What is Dependent Personality Disorder?
Dependent personality disorder is a condition where a person relies excessively on others and exhibits needy and clingy behavior due to a fear of being alone. This dependency often starts to show during late teenage years or early adulthood and arises from a person’s belief that they can’t function properly without the help of others.
These ideas about behavior and its roots date back to ancient times, when Chinese and Greek philosophers believed that our personality traits came from physical parts of our bodies, such as the four human “humors” or body fluids described by Hippocrates. These theories continued to be used up until the 1700s. When such behaviors or traits become so intense that they go against the norms of society and severely impact social and practical abilities, they may be considered as a disorder. In 1952, the American Psychiatry Association identified seven different personality disorders in its first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The latest version of this reference guide, the DSM-5-TR, categorizes personality disorders into three groups, known as Clusters A, B, and C. Each cluster has a different set of personality disorders that share similar symptoms, behaviors, and psychological patterns.
Cluster A includes personality disorders marked by strange or unusual traits. These disorders, such as paranoid, schizoid, and schizotypal personality disorders, are often associated with social isolation, peculiar or paranoid beliefs, and difficulty forming close relationships.
Cluster B includes personality disorders characterized by dramatic, emotional, or unpredictable behaviors. The disorders in this cluster include antisocial, borderline, histrionic, and narcissistic personality disorders, and are often associated with impulsive behavior, emotional instability, and trouble maintaining stable relationships.
Cluster C, which includes dependent personality disorder, encompasses personality disorders with anxious and fearful traits. Also in this category are avoidant and obsessive-compulsive personality disorders, which are characterized by high levels of anxiety, a fear of abandonment, and an excessive need for control or perfection.
However, it’s important to note that categorizing personality disorders into these clusters is still a topic of debate, as research doesn’t always support this approach.
What Causes Dependent Personality Disorder?
There is limited high-quality research on the causes of personality disorders, which are complicated and have many different factors at play. Biological factors, including genetics, have an important role in shaping our personalities. This has been seen in various types of studies, which show a genetic link to the development of personality disorders.
The condition called ‘dependent personality disorder’ needs to be separated from personality traits that come from other medical issues. There are many conditions that could lead to changes in personality such as injuries to the head, stroke, tumors in the central nervous system, epilepsy, infections such as syphilis, multiple sclerosis, hormone-related disorders, toxic metal poisoning, and disorders related to HIV affecting cognitive function.
If someone has a history of long-term physical illness during childhood or adolescent or has suffered from persistent anxiety due to being separated from loved ones, it can make them more likely to develop dependent personality disorder.
The psychological approach to understanding dependent personality disorder considers the unconscious mind, early childhood experiences, and the effect of internal conflicts. The concept of ‘character armor’, coined by psychoanalyst Wilhelm Reich, is seen as a key defense mechanism people develop to reduce internal conflict and anxiety caused by interacting with others. These defenses can be seen in avoidance, introjection (in which the ideas and emotions of others are ‘absorbed’ into a person’s self), and regression (reverting to a more immature state of behavior).
A person’s personality can be seen as a unique blend of behaviors created in response to their changing internal state and the world around them, driven by biological, psychological, social, and developmental factors. Each personality is unique, even among people with defined personality disorders. This uniqueness is largely due to a person’s temperament, which is a set of inherent psychological traits that help shape a person’s personality. These traits, which include harm avoidance, novelty seeking, reward dependence, and persistence, can be further influenced by life experiences, socioeconomic factors, and trauma.
‘Harm avoidance’ is a temperament trait that influences how cautious a person is in avoiding situations that can potentially cause harm. People with high harm avoidance tend to avoid uncertainty, exhibit shy behavior, and avoid risky situations and unsafe environments. Dependent personality disorder often shows high harm avoidance. Some other personality disorders, like antisocial, histrionic, and borderline, show low harm avoidance.
The temperament trait of ‘novelty seeking’ refers to the desire to try out new activities that could yield a reward. In dependent personality disorder, novelty seeking is often low, leading to behaviors such as being isolated and stoic.
‘Reward dependence’ is the desire to adapt behaviors based on social reward signals. Low reward dependence results in behaviors with little need for social reward. However, dependent personality disorder often involves high reward dependence and the need for approval from others.
The trait of ‘persistence’ refers to maintaining behaviors despite frustration, fatigue, and limited reinforcement. Low persistence is linked to dependent personality disorder and manifests as laziness, lack of activity, and a tendency to quickly feel frustrated.
Risk Factors and Frequency for Dependent Personality Disorder
Dependent personality disorder is a condition characterized by over-reliance on others for emotional or physical needs. The prevalence of the disorder varies according to different surveys and interpretations of diagnostic guidelines. Here are some key points to know:
- According to a particular part of the National Comorbidity Survey Replication, the frequency of this disorder is about 0.6%.
- In the 2015 National Epidemiologic Survey on Alcohol and Related Conditions, which used different diagnostic standards (DSM-IV), found the prevalence to be a little lower at 0.5%. This is lower than the rates of other personality disorders.
- The disorder is slightly more common in women (0.6%) than in men (0.4%).
- Race and ethnicity do not seem to greatly influence the prevalence of the disorder.
- The disorder tends to be more common in younger adults, with a prevalence of 0.9% in individuals aged 18 to 29. In older people above the age of 65, the prevalence drops to 0.3%.
Signs and Symptoms of Dependent Personality Disorder
Dependent personality disorder (DPD) is a mental health condition that presents in various ways. Gathering an extensive history of the disorder, as well as the person’s medical and social background, is important. Since individuals with DPD often struggle with self-confidence, they may be reluctant to discuss their feelings without a family member present. Healthcare providers need to be aware of this communication pattern and strive to create a trustworthy and supportive atmosphere, encouraging individuals to openly express their thoughts and feelings.
Individuals with DPD tend to display submissive and needy behavior, always seeking affirmation and care from others. They worry excessively about rejection or abandonment and may put significant effort into maintaining relationships, even if those relationships are emotionally or physically harmful. Clinicians should be on the lookout for signs of abuse in these patients, but it is unclear whether the higher incidence of abuse is due to the individual’s tendency to form relationships with more abusive partners or if they have a higher tolerance for abuse.
A mental status examination plays a crucial role in evaluating individuals with DPD. This examination should include:
- Appearance: Observing personal grooming and clothing choices. Individuals with DPD may dress based on the preferences of others and often seek approval for their clothing and fashion decisions.
- Behavior: Noting whether they often seek approval from family members for their decisions and responses to questions.
- Speech: Checking if they have a decreased speech rate due to shyness but maintain a normal tone.
- Affect: Looking for signs of anxiety, particularly during the clinical evaluation when they might be seeking approval from the clinician and any family present.
Their thought content might revolve around the fear of losing others’ support. Thoughts of suicide could point towards a borderline personality disorder, particularly if they stem from the fear of abandonment. Their thought process is anticipated to be linear but restricted in range and logic, with the structure of seeking others’ approval. General cognition and orientation are not expected to be affected, but their insight is usually poor. Their judgement is also seen as poor, as the frequent seeking of approval can hinder the individual from making rational decisions.
Testing for Dependent Personality Disorder
To formally diagnose dependent personality disorder, several criteria specified in the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision), a manual used by healthcare professionals worldwide to diagnose psychiatric conditions, must be met. The process involves multiple information sources, including a person’s history, information from people close to them, and a mental health examination.
A more accurate diagnosis of a personality disorder is achieved by observing a person’s behavior over time in different situations. This helps understand the long-term pattern of their behavior. Features of personality disorder can sometimes seem similar to symptoms seen in acute psychiatric conditions. Thus, a person should be diagnosed with dependent personality disorder when there is no other existing severe mental health condition. Establishing a firm diagnosis may require several visits with a patient.
Tools like the Minnesota Multiphasic Personality Inventory-2 and the Rorschach Perceptual Thinking Index could also be employed to confirm if a personality disorder is present.
The DSM-5-TR stipulates some criteria for diagnosing Dependent Personality Disorder:
- Has difficulty making everyday decisions without excessive advice and reassurance from others.
- Needs others to assume responsibility for most major areas of life.
- Finds it hard to disagree with others because of fear of loss of support or approval.
- Struggles to start or carry out tasks on their own due to a lack of self-belief in their abilities.
- Goes to great lengths to receive nurturance and support from others, even going to the extent of volunteering for unpleasant tasks.
- Feels uncomfortable or helpless when alone due to exaggerated fears of being unable to take care of oneself.
- Seeks another close relationship urgently as a pillar of care and support when a close relationship ends.
- Has unrealistic fears of having to take care of oneself.
In a recent update, the International Classification of Diseases, Eleventh Revision (ICD-11), no longer identifies specific categories of personality disorders (like the DSM-5 does). Instead, it operates with a single diagnosis of personality disorder, with different severity levels. The diagnosis is determined by the level of dysfunction, from mild to severe. Once diagnosed, the ICD-11 may describe the personality disorder further by using certain maladaptive personality traits, such as negative affectivity, detachment, dissociality, disinhibition, borderline pattern, and anankastia.
Treatment Options for Dependent Personality Disorder
There are limited studies available on treating dependent personality disorder. In patients with a variety of similar personality disorders, one study suggested that a type of therapy called psychodynamic psychotherapy was beneficial. Pyschodynamic therapy involves exploring the full range of the patient’s emotions and sorting through them to reduce distress and improve their social function.
Another study compared short-term psychotherapy with cognitive therapy, a type of therapy where a mental health counselor helps the patient become aware of inaccurate or negative thinking. They found considerable improvement in both groups. This approach might help patients by highlighting unhealthy thinking patterns, improving self-confidence, enhancing social skills, and tackling the need for reassurance and acceptance. But since dependent personality disorder may not improve significantly with any treatment, the main aim is often to reduce interpersonal stress and stabilize the patient’s living conditions.
Drug treatments for dependent personality disorder are not well-studied, and there aren’t any medications specifically approved by the Food and Drug Administration (FDA) for this disorder. However, any co-existing mental health conditions such as anxiety or depression can be treated with a class of drugs called selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications work by increasing the level of certain chemicals in the brain that help improve mood.
Potential strategies for managing dependent personality disorder may entail getting a proper diagnosis, teaching patients about their condition (psychoeducation), defining treatment goals, managing various medications (psychopharmacology), combining cognitive-behavioral therapy and psychodynamic techniques, and providing practical advice to manage crises.
What else can Dependent Personality Disorder be?
When looking at a diagnosis of dependent personality disorder, there are other conditions that may be considered, such as:
- Separation anxiety disorder in adults. This is where the individual has a huge concern for family members or pets and doesn’t like to be apart from them. This is different from dependent personality disorder, where there is a strong fear of being unable to care for themselves if they’re alone.
- Other mental health conditions that involve dependency, including depressive disorders, panic disorder, agoraphobia, and certain other medical conditions.
Dependent personality disorder may share features with other personality disorders or personality traits. If a patient fits the criteria for multiple personality disorders, they may be diagnosed with all of them. For instance, certain personality disorders share traits such as feelings of inadequacy, fear of being abandoned, and needing reassurance. These are present in all, but behave differently depending on the disorder:
- People with avoidant personality disorder withdraw from others.
- Those with borderline personality disorder can become emotional or angry out of fear of imagined or real abandonment.
- People with histrionic personality disorder make grand, attention-seeking gestures.
What to expect with Dependent Personality Disorder
There is a lack of extensive research studies on the long-term outlook for people with dependent personality disorder. However, some researchers suggest that traits of this disorder may gradually improve as a person gets older. But while this happens, people might miss various opportunities, their relationships may be strained, and the ability to function in daily life can be hindered.
The success of therapy in the treatment for dependent personality disorder is linked to the extent to which a person can understand their tendencies towards dependency and how this affects their relationships and personal functioning.
Possible Complications When Diagnosed with Dependent Personality Disorder
Men who depend heavily on others are more likely to become perpetrators of domestic violence, while both men and women with dependency issues might engage in child abuse. Women suffering from dependency issues often find themselves in multiple abusive relationships.
People who are overly dependent on others also run a greater risk of attempting or committing suicide, especially if a significant relationship in their life ends.
It has been observed that people with personality disorders often suffer from substance abuse. Those with a dependency personality disorder are also more prone to suffer from depression, anxiety, or adjustment disorders. They may even have other personality disorders.
Below is a list of potential risks:
- Domestic violence
- Child abuse
- Multiple abusive relationships
- Risk of suicide or attempted suicide if a crucial relationship ends
- Substance abuse disorders
- Increased likelihood of suffering from depression, anxiety, or adjustment disorders
- Potential to have other personality disorders
Preventing Dependent Personality Disorder
In treating dependent personality disorder, it’s crucial to build and maintain a relationship of trust between the patient and their healthcare team. This process should take place in an environment that is safe, supportive, and encourages open communication. Patients are encouraged to freely express the symptoms they wish to address and any stressful life issues that the healthcare team can assist with.
Instead of trying to change the way the patient sees the world, healthcare professionals should strive to understand and address the specific issues and challenges that the patient is dealing with. This approach is especially relevant if the patient is not going through an acute crisis at the time.
Furthermore, patients are encouraged to use their social connections as support networks and to expand these as they become more comfortable and confident. Involving the patient’s family can be helpful for both noticing any signs of worsening symptoms (decompensation) and educating family members on how to provide a stable social environment for the patient.
Using standard assessments to measure the quality of life can reveal ways to improve the patient’s ability to function in important areas of their life. This can be very beneficial for individuals with dependent personality disorder.
