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Dependent Personality Disorder
Introduction
Dependent personality disorder describes a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors with fears of separation. The pattern of dependent behavior typically begins in late adolescence and early adulthood. The submissive behaviors stem from the self-perception of being unable to function adequately without the help of others and intentionally trying to evoke a caregiving response from others.[1]
The conceptualization of behavior and its origins dates back to the 5th century BC among ancient Chinese and Greek philosophers. These early philosophers surmised that temperament and personality traits derived from bodily components, such as the four humors described by the Hippocratic school. These concepts of the humoral influences on temperament continued to be utilized well into the 1700s.[2] When personality traits or behaviors become so pervasive they go against cultural norms, causing significant social and functional impairment, they may qualify as a disorder. In 1952, the American Psychiatry Association published the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), outlining seven separate personality disorders.[3]
The current version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) divides personality disorders into Cluster A, Cluster B, and Cluster C. Each cluster encompasses a distinct set of personality disorders with commonalities regarding symptoms, behaviors, and underlying psychological patterns.[4]
Cluster A refers to personality disorders with odd or eccentric characteristics. These include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Individuals within this cluster often exhibit social withdrawal, peculiar or paranoid beliefs, and difficulties forming close relationships.
Cluster B comprises personality disorders with dramatic, emotional, or erratic behaviors. This cluster includes antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. Individuals within this cluster often display impulsive actions, emotional instability, and challenges in maintaining stable relationships.
Cluster C consists of personality disorders with anxious and fearful characteristics. These include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Individuals within this cluster tend to experience significant anxiety, fear of abandonment, and an excessive need for control or perfectionism.
Despite the historical division of personality disorders into clusters, the literature does not consistently validate this approach.[5]
Etiology
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Etiology
There are limited high-quality, evidence-based studies on the etiology of personality disorders, which are complex and multifactorial. Biological factors may contribute to the development of personality. Genetic factors may be related to the development of personality disorders, as shown in twin and family studies of heritability, linkage studies, candidate gene association studies, genome-wide association studies, and polygenic analyses.[6]
Dependent personality disorder must be distinguished from personality traits arising from other medical conditions. Conditions associated with personality changes include head trauma, cerebrovascular accident, central nervous system neoplasms, epilepsy, neurosyphilis, multiple sclerosis, endocrine disorders, heavy metal poisoning, and HIV-associated neurocognitive disorders.[7]
If an individual has a childhood or adolescent history of chronic physical illness or persistent separation anxiety, it may predispose them to dependent personality disorder.
Psychoanalytic approaches to dependent personality disorder focus on unconscious processes, early childhood experiences, and the influence of internal conflicts.[8] Psychoanalyst Wilhelm Reich introduced the concept of "character armor," referring to defense mechanisms individuals develop to alleviate cognitive conflict arising from internal impulses and interpersonal anxiety.[9][10] Defense mechanisms associated with dependent personality disorder are avoidance, introjection, and regression.[10][11]
Personality is a unique pattern of behaviors that an individual adopts in response to constantly changing internal and external stimuli. It is a complex summation of biological, psychological, social, and developmental factors. Each personality is unique, even among people with a defined personality disorder. This uniqueness is broadly described as temperament. Temperament is a heritable and innate psychobiological characteristic contributing to personality development.[6][12] Temperament provides a framework for an individual's personality development. Temperament is further shaped through epigenetic mechanisms, such as life experiences, trauma, and socioeconomic conditions. These mechanisms are adaptive etiological factors in personality development.[13][14] Temperament traits include harm avoidance, novelty seeking, reward dependence, and persistence.
Harm avoidance involves a bias towards inhibiting behavior that would result in punishment or non-reward.[15] High harm avoidance is present in dependent personality disorder and results in fear of uncertainty, social inhibition, shy behavior, and avoidance of danger or the unknown. In comparison, low harm avoidance is evident in antisocial personality disorder, histrionic personality disorder, and borderline personality disorder.
Novelty seeking describes an inherent desire to initiate new activities likely to produce a reward signal.[16] Low novelty-seeking is characteristic of dependent personality disorder and results in uninquiring, isolative, and stoical behaviors.
Reward dependence describes the amount of desire to alter behaviors in response to social reward cues.[17] Low reward dependence results in isolative behaviors with little need for social reward. Dependent personality disorder is centered around high-reward dependence and the need for the approval of others.
Persistence describes maintaining behaviors despite frustration, fatigue, and limited reinforcement. Low persistence is associated with dependent personality disorder and presents as indolence, inactivity, and ease of frustration.[17][18]
Epidemiology
According to the DSM-5-TR, the estimated prevalence of dependent personality disorder based on Part II of the National Comorbidity Survey Replication was 0.6%. Based on data from the 2015 National Epidemiologic Survey on Alcohol and Related Conditions, the total prevalence of dependent personality disorder defined by the DSM-IV is 0.5%, which is lower than the other nine personality disorders. Dependent personality disorder appears to be more common among women (0.6%) than among men (0.4%).[19][20] Race and ethnicity show little difference among groups. Dependent personality disorder is more common in younger individuals, occurring in 0.9% of individuals aged 18 to 29. Prevalence in people older than 65 was 0.3%.[19]
Pathophysiology
The pathophysiology of dependent personality disorder is unknown. There are no genetic studies of dependent personality disorder. One small study showed white and gray matter abnormalities in young adult women with dependent personality disorder.[21]
History and Physical
The presentation of dependent personality disorder is variable. A thorough history of the illness, medical history, and social history is essential. The chief complaint may be related to anxiety or depression. Patients with dependent personality disorder tend to be fearful and introverted, and the psychiatric evaluation may be at the behest of a concerned family member.[22] During clinical interviews, patients with dependent personality disorder may lack self-confidence and may also hesitate to express themselves without seeking permission from a family member.[20][23] Clinicians working with individuals with dependent personality disorder should be aware of these communication patterns and create a supportive environment that fosters trust and encourages open expression. Establishing a nonjudgmental clinical atmosphere where individuals with dependent personality disorder feel safe to share their thoughts and feelings is crucial.[1]
Dependent personality disorder is distinguished by submissive, unassertive, and needy behavior. Patients feel a strong need for affirmation and care from others and are excessively worried about rejection or abandonment. Individuals with dependent personality disorder may go to great lengths to retain relationships, even when they are emotionally or physically abusive.[24] Clinicians should be alert for intimate partner violence, as patients with dependent personality disorder have a higher likelihood of being abused. Whether the increased incidence stems from selecting more abusive partners or from a higher tolerance for abuse in relationships remains unclear.[20][25]
The mental status examination is crucial in assessing individuals with dependent personality disorder. The specific elements and findings of the examination can vary depending on the individual. Assessment of patients should include:
- Appearance: General grooming and attire. Individuals with dependent personality disorder may dress according to others' choices and frequently seek approval for clothing and fashion decisions.
- Behavior: Frequently ask for approval from family regarding decisions and answers to questions.
- Speech: Individuals with dependent personality disorder may exhibit decreased speech due to shyness, but it is normal rate and tone.
- Affect: May have anxious affect, particularly in the perceived uncomfortable environment of a clinical evaluation when seeking approval from the clinician and any family present.
- Thought content: This may center around the fear of losing support from others. Thoughts of suicide, particularly in the context of fear of abandonment, may suggest borderline personality disorder rather than dependent personality disorder.
- Thought process: Expected to be linear but limited in range and logic with the structure of seeking the approval of others.
- Cognition: General cognition and orientation are not expected to be impaired.
- Insight: Usually poor and rather concrete.
- Judgment: Poor, as the frequent seeking of approval is usually unnecessary and can hinder the individual from making rational decisions.[26]
Evaluation
Individuals must meet the diagnostic criteria specified in the DSM-5-TR to diagnose dependent personality disorder formally. The diagnosis requires a thorough evaluation with multiple sources of information, including personal history, collateral information, and a mental status examination.
Diagnostic accuracy of a personality disorder is improved by longitudinal observation of an individual's behaviors in various circumstances to understand long-term functioning. Many personality disorder features can overlap with symptoms observed during acute psychiatric conditions and should be diagnosed when there is no concurrent acute psychiatric process.[27] Establishing a firm diagnosis of dependent personality disorder may require several visits with a patient.
Psychological testing such as the Minnesota Multiphasic Personality Inventory-2 and the Rorschach Perceptual Thinking Index may be used to verify the presence of a personality disorder.[28][29][30]
The DSM-5-TR Diagnostic Criteria forDependent Personality Disorder
A pervasive and excessive need to be taken care 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:
- Has difficulty making everyday decisions without excessive advice and reassurance from others.
- Needs others to assume responsibility for most major areas of his or her life.
- Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
- Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
- Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do unpleasant things.
- Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for oneself.
- Urgently seeks another relationship as a source of care and support when a close relationship ends.
- Is unrealistically preoccupied with fears of being left to care for himself or herself.
The 2022 International Classification of Diseases, Eleventh Revision (ICD-11) eliminated the categorical classes of personality disorders previously found in the ICD-10 that paralleled the DSM-5. The ICD-11 now has a single personality disorder diagnosis with different levels of severity, from mild to severe, based on the degree of dysfunction. The ICD-11 diagnosis may then be further described by one or more maladaptive personality traits such as negative affectivity, detachment, dissociality, disinhibition, borderline pattern, and anankastia.[31][32]
Treatment / Management
Research on the treatment and management of dependent personality disorder remains limited.[24] In patients with mixed cluster C disorders, one trial suggested that psychodynamic psychotherapy reduced distress and improved social function.[33] Another trial comparing short-term psychotherapy with cognitive therapy in patients with mixed cluster C disorders showed significant improvements in both groups.[34] Cognitive therapy may address maladaptive thinking patterns, enhance self-esteem, improve social skills, and challenge the need for reassurance and approval.[35] As dependent personality disorder is unlikely to remit with or without treatment, a focus of treatment may be reducing interpersonal stress and stabilizing socioeconomic conditions.[36](A1)
Randomized controlled trials of drug treatment for dependent personality disorder are lacking, and no FDA-approved medications are available for this condition. Treating comorbid conditions such as anxiety or depression with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may be helpful.[37][38]
Good psychiatric management includes making the diagnosis of dependent personality disorder, providing psychoeducation, articulating treatment goals, managing psychopharmacology, combining cognitive behavioral therapy and psychodynamic techniques, and offering practical suggestions for managing crises.[39]
Differential Diagnosis
The differential diagnosis of dependent personality disorder includes the following:
- Separation anxiety in adults, in which individuals are overly concerned about family members and pets and feel uncomfortable when separated from them, in contrast to individuals with dependent personality disorder who have intense fears of being unable to take care of themselves when alone.
- Other mental disorders where individuals are dependent, such as depressive disorders, panic disorder, agoraphobia, and other medical conditions.
- Other personality disorders and personality traits have features in common with dependent personality disorder. If a patient meets the criteria for more than one personality disorder, then those may be diagnosed in addition to dependant personality disorder. Certain personality disorders share features of dependent personality disorder, such as feelings of inadequacy, fear of abandonment, and a need for reassurance.[40] These can be delineated by how individuals with avoidant personality disorder withdraw from others, individuals with borderline personality disorder become emotional or enraged with fear of imagined or actual abandonment, and individuals with histrionic personality disorder flamboyantly seek attention.[41][42][43]
Pertinent Studies and Ongoing Trials
Research on the treatment and management of dependent personality disorder remains limited. Most current knowledge is based on older, small sample-size investigations, case reports, or case series. There are also significant limitations to the existing models for describing personality disorders. The cluster system is the most commonly used model based on the different editions of the Diagnostic and Statistical Manual of Mental Disorders. The uniqueness of each individual's personality also poses challenges for diagnosing and researching specific personality disorders.[5]
Experts in personality disorders have suggested switching to a dimensional model of personality rather than a cluster model. The proposed dimensional models are variously based on temperament, utilization of defense mechanisms, level of functioning, and pathological personality traits.[44] The DSM-5-TR includes an "Alternative DSM-5 Model for Personality Disorders," which no longer includes dependent personality disorder.[45][46]
Overlooked areas for research on dependent personality disorder are biological studies, cultural considerations, cognitive processes, use of community samples, and treatment.[1]
Prognosis
High-quality population studies to inform the prognosis of dependent personality disorder are lacking. Some research has shown that most personality disorder traits slowly remit with age. In the meantime, opportunities are lost, relationships suffer, and functioning is limited.[47][48] Clinical improvement of dependent personality disorder in the setting of therapy relies on the extent of insight the patient develops regarding their dependency and how it impacts their interpersonal and intrapersonal functioning.[39]
Complications
Dependent men have an increased risk of perpetrating domestic violence, and dependent men and women are more likely to engage in child abuse. Women with dependent personality disorder are more likely to be in multiple abusive relationships.[1] Dependent individuals are also at higher risk for parasuicide and suicide, especially when an important relationship ends.[1][25][39][49][50] Substance use disorders are common among individuals with personality disorders.[51] Individuals with dependent personality disorder may be at increased risk for depressive disorders, anxiety disorders, and adjustment disorders, as well as other personality disorders.
Deterrence and Patient Education
The treatment of dependent personality disorder depends on developing and maintaining a therapeutic alliance with the patient in a safe and supportive environment. Patients are encouraged to express the symptoms they wish to have addressed and communicate any psychosocial stressors that a treatment team can help alleviate. Rather than primarily focusing on changing the patient's worldview, clinicians should aim to understand and address the specific concerns and challenges that the patient is facing. This approach is particularly relevant when the patient is not in acute distress or crisis.[26]
Further, patients are encouraged to utilize support networks through their social relationships and expand on these as they develop comfort and confidence. Involving the patient's family is a way of monitoring for decompensation and providing education on how to provide stable social factors for the patient.[52] Utilizing standardized assessments for quality of life may reveal ways to optimize the ability to function in significant areas of life for an individual with dependent personality disorder.
Pearls and Other Issues
Good psychiatric management includes making the diagnosis of dependent personality disorder, providing psychoeducation, articulating treatment goals, managing psychopharmacology, combining cognitive behavioral therapy and psychodynamic techniques, and offering practical suggestions for managing crises.[39]
Enhancing Healthcare Team Outcomes
When a treatment team suspects that an individual has dependent personality disorder, a comprehensive history with collateral information and a mental status examination are recommended to clarify the diagnosis.[26] Including the patient's perspective and determining the appropriate care goals for an individual with dependent personality disorder is essential to prevent overmedicalization or iatrogenic harm to a patient who may not be suffering from any treatable symptoms. Collaboration with primary care providers, psychologists, social workers, therapists, and family to optimize the social factors in a patient's life can offer stability to individuals with dependent personality disorder.
Strong transference and countertransference reactions may develop within the treatment team. Some clinicians may experience rescue fantasies, requiring coordinated strategies among treatment team members for managing these complex interactions. Specifically, a tactful and direct approach that is nonjudgmental, empathic, and reality-based may help the individual manage his limitations while leaving room for improvement.[39]
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