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Clinical interest in dependent personality disorder has existed since Abraham first described the oral character. As a disorder, the personality type first appeared in a War Department Technical Bulletin in 1945 and later in the first edition of the Diagnostic and Statistical Manual in 1952 (American Psychiatric Association 1952) as a subtype of passive-aggressive personality disorder. Since then, a surprising number of studies have upheld the descriptive validity of dependent personality traits, viewed as submissiveness, oral character traits, oral dependence, or passive dependence, or as a constellation of both pathological and adaptive traits under the rubric dependency.
Dependent Personality Disorder
- DSM-IV Criteria
- Presenting Complaints
- Psychodynamics and the Functional Maintenance of Dependent Behavior
- L Problems Arising in Psychotherapy
- L Individual Dynamic Psychotherapy
- L Cognitive-Behavioral Therapy
- L Group Psychotherapy
- Biological Therapies
- Residential and Day Treatment Therapies
- Separation Anxiety and Dependent Personality
DSM-IV (American Psychiatric Association 1994) emphasizes two sets of traits (Table 88-1): 1) dependency (criteria 1-5) and 2) insecure attachment (criteria 6-8). The description overlaps that of asthenic personality disorder in the International Classification of Diseases, Ninth Revision, which emphasizes compliance and a weak response to the demands of daily life.
The treatment literature is limited largely to case descriptions and uncontrolled studies, although several controlled treatment trials with admixtures of personality disorders address issues relevant to dependent personality disorder. Nonetheless, there is an apparent consensus in the clinical literature that the treatment of dependent personality disorder is often successful. This is indirectly supported by the relative lack of articles that report failures or focus on difficulties in treatment, in contrast to the plethora of such reports for other personality disorders.
Dependency is a universal personality trait; however, this review is limited to reports that are relevant to the treatment of the personality disorder only. Although dependent personality is common in the general population - the Midtown Manhattan Study found that it was present in 2.5% of the entire sample (Langer and Michael 1963) - it often occurs with other personality disorders, especially borderline, histrionic, and avoidant personality disorders (Bornstein 1995b; Hirschfeld et al. 1991; Zanarini et al. 1998), and less consistently with self-defeating, passive-aggressive, compulsive, schizotypal, and paranoid types (Bornstein 1995b; Reich 1996; Skodol et al. 1996); treatment should be modified accordingly. Patterns of comorbidity vary widely depending on sample source, reason for selection (e.g., major depression), and assessment method. This review does not include a discussion of managing the dependency that often accompanies chronic major psychiatric syndromes such as schizophrenia or unremitting depression (Bornstein 1992). However, in noting that Axis I disorders such as depression often increase dependency, Skodol et al. (1996) suggested that if maladaptive dependency does not improve after the treated symptomatic disorder improves, then it might become the focus of treatment in its own right.
A common and serious mental disorder characterized by loss of contact with reality (psychosis), hallucinations (false perceptions), delusions (false beliefs), abnormal thinking
Dependent Personality Disorder
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
- needs others to assume responsibility for most major areas of his or her life.
- has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.
- has 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.
- is unrealistically preoccupied with fears of being left to take care of himself or herself.
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 disorderis 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.
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 apporval 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 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 form 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 thinkging is naive, uncritical and lacks descretion.
It is commonly thought that the development of dependence in these individuals is a result of overinvolvement 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.
Individualy with Dependent Personality disorder often have been socially humiliated by others in their development 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.
DSM-IV-TR specifies eight diagnostic criteria for Dependent Personality disorder. Individuals with this disorder:
- Have difficulty making common decisions. These individuals typically need and excessive amount of advice and reassurance before they can make even simple decisions, such as the clothing to wear on a give 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 live. 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, theis dependence upon others may appear childlike.
Dependent Personality disorder should rarely, if ever, be diagnosed in children or adolescents because of their dependence on others because of theis age and developmental limitations.
Separation Anxiety and Dependent Personality
The connection among aging, depression, and dependency is a burgeoning frontier of research. The quality of life for many aging dependent personalities is complicated by the health status of the partner they have always relied on, in many cases for most of their life. Dependents seek out those who are willing to face a cruel and uncertain world and make major life decisions for them. Their chosen protector, usually a spouse but sometimes a mother or father, provides structure and resources intended to shelter dependents from responsibility. Dependents are just along for the ride, so to speak. And that's exactly how they prefer it.
What's a dependent to do, however, when the all-powerful protector begins to succumb to the effects of aging? Because age and stability usually go together, it is not uncommon for the protector to already be many years older. Eventually, the protector may require steady in-home care or even begin to develop a dementing illness, such as Alzheimer's, eliminating his or her role as chief decision maker. Because many families cannot afford round-the-clock nursing care, the burden often shifts to the dependent personality.
A role-reversal may occur in which dependents are required to assume control of the family and take charge of financial and legal responsibilities. They may also be required to administer medications on a schedule, watch over the activities of the ailing partner, coordinate their partner's day, or perform a series of medical chores in a routine program. As the illness worsens, dependents must take control of two lives, whereas previously, they sought to forfeit control of their own. In a study examining the relationship between personality and caregiving, Alzheimer's caregivers who were distressed were found to be six times more likely to possess dependent traits (J. T. Olin, Schneider, & Kaser-Boyd, 1996). As the population of the United States continues to age, individuals with dependent traits can be expected to complicate an already troublesome crisis in health care.
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 adulthhood 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 behaviour. 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 feellings 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.