow-through with mental health referrals—patients with anxious attachment and avoidant coping are less likely to follow through on referrals, so actively assist with barriers to the first appointment 1, 3
• Do not fail to address the interpersonal pattern directly: the demand-making behavior will continue to generate relationship stress unless the underlying attachment-related cognitive and behavioral patterns are modified through CBT 1
• Do not use antidepressant monotherapy without ruling out bipolar disorder, as this can trigger manic episodes 3

Maintenance Treatment

• Continue treatment for several months beyond symptom remission, as both depression and anxiety are chronic conditions, particularly when rooted in insecure attachment patterns 8, 9
• Relapse prevention components are critical given that insecure attachment represents an enduring vulnerability factor 1
• Reassess monthly until symptoms have subsided, evaluating compliance, satisfaction with treatment, and any ongoing interpersonal stressors 1