Dependent personality disorder

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Definition

Dependent personality disorder is characterized by an excessive need to be taken care of or depend upon others. Persons with this disorder are typically submissive and display clinging behavior toward those from whom they fear being separated.

Dependent personality disorder is one of several personality disorders listed in the newest edition of the standard reference guide: Diagnostic and Statistical Manual of Mental Disorders , also known as the DSM-IV-TR .

Description

Persons with dependent personality disorder are docile, passive, and nonassertive. They exert a great deal of energy to please others, are self-sacrificing, and constantly attempt to elicit the approval of others. They are reluctant to express disagreement with others, and are often willing to go to abnormal lengths to win the approval of those on whom they rely. They are easily influenced and can be taken advantage of easily. This compliance and reliance upon others leads to a subtle message that someone should assume responsibility for significant areas of the patient's life. This is often displayed as helplessness, even for completion of seemingly simple tasks.

Patients with dependent personality disorder have a low level of confidence in their own intelligence and abilities. They often have difficulty making decisions and undertaking projects on their own. They are prone to be pessimistic, self-doubting, and belittle their own accomplishments. They shy away from responsibility in occupational settings.

Affected individuals are uneasy being alone and are preoccupied with the fear of being abandoned or rejected by others. Their moods are characterized by frequent bouts of anxiety or fearfulness; generally, their demeanor is sad. Their style of thinking is naïve, uncritical, and lacks discretion.

Causes and symptoms

Causes

It is commonly thought that the development of dependence in these individuals is a result of over-involvement and intrusive behavior by their primary caretakers. Caretakers may foster dependence in the child to meet their own dependency needs, and may reward extreme loyalty but reject attempts the child makes towards independence. Families of those with dependent personality disorder are often do not express their emotions and are controlling; they demonstrate poorly defined relational roles within the family unit.

Individuals with dependent personality disorder often have been socially humiliated by others in their developmental years. They may carry significant doubts about their abilities to perform tasks, take on new responsibilities, and generally function independently of others. This reinforces their suspicions that they are incapable of living autonomously. In response to these feelings, they portray a helplessness that elicits caregiving behavior from some people in their lives.

Symptoms

DSM-IV-TR specifies eight diagnostic criteria for dependent personality disorder. Individuals with this disorder:

Have difficulty making common decisions. These individuals typically need an excessive amount of advice and reassurance before they can make even simple decisions, such as the clothing to wear on a given day.
Need others to assume responsibility for them. Because they view themselves as incapable of being autonomous, they withdraw from adult responsibilities by acting passive and helpless. They allow others to take the initiative for many areas of their life. Adults with this disorder typically depend on a parent or spouse to make major decisions for them, such as where to work, to live, or with whom to be friends.
Have difficulty expressing disagreement with others. Disagreeing with others is often viewed as too risky. It might sever the support or approval of those they upon whom they depend. They are often overly agreeable, as they fear alienating other people.
Have difficulty initiating or doing things on their own. They lack self-confidence and believe they need help to begin or sustain tasks. They often present themselves as inept and unable to understand or accomplish the task at hand.
Go to excessive lengths to obtain support or nurturing from others. They may even volunteer to do unpleasant tasks if they believe that doing so will evoke a positive response from others. They may subject themselves to great personal sacrifice or tolerate physical, verbal, or sexual abuse in their quest to get what they believe they need from others.
Feel helpless when alone. Because they feel incapable of caring for themselves, they experience significant anxiety when alone. To avoid being alone, they may be with people in whom they have little interest.
Quickly seek a new relationship when a previous one ends. When a marriage, dating, or other close relationship ends, there is typically an urgency to find a new relationship that will provide the support of the former relationship.
Are preoccupied with fears of being left to take care of themselves. Their greatest fear is to be left alone and to be responsible for themselves. Even as adults, their dependence upon others may appear childlike.

Demographics

Dependent personality disorder should rarely, if ever, be diagnosed in children or adolescents because of their dependence on others because of their age and developmental limitations.

Diagnosis

Age and cultural factors should be considered in diagnosing dependent personality disorder. Certain cultural norms suggest a submissive, polite, or dependent posture in relating to the opposite sex, or authority figures. Dependent personality disorder should only be diagnosed when it meets the above criteria and is clearly outside one's cultural norms.

The diagnosis of dependent personality disorder is based on a clinical interview to assess symptomatic behavior. Other assessment tools helpful in confirming the diagnosis of dependent personality disorder include:

Minnesota Multiphasic Personality Inventory (MMPI-2)
Millon Clinical Multi-axial Inventory (MCMI-II)
Rorschach Psychodiagnostic Test
Thematic Appreception Test (TAT)

For a person to be diagnosed with dependent personality disorder, at least five of the eight symptoms described above must be the present, and these symptoms must begin by early adulthood and be evident in a variety of contexts.

The diagnosis of dependent personality disorder must be distinguished from borderline personality disorder , as there are common characteristics. Borderline personality disorder is characterized by fear of abandonment, as well, but with feelings of emptiness and rage. In contrast, the dependent personality responds to this fear of abandonment with submissiveness, and searches for a replacement relationship to maintain dependency.

Likewise, persons with histrionic personality disorder have a strong need for reassurance and approval, and may appear childlike in their clinging behavior. Histrionics are characterized by a gregarious demeanor and make active demands for attention, whereas dependents respond with docile and self-deprecating behavior.

The avoidant personality disorder can also be confused with dependent personality disorder. Both are characterized by feelings of inadequacy, an oversensitivity to criticism, and a frequent need for assurance. However, patients with avoidant personality disorder typically have such an intense fear of rejection that they will instinctively withdraw until they are certain of acceptance. People with dependent personality disorder, in contrast, actually seek out contact with others because they need the approval of others.

Treatments

The general goal of treatment of dependent personality disorder is to increase the individual's sense of autonomy and ability to function independently.

Psychodynamically oriented therapies

A long-term approach to psychodynamic treatment can be successful, but may lead to heightened dependencies and difficult separation in the therapeutic relationship over time. The preferred approach is a time-limited treatment plan consisting of a predetermined number of sessions. This has been proved to facilitate the exploration process of dependency issues more effectively than long-term therapy in most patients.

Cognitive-behavioral therapy

Cognitive-behavioral approaches attempt to increase the affected person's ability to act independently of others, improve their self-esteem, and enhance the quality of their interpersonal relationships. Often, patients will play an active role in setting goals. Methods often used in cognitive-behavioral therapy (CBT) include assertiveness and social skills training to help reduce reliance on others, including the therapist.

Interpersonal therapy

Treatment using an interpersonal approach can be useful because the individual is usually receptive to treatment and seeks help with interpersonal relationships. The therapist would help the patient explore their long-standing patterns of interacting with others, and understand how these have contributed to dependency issues. The goal is to show the patient the high price they pay for this dependency, and to help them develop healthier alternatives. Assertiveness training and learning to identify feelings is often used to improve interpersonal behavior.

Group therapy

When a person is highly motivated to see growth, a more interactive therapeutic group can be successful in helping him/her to explore passive-dependent behavior. If the individual is socially reluctant or impaired in his/her assertiveness, decision-making, or negotiation, a supportive decision-making group would be more appropriate. Time-limited assertiveness-training groups with clearly defined goals have been proven to be effective.

Family and marital therapy

Individuals with dependent personality disorder are usually brought to therapy by their parents. They are often young adults who are struggling with neurotic or psychotic symptoms. The goal of family therapy is often to untangle the enmeshed family relationships, which usually elicits considerable resistance by most family members unless all are in therapy.

Marital therapy can be productive in helping couples reduce the anxiety of both partners who seek and meet dependency needs that arise in the relationship.

Medications

Individuals with dependent personality disorder can experience anxiety and depressive disorders as well. In these cases, it may occasionally prove useful to use antidepressants or anti-anxiety agents. Unless the anxiety or depression is considered worthy of a primary diagnosis, medications are generally not recommended for treatment of the dependency issues or the anxiety or depressive responses. Persons with dependent personality disorder may become overly dependent on any medication used.

Prognosis

The general prognosis for individuals with dependent personality disorder is good. Most people with this disorder have had a supportive relationship with at least one parent. This enables them to engage in treatment to varying degrees and to explore the source of their dependent behavior. If persons who enter treatment can learn to become more autonomous, improved functioning can be expected.

Prevention

Since dependent personality disorder originates in the patient's family, the only known preventive measure is a nurturing, emotionally stimulating, and expressive caregiving environment.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., M.D., and Robert Berkow, M.D., eds. The Merck Manual of Diagnosis and Therapy. 17th edition. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Millon, Theodore, Ph.D., D.Sc. Disorders of Personality: DSM IV and Beyond. New York: John Wiley and Sons, Inc., 1996.

Sperry, Len, M.D., Ph.D. Handbook of Diagnosis and Treatment of DSM-IV Personality Disorders. New York: Brunner/Mazel, Inc., 1995.

PERIODICALS

International Society for the Study of Personality Disorders. Journal of Personality Disorders. Guilford Publications, 72 Spring St., New York, NY 10012.

<http://www.guilford.com> . (800) 365-7006.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005 <http://www.psych.org> .

Gary Gilles, M.A.