Dependent Personality Disorder

Dependent Personality Disorder

Definition

Dependent personality disorder (DPD) involves a pervasive and excessive need to be taken care of that leads to submissiveness, clinging and fears of separation (American Psychiatric Associa-tion, 2000). Persons with DPD will also have low self-esteem, and will often be self-critical and self-denigrating. DPD is indicated by the presence of five or more of the eight diagnostic criteria presented in DSM-IV-TR Criteria for DPD.

Etiology and Pathology

Central to the etiology and pathology of DPD is an insecure inter-personal attachment. Insecure attachment and helplessness may be generated through a parent–child relationship, perhaps by a clinging parent or a continued infantilization during a time in which individuation and separation normally occurs., However, DPD may also represent an interaction of an anxious–inhibited temperament with inconsistent or overprotective. Dependent persons may turn to a parental figure to provide a reassurance, security and confidence that they are unable to generate for themselves. They may eventually believe that their self-worth is contingent upon the worth or importance they have to another person.

Differential Diagnosis

Excessive dependency will often be seen in persons who have developed debilitating mental and general medical disorders such as agoraphobia, schizophrenia, mental retardation, severe injuries and dementia. However, a diagnosis of DPD requires the pres-ence of the dependent traits since late childhood or adolescence (American Psychiatric Association, 2000). One can diagnose the presence of a personality disorder at any age during a person’s lifetime, but if, for example, a DPD diagnosis is given to a person at the age of 75 years, this presumes that the dependent behavior was evident since the age of approximately 18 years (i.e., predates the onset of a comorbid mental or physical disorder).

Deference, politeness and passivity will also vary sub-stantially across cultural groups. It is important not to confuse differences in personality that are due to different cultural norms with the presence of a personality disorder. The diag-nosis of DPD requires that the dependent behavior be maladap-tive, resulting in clinically significant functional impairment or distress.

Many persons with DPD will also meet the criteria for histrionic and borderline personality disorders. Persons with DPD and HPD may both display strong needs for reassurance, attention and approval. However, persons with DPD tend to be more self-effacing, docile and altruistic, whereas persons with HPD tend to be more flamboyant, assertive and self-centered and persons with BPD will tend to be much more dysfunctional and emotionally dysregulated.

Epidemiology and Comorbidity

DPD is among the most prevalent of the personality disorders (American Psychiatric Association, 2000), occurring in 5 to 30% of patients and 2 to 4% of the general community (Mattia and Zimmerman, 2001). A controversial issue is its differential sex prevalence. DPD is diagnosed more frequently in females but there is some concern that there might be a failure to recog-nize adequately the extent of dependent personality traits within males. Many studies have indicated that dependent personality traits provide a vulnerability to the development of depression in response to interpersonal loss.

Course

Persons with DPD are likely to have been excessively submissive as children and adolescents, and some may have had a chronic physical illness or a separation anxiety disorder during child-hood (American Psychiatric Association, 2000). Persons with DPD fear intensely a loss of concern, care and support from others, particularly the person with whom they have an emo-tional attachment. They are unable to be by themselves, as their sense of self-worth, value, or meaning is obtained by or through the presence of a relationship. They have few other sources of self-esteem. Along with the need for emotional support are perpetual doubts and insecurities regarding the current source of support. Persons with DPD constantly require reassurance and reaffirmation that any particular relationship will continue, because they anticipate or fear that at some point they may again be alone. Because of their intense fear of being alone they may become quickly attached to persons who are unreliable, unempathic and even exploitative or abusive. More desirable or reliable partners are at times driven away by their excessive clinging and continued demands for reassurance. Occupational functioning is impaired to the extent that independent respon-sibility and initiative are required. Persons with DPD are prone to mood disorders, particularly major depressive disorder and dysthymic disorder, and to anxiety disorders, particularly ago-raphobia, social phobia and perhaps panic disorder. However, the severity of the symptomatology tends to decrease with age, particularly if the person has obtained a reliable, dependable and empathic partner.

Treatment

Persons with DPD are often in treatment for one or more Axis I disorders, particularly a mood (depressive) or an anxiety disorder. They tend to be very agreeable, compliant and grateful patients, at times to excess. An important issue in the treatment of persons with DPD is not letting the relationship with the therapist become an end in itself (Stone, 1993). Many persons with DPD find the therapeutic relationship to satisfy their need for support, concern and involvement. The therapist can be perceived as a nurturing, caring and dependable partner who is always available for as long as the patient desires. Successful treatment can in fact be feared because it suggests the termination of the relationship, an out-come that is at times avoided at all costs. As a result, they be may be excessively compliant, submissive, agreeable and coop-erative in order to be the patient that the therapist would want to retain. Therapists need to be careful not unwittingly to encourage or exploit this submissiveness, nor to commit the opposite error of rejecting and abandoning them to be rid of their needy and clinging dependency. Such responses are common in the inter-personal (marital and sexual) history of persons with DPD, and are at times experienced as well within therapeutic relationships. Persons with DPD tend to have unrealistic expectations regarding their therapist. They may attempt to have the therapist take con-trol of their lives, and may make unrealistic requests or demands for their therapist’s time, involvement and availability.

Exploration of the breadth and source of the need for care and support is often an important component of treatment. Persons with DPD often have a history of exploitative, rejecting and per-haps even abusive relationships that have contributed to their cur-rent feelings of insecurity and inadequacy. Cognitive–behavioral techniques are useful in addressing the feelings of inadequacy, incompetence and helplessness (Beck and Freeman, 1990). Social skills, problem-solving and assertiveness training also makes im-portant contributions.

Persons with DPD may also benefit from group therapy. A supportive group is useful in diffusing the feelings of dependency onto a variety of persons, in providing feedback regarding their manner of relating to others, and in providing practice and role models for more assertive and autonomous interpersonal func-tioning. There is no known pharmacologic treatment for DPD.