Dependent personality disorder

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Overview
Dependent personality disorder (DPD), formerly known as asthenic personality disorder, is a personality disorder that is characterized by a pervasive psychological dependence on other people. The difference between a 'dependent personality' and a 'dependent personality disorder' is somewhat subjective, which makes a diagnosis sensitive to cultural influences such as gender role expectations.

Clinical interest in dependent personality disorder has existed since Karl Abraham first described the oral character. As a disorder, the personality type first appeared in a War Department technical bulletin in 1945 and later in the first edition of the Diagnostic and Statistical Manual in 1952 (American Psychiatric Association, 1952) as a subtype of passive-aggressive personality disorder. Since then, a surprising number of studies have upheld the descriptive validity of dependent personality traits, viewed as submissiveness, oral character traits, oral dependence, or passive dependence, or as a constellation of both pathological and adaptive traits under the rubric dependency.

Diagnostic criteria (DSM-IV-TR)
The DSM-IV-TR, a widely used manual for diagnosing mental disorders, defines dependent personality disorder as 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:
 * 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 (this does not include realistic fears of retribution)
 * 4) 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)
 * 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 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

Many cases of dependent also have roots to Obsessive-compulsive disorder, and instead of being afraid if they are alone when not in a relationship, tend to think everything is wrong.

Mnemonic
A mnemonic that can be used to remember the criteria for dependent personality disorder is DEPENDENT.
 * D – Difficulty making everyday decisions
 * E – Excessive lengths to obtain nurturance and support from others
 * P – Preoccupied with fears of being left to take care of self
 * E – Exaggerated fears of being unable to care for himself or herself
 * N – Needs others to assume responsibility for his or her life
 * D – Difficulty expressing disagreement with others
 * E – End of a close relationship is the beginning of another relationship
 * N – Noticeable difficulties in initiating projects or doing things on his or her own
 * T – “Take care of me” is his or her motto

Treatment Techniques
Treatment Techniques (Zimmerman, 1994, pp. 118-119) suggests the following questions when assessing individuals for DPD:
 * Some people enjoy making decisions. Others prefer to have someone they trust guide them. Which do you prefer?
 * Do you seek advice for everyday decisions?
 * Do you find yourself in situations where other people have made decisions about important areas in your life, e.g. what job to take?
 * Is it hard for you to express a different opinion with someone you are close to? What do you think might happen if you did?
 * Do you often pretend to agree with others even if you do not? Why?
 * Do you often need help to get started on a project?
 * Do you ever volunteer to do unpleasant things for others so they will take care of you when you need it?
 * Are you uncomfortable when you are alone? Are you afraid you will not be able to take care of yourself?
 * Have you found that you are desperate to get into another relationship right away when a close relationship ends? Even if the new relationship might not be the best person for you?
 * Do you worry about important people in your life leaving you?

Treatment Goals
Adler (Adler, ed., 1990, pp. 26-28) suggests that treatment goals for all personality disorders include: preventing further deterioration, regaining an adaptive equilibrium, alleviating symptoms, restoring lost skills, and fostering improved adaptive capacity. Goals may not necessarily include characterological restructuring. The focus of treatment is adaptation, i.e., how individuals respond to the environment. Treatment interventions teach more adaptive methods of managing distress, improving interpersonal effectiveness, and building skills for affective regulation. For individuals with DPD, the goal of treatment is not independence but autonomy. Autonomy has been defined as the capacity for independence and the ability to develop intimate relationships (Beck & Freeman, 1990, p. 291). Sperry (1995, p. 86 - 91) suggests that the basic goal for DPD treatment is self-efficacy. Individuals with DPD must recognize their dependent patterns and the high price they pay to maintain those patterns. This allows them to explore alternatives. The long-range goal is to increase DPD individuals' sense of independence and ability to function. Clients with DPD must build strength rather than foster neediness (Benjamin, 1993, p. 238). As with other personality disorders, treatment goals should not be in contradiction to the basic personality and temperament of these individuals. They can work toward a more functional version of those characteristics that are intrinsic to their style. Oldham (1990, p. 104) suggests seven traits and behaviors of the "devoted personality style," i.e, the non-personality-disordered version of DPD:
 * ability to make commitments;
 * enjoyment of intimacy;
 * skills as a team player -- without need to compete with the leader;
 * willingness to seek the opinions and advice of others;
 * ability to promote interpersonal harmony;
 * thoughtfulness and consideration for others; and,
 * willingness to self-correct in response to criticism.

Group Psychotherapy
Several reports suggest that group psychotherapy can be successful for the treatment of dependent personality disorder. Montgomery used group therapy for dependent patients who used medications for chronic complaints such as insomnia and nervousness. All but 3 of 30 patients eventually discontinued medications and began to confront their anger at being dependent on the therapist.

Sadoff and Collins administered weekly group psychotherapy to 22 patients who stuttered, most of whom had passive-dependent traits. Although the dropout rate was high, the authors found that the interpretation of passive-dependent behavior and attitudes (e.g., asking for help, believing that others are responsible for helping them) as a defense against recognizing and expressing anger proved helpful. Both stuttering and passive dependency improved in 2 patients who became angry and were able to confront their anger.

Torgersen studied college students who attended a weekend-long encounter group. On follow-up several weeks later, individuals who initially scored high on dependent traits had mixed responses. Although the group experience left them feeling disturbed and anxious, they also reported becoming more accepting of their own feelings and opinions. No other changes were found.

Attrition tends to be higher in group than in individual therapy for personality disorders but may be less of a problem for individuals with dependent personality disorder. Budman et al. reported moderate improvements after an 18-month group for personality disorders (10% with dependent personality disorder), with some changes not beginning until after 6 months.

These reports suggest the usefulness of group psychotherapy for dependent personality disorder. Most clinicians use weekly sessions of an hour to an hour and a half. Treatment generally lasts several years.

Biological Therapies
Four studies have explored the use of medications in the treatment of dependent personality disorder, and two studies have investigated their use in the treatment of dependent traits. Diagnostic and other limitations of the studies prevent firm conclusions about the efficacy of medications.

Klein and colleagues compared placebo with either imipramine or chlorpromazine in hospitalized patients with passive-aggressive and passive-dependent personality disorders that had been diagnosed according to DSM criteria. None of the patients showed a positive drug response.

Patients with major depressive disorder and an anxious-cluster personality disorder, many with dependent personality disorder, showed significant improvement in depression with imipramine or psychotherapeutic treatment. Fewer patients with Cluster C disorders fully recovered, however, and social adjustment problems remained.

Tyrer et al. drew a similar conclusion after studying patients with "general neurotic syndrome," which includes mixed anxiety-depression and dependent or obsessive personality. Although such patients initially appeared to be as responsive as others to 10-week treatments, including dothiepin (an antidepressant), diazepam, placebo, cognitive-behavioral therapy, or self-help, at 2-year follow-up, they had greater symptom levels and did significantly worse than other outpatients.

Ekselius and von Knorring studied 145 depressed patients, 61% of whom scored in the personality disorder range by self-report questionnaire, who received sertraline or citalopram for 24 weeks. From baseline to termination, the percentage above the cutoff score for dependent personality disorder improved significantly (21% versus 8%) as did the mean number of dependent personality disorder criteria met by the whole sample (3.3 versus 2.3). The self-reported change in dependent personality disorder criteria was significant, even after controlling for change in observer-rated depressive symptoms. Although the comparison across two different measurement perspectives complicates these findings, self-reported dependent symptoms seem to improve with 24 weeks of selective serotonin reuptake inhibitor treatment. Whether this generalizes to observer-rated improvement in life functioning is unknown.

Residential and Day Treatment Therapies
Although hospitalization is sometimes necessary for the treatment of an Axis I disorder in individuals with dependent personality disorder, residential treatments are generally not indicated. However, residential and day treatment may provide support necessary to allow definitive psychotherapy to continue, when dependent personality disorder is complicated by recurrent depression, severe anxiety disorders, repetitive suicide attempts, other more severe personality disorders (such as borderline personality) or overwhelming life stress.

Several day treatment and residential programs for severe personality disorders have included individuals with dependent personality disorder. Active treatment days varied from 4 to 5 days per week over a range of 17-30 weeks and usually involved both group and individual sessions, most within a dynamic framework. All had moderate to large effect sizes. Piper et al. (1993) conducted a randomized controlled trial and found significantly greater changes in the day treatment than in the control groups. These data suggest a valuable role for these modalities when dependent personality disorder is not responsive to other outpatient therapies.

Medication Issues
There is little evidence to suggest that the use of medication will result in long-term benefits in the personality functioning of individuals with DPD (Perry, Gabbard & Atkinson, eds., 1996, p. 998). DPD is not amenable to pharmacological measures; treatment relies upon verbal therapies (Stone, 1993, pp. 341-343). It is recommended that target symptoms rather than specific personality disorders be medicated. One of these target symptoms of particular importance is dysphoria -- marked by low energy, leaden fatigue, and depression. Dysphoria can also be associated with a craving for chocolate and for stimulants, e.g. cocaine. DPD is one of the most vulnerable personality disorders to dysphoria and some individuals with DPD respond well to antidepressant medications (Ellison & Adler, Adler, ed., 1990, p. 53). People with DPD are prone to both depressive and anxiety disorders. Stone (1993, pp. 341-343) suggests that these individuals may respond well to benzodiazepines in a crisis. However, clients with DPD are likely to abuse anxiolytics and their use should be limited and monitored with caution (Sperry, 1995, pp. 93-94). Unfortunately, individuals with DPD tend to be appealing clients. They are not inclined to be demanding and provocative. This can be precisely why they are given benzodiazepines by psychiatrists who may feel both benevolent and protective. Their inclination to use denial and escape to manage their lives makes the use of sedative-hypnotics familiar and pleasant. Iatrogenic addiction is a serious concern.

View of Others
Individuals with DPD see other people as much more capable to shoulder life's responsibilities, to navigate a complex world, and to deal with the competitions of life (Millon, 1981, p. 114). Other people are powerful, competent, and capable of providing a sense of security and support to individuals with DPD. Dependent individuals avoid situations that require them to accept responsibility for themselves; they look to others to take the lead and provide continuous support (Richards, 1993, p. 243). DPD judgment of others is distorted by their inclination to see others as they wish they were rather than as they are (Kantor, 1992, p. 172). These individuals are fixated in the past. They maintain youthful impressions; they retain unsophisticated ideas and childlike views of the people toward whom they remain totally submissive (Millon & Davis, 1996, p. 333). Individuals with DPD view strong caretakers, in particular, in an idealized manner; they believe they will be all right as long as the strong figure upon whom they depend is accessible (Beck & Freeman, 1990, p. 44).

Self-Image
Individuals with DPD see themselves as inadequate and helpless; they believe they are in a cold and dangerous world and are unable to cope on their own. They define themselves as inept and abdicate self-responsibility; they turn their fate over to others. These individuals will decline to be ambitious and believe that they lack abilities, virtues and attractiveness (Beck & Freeman, 1990, p. 290) (Millon, 1981, pp. 113- 114). The solution to being helpless in a frightening world is to find capable people who will be nurturing and supportive toward those with DPD. Within protective relationships, individuals with DPD will be self-effacing, obsequious, agreeable, docile, and ingratiating. They will deny their individuality and subordinate their desires to significant others. They internalize the beliefs and values of significant others. They imagine themselves to be one with or a part of more powerful and supporting others. By seeing themselves as protected by the power of others, they do not have to feel the anxiety attached to their own helplessness and impotence (Millon & Davis, 1996, pp. 325-334). However, to be comfortable with themselves and their inordinate helplessness, individuals with DPD must deny the feelings they experience and the deceptive strategies they employ. They limit their awareness of both themselves and others. Their limited perceptiveness allows them to be naive and uncritical (Millon & Davis, 1996, pp. 333-334). Their limited tolerance for negative feelings, perceptions, or interaction results in the interpersonal and logistical ineptness that they already believe to be true about themselves. Their defensive structure reinforces and actually results in verification of the self-image they already hold.

Relationships
Individuals with DPD see relationships with significant others as necessary for survival. They do not define themselves as able to function independently; they have to be in supportive relationships to be able to manage their lives. In order to establish and maintain these life-sustaining relationships, people with DPD will avoid even covert expressions of anger. They will be more than meek and docile; they will be admiring, loving, and willing to give their all. They will be loyal, unquestioning, and affectionate. They will be tender and considerate toward those upon whom they depend (Millon, 1981, p. 114). Dependent individuals play the inferior role to the superior other very well; they communicate to the dominant people in their lives that they are useful, sympathetic, strong, and competent (Millon, 1981, p. 114). With these methods, individuals with DPD are often able to get along with unpredictable, isolated, or unpleasant people (Kantor, 1992, p. 170). To further make this possible, individuals with DPD will approach both their own and others' failures and shortcomings with a saccharine attitude and indulgent tolerance (Millon, 1981, p. 113). They will engage in a mawkish minimization, denial, or distortion of both their own and others' negative, self-defeating, or destructive behaviors to sustain an idealized, and sometimes fictional, story of the relationships upon which they depend. They will deny their individuality, their differences, and ask for little other than acceptance and support (Millon & Davis, 1996, p. 332).

Not only will individuals with DPD subordinate their needs to those of others, they will meet unreasonable demands and submit to abuse and intimidation to avoid isolation and abandonment (Millon, 1981, pp.107-108). Dependent individuals so fear being unable to function alone that they will agree with things they believe are wrong rather than risk losing the help of people upon whom they depend (DSM-IV, 1994, p. 665). They will volunteer for unpleasant tasks if that will bring them the care and support they need. They will make extraordinary self-sacrifices to maintain important bonds (DSM-IV, 1994, pp. 665-666). It is important to note that individuals with DPD, in spite of the intensity of their need for others, do not necessarily attach strongly to specific individuals, i.e., they will become quickly and indiscriminately attached to others when they have lost a significant relationship (DSM-IV, 1990, p. 666). It is the strength of the dependency needs that is being addressed; attachment figures are basically interchangeable. Attachment to others is a self-referenced and, at times, haphazard process of securing the protection of the most readily available powerful other willing to provide nurturance and care. Both DPD and HPD are distinguished from other personality disorders by their need for social approval and affection and by their willingness to live in accord with the desires of others. They both feel paralyzed when they are alone and need constant assurance that they will not be abandoned. Individuals with DPD are passive individuals who lean on others to guide their lives. People with HPD are active individuals who take the initiative to arrange and modify the circumstances of their lives. They have the will and ability to take charge of their lives and to make active demands on others (Millon & Davis, 1996, p. 325).