Dependent personality disorder

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.

Dependent personality disorder

Definition

Dependent personality disorder is a lack of self-confidence coupled with excessive dependence on others.

Description

Persons affected by dependent personality disorder have a disproportionately low level of confidence in their own intelligence and abilities and have difficulty making decisions and undertaking projects on their own. Their pervasive reliance on others, even for minor tasks or decisions, makes them exaggeratedly cooperative out of fear of alienating those whose help their need. 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. Another common feature of the disorder is an exaggerated fear of being left to fend for oneself. Adolescents with dependent personality disorder rely on their parents to make even minor decisions for them, such as what they should wear or how they should spend their free time, as well as major ones, such as what college they should attend or which career they should choose.

It is important to note that in other societies where cultural norms are different, dependent and/or passive traits may be valued, particularly in women. The criteria outlined here for dependent personality disorder is applicable to Americans only, and even then may not apply to all cultural groups within the United States.

Demographics

Dependent personality disorder occurs equally in males and females and usually begins by early adulthood. Overall prevalence is approximately one to two percent of the general population. Because children and adolescents are dependent on adults by necessity, dependent personality disorder is very rarely diagnosed in these age groups.

Causes and symptoms

In the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR), the American Psychiatric Association states that five of the following criteria should be present for a diagnosis of dependent personality disorder:

• difficulty making decisions, even minor ones, without guidance and reassurance from others
• requiring others to take responsibility for major decisions and responsibilities beyond what would be age-appropriate (e.g., letting a parent choose a college without offering any input on the decision)
• difficulty disagreeing with others due to an unreasonable fear of alienation
• unable to initiate or complete projects or tasks due to a belief that he or she is either inept or that the appearance of success would lead a support person(s) to abandon him or her
• takes on unreasonably unpleasant tasks or sacrifices things in order to win the approval of others
• unable to spend time alone due to a lack of self-reliance and an unreasonable fear of being unable to care for oneself
• inability to remain independent of a close relationship as manifested by seeking a substitute support relationship immediately after one ends (e.g., a teenager who feels she must have a boyfriend constantly to validate her self-worth)
• unrealistic preoccupation with the thought of being left to care for oneself

Dependent personality disorder is more common in those who have suffered from chronic illness in childhood. A child may also exhibit dependent behavior in response to a specific stressful life event (such as the death of a caregiver or a divorce ). However, it should not be considered a potential symptom of dependent personality disorder unless the behavior becomes chronic and significantly interferes with day-to-day functioning and/or causes the child significant distress.

When to call the doctor

It is developmentally suitable for young children to go through "clingy" stages where overt dependent behavior on a parent or caregiver is commonplace. However, if dependency in a child or adolescent starts to interfere with school work, daily living, and the child's sense of self-esteem and well-being, parents should seek professional help from their child's doctor. If a child or teen indicates at any time that he/she has had recent thoughts of self-injury, suicide , or of inflicting harm on others, professional assistance from a mental health care provider or care facility should be sought immediately.

Diagnosis

Older teens or young adults who have demonstrated at least five of the DSM-IV-TR criteria (or symptoms) outlined above are eligible for a diagnosis of dependent personality disorder. In the DSM-IV-TR, the APA warns that a diagnosis of dependent personality disorder "should be used with great caution, if at all, in children and adolescents, for whom dependent behavior may be developmentally appropriate." Children are dependent on parents and other adults in their lives for support and physical and emotional safety by necessity; it is only when the behaviors are excessive and age inappropriate that a diagnosis of dependent personality disorder can be contemplated.

Treatment

The primary treatment for dependent personality disorder is psychotherapy, with an emphasis on learning to cope with anxiety , developing assertiveness, and improving decision-making skills. Group therapy can also be helpful. In cases where parents or other adult caregivers seem to be facilitating the behavior, therapy for them is also appropriate.

Prognosis

Dependent personality disorder frequently occurs in tandem with other personality-based mental illness, such as borderline, histrionic, and avoidant personality disorders . It is also believed that those diagnosed with dependent personality disorder are at an increased risk of mood and anxiety disorders.

Prevention

There is no known prevention strategy for dependent personality disorder. However, some tactics that can promote healthy socialization and positive self-esteem from an early age include encouraging healthy peer relationships, investing a child with increasing levels of age-appropriate responsibilities and independence, and offering choices to even the smallest children.

Parental concerns

Dependent personality disorder is an extremely rare diagnosis in children. Parents of children who have been diagnosed with dependent personality disorder may wish to seek a second opinion from a trained psychologist or psychiatrist specializing in pediatric care. Separation anxiety shares some common features with dependent personality disorder, and should be considered as a differential diagnosis.

KEY TERMS

Borderline personality disorder —A mental disorder characterized by mood swings, unstable interpersonal relationships, poor self-image, and self-destructive and impulsive behaviors.

Histrionic personality disorder —A mental disorder characterized by inappropriate attention-seeking behavior, rapid emotional shifts, and exaggerated expression of emotion.

Separation anxiety —Childhood fear of leaving parents for any reason.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Press, Inc., 2000.

PERIODICALS

Grant, BF et al. "Prevalence, correlates, and disability of personality disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions." Journal of Clinical Psychiatry. 65, no. 7 (July 2004): 948–58.

ORGANIZATIONS

The American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016–3007. (202) 966–7300. Web site: <www.aacap.org>.

National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892–9663. (301) 443–4513.

Paula Ford-Martin

Dependent personality disorder

A lack of self-confidence coupled with excessive dependence on others.

Persons affected by dependent personality disorder have a disproportionately low level of confidence in their own intelligence and abilities and have difficulty making decisions and undertaking projects on their own. Their pervasive reliance on others, even for minor tasks or decisions, makes them exaggeratedly cooperative out of fear of alienating those whose help they need. 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. Another common feature of the disorder is an exaggerated fear of being left to fend for oneself. Adolescents with dependent personality disorder rely on their parents to make even minor decisions for them, such as what they should wear or how they should spend their free time, as well as major ones, such as what college they should attend.

Dependent personality disorder occurs equally in males and females and begins by early adulthood. It may be linked to either chronic physical illness or separation anxiety disorder earlier in life. The primary treatment for dependent personality disorder is psychotherapy , with an emphasis on learning to cope with anxiety, developing assertiveness, and improving decision-making skills. Group therapy can also be helpful.

Further Reading

Costa, Paul T., and Thomas A. Widiger, eds. Personality Disorders and the Five-Factor Model of Personality. Washington, DC: American Psychological Association, 1994.

Friedland, Bruce. Personality Disorders. New York: Chelsea House, 1991.