In a study of 400 consecutive outpatients, Whitman et al. (1954) noted that 23% had a passive-dependent personality, the most prevalent personality type. Their presenting complaints included depression (36%), anxiety (29%), somatic symptoms (11%), phobias (7%), and situational reactions (7%). Agoraphobia, with or without panic attacks, and eating disorders were also common. Loranger (1995) reviewed discharge diagnoses of 342 inpatients with dependent personality disorder and found that major depression (31%) and bipolar disorder (12%) were more common, whereas alcohol and substance abuse were less common, than in other types of personality disorders. Common precipitants for seeking treatment include disturbances in or loss of valued attachments, situational or occupational changes that require increased assertive and independent behavior, or failures at achievement.
One factor-analytic study suggested that dependency is best characterized by three related dimensions. The first dimension encompasses close attachments and strong emotional reliance on others. Livesley et al. labeled this dimension “insecure attachment,” after Bowlby. Individuals with this dimension of dependency are prone to separation anxiety and will remain in relationships, even with those who mistreat them, to avoid the resurgence of feeling alone and helpless. To entice others to like them or to secure succor, they often act in ingratiating ways, doing whatever is asked of them.
When hospitalized, very dependent individuals often transfer their attachment needs to the hospital. As separation anxiety increases prior to discharge, their presenting symptoms may recur, possibly prolonging hospitalization. This is less likely to occur whenever the patient has a good, close relationship with someone outside the hospital.
The second dimension involves a lack of self-confidence in social situations, often accompanied by submissive behavior, which Livesley et al. considered the core dependency dimension. Individuals with this trait have difficulty asserting themselves, often agreeing with others despite believing that others are incorrect. They fear self-expression, whether it involves anger, criticism, or their own wishes and needs, and they are often passive when events call for an active response. However, they may be able to confront anxiety-provoking situations courageously to help or protect those dependent on them. Furthermore, Bornstein reported that dependent individuals can be quite assertive, even aggressive, whenever striving to obtain or maintain a supportive relationship.
The third dimension that characterizes dependency is the avoidance of (vs. desire for) autonomy. Those who avoid autonomy want others to make decisions for them; otherwise, they are indecisive and have difficulty initiating or completing activities on their own. They often seek guidance and direction and thereby subordinate their freedom of choice to the will of others. Livesley et al. did not consider this a classic aspect of dependency.
Dependent individuals doubt themselves and view themselves as incompetent and less worthy or deserving than others. They have a pessimistic view of their chances for social and occupational success, perhaps masked by an external attitude of optimism. They may constantly ruminate over their fearful attitudes and phobic anxieties about self-assertion, social activities, independence, and abandonment. J. S. Beck posited that the core belief in dependent personality disorder about the self is “I am helpless” and about others is “others should take care of me.” Situations that touch on these core beliefs then trigger assumptions such as “If I rely on myself, I’ll fail” and “If I depend on others, I’ll survive.” These assumptions then lead to behavioral strategies of relying on others.
Revision date: June 18, 2011
Last revised: by Jorge P. Ribeiro, MD