Dependent personality disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM) contains a dependent personality disorder diagnosis. It refers to a pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of separation. This begins by early adulthood and can be present in a variety of contexts.[9]

In the DSM Fifth Edition (DSM-5), there is one criterion by which there are eight features of dependent personality disorder. The disorder is indicated by at least five of the following factors:[10]

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 their life.
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval.
4. Has difficulty initiating projects or doing things on their own (because of a lack of self confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance 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 themselves.
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 themselves.[11]

The diagnosis of personality disorders in the fourth edition Diagnostic and Statistical Manual of Mental Disorders, including dependent personality disorder, was found to be problematic due to reasons such as excessive diagnostic comorbidity, inadequate coverage, arbitrary boundaries with normal psychological functioning, and heterogeneity among individuals within the same categorial diagnosis.[12]

The World Health Organization's ICD-10 lists dependent personality disorder as F60.7 Dependent personality disorder:[13]

It is characterized by at least 4 of the following:

1. Encouraging or allowing others to make most of one's important life decisions;
2. Subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes;
3. Unwillingness to make even reasonable demands on the people one depends on;
4. Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself;
5. Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;
6. Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.

Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina.

Includes:

• Asthenic, inadequate, passive, and self-defeating personality (disorder)

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

The SWAP-200 is a diagnostic tool that was proposed with the goal of overcoming limitations, such as limited external validity for the diagnostic criteria for dependent personality disorder, to the DSM. It serves as a possible alternative nosological system that emerged from the efforts to create an empirically based approach to personality disorders - while also preserving the complexity of clinical reality.[10] Dependent personality disorder is considered a clinical prototype in the context of the SWAP-200. Rather than discrete symptoms, it provides composite description characteristic criteria - such as personality tendencies.[10]

Based on the Q-Sort method and prototype matching, the SWAP-200 is a personality assessment procedure relying on an external observer's judgment. It provides:

• A personality diagnosis expressed as the matching with ten prototypical descriptions of DSM-IV personality disorders.
• A personality diagnosis based on the matching of the patient with 11 Q-factors of personality derived empirically.
• A dimensional profile of healthy and adaptive functioning.[10]

The traits that define dependent personality disorder according to SWAP-200 are:

1. They tend to become attached quickly and/or intensely, developing feelings and expectations that are not warranted by the history or context of the relationship.
2. Since they tend to be ingratiating and submissive, people with DPD tend to be in relationships in which they are emotionally or physically abused.
3. They tend to feel ashamed, inadequate, and depressed.
4. They also feel powerless and tend to be suggestible.
5. They are often anxious and tend to feel guilty.
6. These people have difficulty acknowledging and expressing anger and struggle to get their own needs and goals met.
7. Unable to soothe or comfort themselves when distressed, they require involvement of another person to help regulate their emotions.[10]

The Psychodynamic Diagnostic Manual (PDM) approaches dependent personality disorder in a descriptive, rather than prescriptive sense and has received empirical support. The Psychodynamic Diagnostic Manual includes two different types of dependent personality disorder:[10]

1. Passive-aggressive
2. Counter-dependent [10]

The PDM-2 adopts and applies a prototypic approach, using empirical measures like the SWAP-200. It was influenced by a developmental and empirically grounded perspective, as proposed by Sidney Blatt.[10] This model is of particular interest when focusing on dependent personality disorder, claiming that psychopathology comes from distortions of two main coordinates of psychological development:

1. The anaclitic/introjective dimension.
2. The relatedness/self-definition dimension.[10]

The anaclitic personality organization in individuals exhibits difficulties in interpersonal relatedness, exhibiting the following behaviours:

• Preoccupation with relationships
• Fear of abandonment and of rejection
• Seeking closeness and intimacy
• Difficulty managing interpersonal boundaries
• Tend to have an anxious-preoccupied attachment style.[10]

Introjective personality style is associated with problems in self-definition.[10]

There are similarities between individuals with dependent personality disorder and individuals with borderline personality disorder, in that they both have a fear of abandonment. Those with dependent personality disorder do not exhibit impulsive behaviour, unstable affect, and poor self-image experienced by those with borderline personality disorder, differentiating the two disorders.[14]

The following conditions commonly coexist (comorbid) with dependent personality disorder:[15]

• mood disorders
• anxiety disorders
• adjustment disorder
• borderline personality disorder
• avoidant personality disorder
• histrionic personality disorder

Psychologist Theodore Millon identified five adult subtypes of dependent personality disorder.[19][20] Any individual dependent may exhibit none or one of the following:

• Beck, Aaron T; Freeman, Arthur (1990). Cognitive Therapy of Personality Disorders. New York: Guilford Press. ISBN 978-0-89862-434-2.
• Millon, Theodore; Davis, Roger Dale (1996). Disorders of Personality: DSM-IV and Beyond. New York: Wiley. ISBN 978-0-471-01186-6.
• Millon, Theodore (1981). Disorders of Personality: DSM-III, Axis II. New York: Wiley. ISBN 978-0-471-06403-9.
• Perry, J. C. (1996). "Dependent personality disorder". In Gabbard, Glen O.; Atkinson, Sarah D. (eds.). Synopsis of Treatments of Psychiatric Disorders. American Psychiatric Press. pp. 995–8. ISBN 978-0-88048-859-4.
• Gjerde, L. C.; Czajkowski, N.; Røysamb, E.; Ørstavik, R. E.; Knudsen, G. P.; Østby, K.; Torgersen, S.; Myers, J.; Kendler, K. S.; Reichborn-Kjennerud, T. (2012). "The heritability of avoidant and dependent personality disorder assessed by personal interview and questionnaire". Acta Psychiatrica Scandinavica. 126 (6): 448–57. doi:10.1111/j.1600-0447.2012.01862.x. PMC 3493848. PMID 22486635. Lay summary – Norwegian Institute of Public Health (September 24, 2012).
• Millon, Theodore; Millon, Carrie M.; Meagher, Sarah; Grossman, Seth; Ramnath, Rowena (2004). Personality Disorders in Modern Life. Wiley. ISBN 978-0-471-66850-3.
• Millon, Theodore (2006). "Personality Subtypes".
• Kantor, Martin (1992). Diagnosis and Treatment of the Personality Disorders. Ishiyaku EuroAmerica. ISBN 978-0-912791-89-0.
• Ellison, J. M.; Adler, D. A. (1990). "A strategy for the pharmacotherapy of personality disorders". In Adler, David A. (ed.). Treating Personality Disorders. San Francisco: Jossey-Bass. pp. 43–63. ISBN 978-1-55542-811-2.
• Adler, David A., ed. (1990). Treating Personality Disorders. San Francisco: Jossey-Bass. ISBN 978-1-55542-811-2.
• Richards, Henry Jay (1993). Therapy of the Substance Abuse Syndromes. New York: Jason Aronson. ISBN 978-0-87668-539-6.
• Zimmerman, Mark (1994). Diagnosing DSM-IV-R Psychiatric Disorders in Primary Care Settings: An Interview Guide for the Nonpsychiatrist Physician. Psych Products. ISBN 978-0-9633821-3-9.
• Ekleberry, Sharon (2014). "Dependent Personality Disorder (DPD)". Treating Co-Occurring Disorders. pp. 63–4. ISBN 978-1-317-82549-4.
• Oldham, John M.; Morris, Lois B. (1990). The Personality Self-portrait: Why You Think, Work, Love, and Act the Way You Do. Bantam. ISBN 978-0-553-05757-7.
• Sperry, Len (1995). Psychopharmacology and Psychotherapy: Strategies for Maximizing Treatment Outcomes. Psychology Press. ISBN 978-0-87630-787-8.
• Stone, Michael H. (1993). Abnormalities of Personality: Within and Beyond the Realm of Treatment. Norton. ISBN 978-0-393-70127-2.
• Benjamin, Lorna Smith (1993). Interpersonal Diagnosis and Treatment of Personality Disorders. Guilford Press. ISBN 978-0-89862-990-3.
• Benjamin, Lorna Smith (1996). "Dependent Personality Disorder". Interpersonal Diagnosis and Treatment of Personality Disorders. Guilford Press. pp. 221–39. ISBN 978-0-89862-990-3.