206 Dependent Personality Disorder

DSM-IV-TR criteria

• A pervasive and excessive need to be taken are 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:

1. has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
2. needs others to assume responsibility for most major areas of his or her life
3. has difficulty expressing disagreement with others because of fear of loss of support or approval NOTE: Do not include realistic fears of retribution.
4. has difficulty initiating projects or doing things on his or her own (because of lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
5. goes to excessive lengths to obtain nurture and support from others, to the point of volunteering to do things that are unpleasant
6. feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
7. urgently seeks another relationship as a source of care and support when a close relationship ends
8. is unrealistically preoccupied with fears of being left to take care of himself or herself

Associated features

• Dependent individuals are often very pessimistic, self-defeating, and exhibit low self-esteem. They tend to belittle their assets and to refer to themselves as “stupid.” They take criticism very personally, seeing it as “proof” of their worthlessness. Their tendency is to seek out over protection and dominance from others. These individuals become very anxious when faced with a decision and may avoid positions of responsibility. Chronic physical illness or Separation Anxiety Disorder in childhood may predispose an individual to developing Dependent Personality Disorder.
• There may be an increased risk of Mood Disorders, Adjustment Disorder, and Anxiety Disorders.
• These individuals lack self confidence and lack a sense of autonomy. They see themselves as extremely weak and others very powerful. They are extremely dependent on others and have a great need to be taken care of, which makes these individuals cling to others and to be submissive to others’ wishes and demands. When one relationship ends, they become desperate and have to form another relationship to replace the broken one. Some individuals panic if they have to be alone or separated from depended-upon people.
• They do not demonstrate appropriate anger with other people because they are terrified of losing their support. As a result, they remain in psychologically and physically damaging and abusive relationships. They, in effect, lose their individuality because they let others make the decisions, both large and small in their lives.

Child vs. Adult Presentation

• This diagnosis is only cautiously given to children and adolescents, as some dependent behavior may be developmentally appropriate at this time.
• Symptoms in adults are very similar to Separation Anxiety in children.

Gender and Cultural Differences in Presentation

• Prevalence rates are significantly higher in India and Japan, possible because dependent behaviors is expected and encouraged, especially for women.
• Dependent Personality Disorder occurs more frequently in women, and is co-morbid with Borderline, Schizoid, Histrionic, Schizotypal, and Avoidant Personality disorders. There is also co-morbidity within the Axis I disorders of Bipolar Disorder, unipolar depression (or major depressive episode), anxiety disorders, and Bulimia Nervosa.

Epidemiology

• Dependent PD is one of the most reported Personality Disorders in mental health clinics and they do not give a percentage of prevalence. But a reasonable estimate is from 0.5% to 1.5% of people in the general population have this type of PD. There is around 1.4% in outpatient psychiatric settings; there are no significant familial problems.
• It is reported that about 10% of outpatients seen in mental health clinics also have Dependent PD (SAMHSA, 2009).

Etiology

• Parents who are more authoritative (holds very high standard for achievement and low in giving love and attention to the child) can cause person to develop Dependent PD because the person is not used to making their own choices and decisions. Parenting styles are authoritative, meaning many rules and chores.

• People with Dependent PD have very low sense of self-efficacy. There is restricted development of self-efficacy. They often don’t believe that they are able to do some things by themselves.
• Females diagnosed with Dependent PD generally have a history of depression or depressive symptoms in early adolescent girls.
• Peers may have responded to these individuals with rejection, teasing, and other remarks on their dependence and incompetence, thereby reinforcing the views conveyed by caregivers that the person with DPD is in dire need of constant care.
• Infantile temperament may be an additional variable that interacts with parenting style to further elicit overprotective and authoritarian responses to the individual child.

Empirically Supported Treatments

Psychotherapy

• Used as treatment for people with dependent personality disorder. Cognitive-behavioral therapy focuses on patterns of maladaptive thinking and seeks to eliminate them. Often people in cognitive-behavioral therapy set goals that they eventually try to achieve without relying on others. Interpersonal therapy is also a useful approach. Often the patient is receptive to the treatment and seeks help with their personal relationships. With this particular kind of therapy, the therapist will help the patient understand how they interact with others and how this contributes to their dependency issues. This particular therapies purpose is to show the patient that their dependency comes with a high price and that they do have alternatives. Another type of therapy used to treat dependent personality disorder is group therapy. Often people taking part in group therapy must be highly motivated to see improvement. Studies show that time-limited assertiveness-training groups with very clear goals are successful. It has also been said that family or martial therapy can improve a person’s independence by working on the families relationship as a whole.

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

• According to the encyclopedia of mental disorders, 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
• Antidepressants, anti-anxiety agents, sedatives, and tranquilizers.
• Dependency can eventually become an issue for someone using one of these medications, therefore most often they are not prescribed.

Prevention

• Since dependent personality disorder originates in the patient’s family, the only known preventive measure is a nurturing, emotionally stimulating, and expressive care giving environment

Portrayed in Popular Culture

• Bella/Edward relationship from Twilight
• They are completely dependent on each other to the point of being suicidal without the other
• Peter Pettigrew from Harry Potter

• The once friend of James Potter shifts the target of his submissive behavior from James and his friends to Voldemort and the Death Eaters.
• In The Prisoner of Azkaban, when his transgressions are revealed, Peter soon tries to gain anybody’s approval by groveling and pleading

DSM-V Changes

• Dependent Personality Disorder will be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
• Prominent Personality Traits
• Submissiveness, Anxiousness, Separation Insecurity (APA, 2010)