Dependent personality disorder#Alternative model

Dependent Personality Disorder (DPD) is a mental health condition characterized by an excessive reliance on others for decision-making and emotional support. Individuals with DPD often struggle to make independent decisions and seek constant reassurance from others. This dependence can result in a tendency to prioritize the needs and opinions of others over their own, as they may lack confidence in their judgment.  

People with DPD commonly exhibit passive and clingy behaviors, driven by a strong fear of separation. They typically prefer not to be alone and may experience distress, isolation, or loneliness when separated from their support system. Additionally, individuals with this disorder often display a pessimistic outlook, anticipating negative outcomes in various situations. They may also be introverted, highly sensitive to criticism, and fearful of rejection.  

DPD is classified as a Cluster C personality disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Treatment options typically include psychotherapy, particularly cognitive-behavioral therapy (CBT), which aims to improve self-confidence, autonomy, and coping mechanisms. In some cases, medication may be prescribed to manage co-occurring conditions such as anxiety or depression.  {{cite book |last1=Beitz |first1=Kendra |title=Practitioner's Guide to Evidence-Based Psychotherapy |last2=Bornstein |first2=Robert F. |date=2006 |publisher=Springer |isbn=978-0-387-28369-2 |editor1-last=Fisher |editor1-first=Jane E. |location=Boston, Massachusetts |pages=230–237 |chapter=Dependent Personality Disorder |doi=10.1007/978-0-387-28370-8_22 |editor2-last=O’Donohue |editor2-first=William T. |s2cid=142569348}}

The development of Dependent Personality Disorder (DPD) has been associated with various genetic and environmental factors. Individuals with a history of neglect or an abusive upbringing may have an increased risk of developing DPD, particularly those who have experienced long-term abusive relationships. Additionally, individuals raised by overprotective or authoritarian parents may be more susceptible to developing the disorder. Individuals with DPD seem to have a myriad of negative consequences for themselves and those around them. High levels of trait dependency and DPD are associated with elevated risk for physical illness, partner and child abuse, and suicidality, as well as with high levels of functional impairment and increased health care expenditure{{Cite journal |last=Bornstein |first=Robert F. |date=2012 |title=Illuminating a Neglected Clinical Issue: Societal Costs of Interpersonal Dependency and Dependent Personality Disorder |url=https://onlinelibrary.wiley.com/doi/10.1002/jclp.21870 |journal=Journal of Clinical Psychology |language=en |volume=68 |issue=7 |pages=766–781 |doi=10.1002/jclp.21870 |issn=1097-4679}}

Genetic predisposition may also play a role in the development of DPD. Research suggests a link between DPD and a family history of anxiety disorders. A 2004 twin study reported a heritability estimate of 0.81 for personality disorders collectively, indicating a strong genetic component in their development.{{cite book |author1=Coolidge, F.L. |title=Are personality disorders psychological manifestations of executive function deficits? Bivariate heritability evidence from a twin study. Behavior Genetics (2004), pp. 34, 75-84, cited in Nolan-Hoeksema, Abnormal Psychology (6th. ed.), pp. 273, McGraw Hill Education (2014) |author2=Thede, L. |author3=Jang, K.L. |date=2 December 2013 |publisher=McGraw-Hill Education |isbn=978-0-07-803538-8}}

While the exact cause of dependent personality disorder is unknown,{{cite book|url=https://books.google.com/books?id=7_7-5dQIpBQC&pg=PA30|title=Blueprints psychiatry|last1=Sederer|first1=Lloyd I.|date=2009|publisher=Wolters Kluwer/Lippincott Williams & Wilkins|isbn=9780781782531|edition=5th|location=Philadelphia, Pennsylvania|page=30|access-date=2019-01-31|archive-url=https://web.archive.org/web/20180915192415/https://books.google.ca/books?id=7_7-5dQIpBQC&pg=PA30|archive-date=2018-09-15|url-status=live}} the formation of dependent personality disorder is mainly divided into three parts, the biological influences, environmental factors and social factors.{{Cite journal |last=Liang |first=Wei |date=2022 |title=How Does Dependent Personality Disorder Form, Develop and Affect Human Life?: |url=https://www.atlantis-press.com/article/125974901 |doi=10.2991/assehr.k.220504.318|doi-access=free }} A study in 2012 estimated that between 55% and 72% of the risk of the condition is inherited from one's parents.{{sfn|Gjerde|Czajkowski|Røysamb|Ørstavik|2012}} The difference between a "dependent personality" and a "dependent personality disorder" is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations.{{cite journal|title=Gender Role and Personality Disorders|first1=E. David|last1=Klonsky|first2=J. Serrita|last2=Jane|first3=Eric|last3=Turkheimer|first4=Thomas F.|last4=Oltmanns|journal=Journal of Personality Disorders|publisher=Guilford Press|location=New York City|url=https://www.researchgate.net/publication/10985243|date=November 2002|volume=16|issue=5|pages=464–476|doi=10.1521/pedi.16.5.464.22121|pmid=12489312 |pmc=4364134}}

Dependent traits in children tended to increase with parenting behaviours and attitudes characterized by overprotectiveness and authoritarianism. Thus the likelihood of developing dependent personality disorder increased, since these parenting traits can limit them from developing a sense of autonomy, rather teaching them that others are powerful and competent.{{Cite book|title=Encyclopedia of Personality and Individual Differences |last1=Simonelli |first1=Alessandra |last2=Parolin |first2=Micol|date=2017|publisher=Springer, Cham|pages=1–11|language=en|doi=10.1007/978-3-319-28099-8_578-1|chapter = Dependent Personality Disorder|isbn = 978-3-319-28099-8|s2cid=202238251 }}

Traumatic or adverse experiences early in an individual's life, such as neglect and abuse or serious illness, can increase the likelihood of developing personality disorders, including dependent personality disorder, later in life. This is especially prevalent for those individuals who also experience high interpersonal stress and poor social support.

There is a higher frequency of the disorder seen in women than men; hence, expectations relating to gender role may contribute to some extent.

Clinicians and clinical researchers conceptualize dependent personality disorder in terms of four related components:

• Cognitive: a perception of oneself as powerless and ineffectual, coupled with the belief that other people are comparatively powerful and potent.
• Motivational: a desire to obtain and maintain relationships with protectors and caregivers.
• Behavioral: a pattern of relationship-facilitating behavior designed to strengthen interpersonal ties and minimize the possibility of abandonment and rejection.
• Emotional: fear of abandonment, fear of rejection, and anxiety regarding evaluation by figures of authority.{{Cite book|title=Practitioner's Guide to Evidence-Based Psychotherapy|last1=Beitz|first1=Kendra|last2=Bornstein|first2=Robert F.|chapter=Dependent Personality Disorder |date=2006|publisher=Springer, Boston, MA|isbn=978-0387283692|pages=230–237|language=en|doi=10.1007/978-0-387-28370-8_22|s2cid=142569348 }}

The American Psychiatric Association's 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 prior to early adulthood and can be present in a variety of contexts.{{cite web|url=http://behavenet.com/dependent-personality-disorder|title=Dependent Personality Disorder|access-date=2019-01-31|archive-url=https://web.archive.org/web/20150210115542/http://behavenet.com/dependent-personality-disorder|archive-date=2015-02-10|url-status=live}}

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:{{Cite book|title=Encyclopedia of Personality and Individual Differences|last1=Simonelli|first1=Alessandra|last2=Parolin|first2=Micol|date=2017|publisher=Springer, Cham|pages=1–11|language=en|doi=10.1007/978-3-319-28099-8_578-1|chapter = Dependent Personality Disorder|isbn = 978-3-319-28099-8|s2cid=202238251 }}

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.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

The diagnosis of personality disorders in the fourth edition of the DSM, 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.{{Cite journal|last=Clark|first=Lee Anna|date=2007|title=Assessment and Diagnosis of Personality Disorder: Perennial Issues and an Emerging Reconceptualization|journal=Annual Review of Psychology|publisher=Annual Reviews|location=San Mateo, California|volume=58|issue=1|pages=227–257|doi=10.1146/annurev.psych.57.102904.190200|pmid=16903806|issn=0066-4308|url=https://zenodo.org/record/1134186|s2cid=2728977}} As a result of deficits of this system for personality disorders, the DSM-5 introduced a new model called the Alternative DSM-5 Model for Personality Disorders (AMPD).{{Cite book |title=Diagnostic and statistical manual of mental disorders: DSM-5 |date=2013 |publisher=American psychiatric association |isbn=978-0-89042-554-1 |edition=5th |location=Washington |pages=761}} The AMPD does not list dependent personality disorder as its own diagnostic entity. However, it is stated in the AMPD that what is conceptualized as DPD can instead be diagnosed as Personality Disorder - Trait Specified, which is a dimensional diagnosis for personality disorders found in the alternative model.{{Cite book |title=Diagnostic and statistical manual of mental disorders: DSM-5 |date=2013 |publisher=American psychiatric association |isbn=978-0-89042-554-1 |edition=5th |location=Washington |pages=771}}

The World Health Organization's ICD-10 lists dependent personality disorder as {{ICD10|F|60|7|f|60}} Dependent personality disorder:[http://www.mentalhealth.com/icd/p22-pe09.html Dependent personality disorder -] International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) {{webarchive|url=https://web.archive.org/web/20060427115243/http://www.mentalhealth.com/icd/p22-pe09.html|date=2006-04-27}}

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. 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.

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.

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.

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:

1. Passive-aggressive
2. Counter-dependent

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. 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.

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.

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

Similarities between individuals with dependent personality disorder and individuals with borderline personality disorder include having a fear of abandonment. Those with dependent personality disorder do not necessarily exhibit impulsive behaviour or unstable affect experienced by those with borderline personality disorder, differentiating the two disorders.{{Cite book |url=https://books.google.com/books?id=7_7-5dQIpBQC |title=Blueprints Psychiatry |last1=Murphy |first1=Michael |last2=Cowan |first2=Ronald |date=2009 |publisher=Lippincott Williams & Wilkins |location=Philadelphia, Pennsylvania |isbn=978-0781782531 |language=en |access-date=2019-01-31 |archive-url=https://web.archive.org/web/20181217110739/https://books.google.ca/books?id=7_7-5dQIpBQC&printsec=frontcover |archive-date=2018-12-17 |url-status=live }}

Individuals who have DPD are generally treated with psychotherapy. The main goal of this therapy is to make the individual more independent and help them form healthy relationships with the people around them. This is done by improving their self-esteem and confidence.{{cite web|last1=Goldberg|first1=Joseph|title=Dependent Personality Disorder|url=https://www.webmd.com/anxiety-panic/guide/dependent-personality-disorder#3|website=WebMD|access-date=2019-01-31|archive-url=https://web.archive.org/web/20180810010738/https://www.webmd.com/anxiety-panic/guide/dependent-personality-disorder#3#3|archive-date=2018-08-10|url-status=live}}

Medication can be used to treat patients who suffer from depression or anxiety because of their DPD, but this does not treat the core problems caused by the disorder.

Based on a recent survey of 43,093 Americans, 0.49% of adults meet diagnostic criteria for DPD (National Epidemiologic Survey on Alcohol and Related Conditions; NESARC; Grant et al., 2004).{{cite book|last1=Beitz|first1=Kendra|title=Practitioner's Guide to Evidence-Based Psychotherapy|date=2006|publisher=Springer|location=Boston, Massachusetts|pages=230–237|edition=|doi=10.1007/978-0-387-28370-8_22|isbn=978-0-387-28369-2|chapter=Dependent Personality Disorder|s2cid=142569348 }}

Traits related to DPD, like most personality disorders, emerge in childhood or early adulthood. Findings from the NESArC study found that 18 to 29 year olds have a greater chance of developing DPD. DPD is more common among women compared to men as 0.6% of women have DPD compared to 0.4% of men.

A 2004 twin study suggests a heritability of 0.81 for developing dependent personality disorder. Because of this, there is significant evidence that this disorder runs in families.

Children and adolescents with a history of anxiety disorders and physical illnesses are more susceptible to acquiring this disorder.{{cite book|last1=Nolen-Hoeksema|first1=Susan|title=Abnormal Psychology|date=2014|publisher=McGraw Hill Education|isbn=978-0-07-803538-8|edition=6th}}

Psychologist Theodore Millon identified five adult subtypes of dependent personality disorder.{{sfn|Millon|Millon|Meagher|Grossman|2004|p=290}}{{sfn|Millon|2006}} Any individual dependent may exhibit none or one or more of the following:

The conceptualization of dependency, within classical psychoanalytic theory, is directly related to Sigmund Freud's oral psychosexual stage of development. Frustration or over-gratification was said to result in an oral fixation and in an oral type of character, characterized by feeling dependent on others for nurturing and by behaviors representative of the oral stage. Later psychoanalytic theories shifted the focus from a drive-based approach of dependency to the recognition of the importance of early relationships and establishing separation from these early caregivers, in which the exchanges between the caregiver and the child become internalized, and the nature of these interactions becomes part of the concepts of the self and of others.

{{reflist}}

• {{cite book |first1=Aaron T |last1=Beck |first2=Arthur |last2=Freeman |year=1990 |title=Cognitive Therapy of Personality Disorders |location=New York |publisher=Guilford Press |isbn=978-0-89862-434-2}}
• {{cite book |first1=Theodore |last1=Millon |first2=Roger Dale |last2=Davis |year=1996 |title=Disorders of Personality: DSM-IV and Beyond |location=New York |publisher=Wiley |isbn=978-0-471-01186-6}}
• {{cite book |first1=Theodore |last1=Millon |year=1981 |title=Disorders of Personality: DSM-III, Axis II |location=New York |publisher=Wiley |isbn=978-0-471-06403-9 |url=https://archive.org/details/disordersofperso00mill }}
• {{cite book |first1=J. C. |last1=Perry |year=1996 |chapter=Dependent personality disorder |pages=995–998 |editor1-first=Glen O. |editor1-last=Gabbard |editor2-first=Sarah D. |editor2-last=Atkinson |title=Synopsis of Treatments of Psychiatric Disorders |publisher=American Psychiatric Press |isbn=978-0-88048-859-4}}
• {{cite journal |last1=Gjerde |first1=L. C. |last2=Czajkowski |first2=N. |last3=Røysamb |first3=E. |last4=Ørstavik |first4=R. E. |last5=Knudsen |first5=G. P. |last6=Østby |first6=K. |last7=Torgersen |first7=S. |last8=Myers |first8=J. |last9=Kendler |first9=K. S. |last10=Reichborn-Kjennerud |first10=T. |year=2012 |title=The heritability of avoidant and dependent personality disorder assessed by personal interview and questionnaire |journal=Acta Psychiatrica Scandinavica |volume=126 |issue=6 |pages=448–457 |doi=10.1111/j.1600-0447.2012.01862.x |pmid=22486635 |pmc=3493848 }}
• {{cite book |first1=Theodore |last1=Millon |first2=Carrie M. |last2=Millon |first3=Sarah |last3=Meagher |first4=Seth |last4=Grossman |first5=Rowena |last5=Ramnath |year=2004 |title=Personality Disorders in Modern Life |publisher=Wiley |isbn=978-0-471-66850-3}}
• {{cite web |first=Theodore |last=Millon |year=2006 |title=Personality Subtypes |url=http://millon.net/taxonomy/summary.htm}}
• {{cite book |first1=Martin |last1=Kantor |year=1992 |title=Diagnosis and Treatment of the Personality Disorders |publisher=Ishiyaku EuroAmerica |isbn=978-0-912791-89-0}}
• {{cite book |first1=J. M. |last1=Ellison |first2=D. A. |last2=Adler |year=1990 |chapter=A strategy for the pharmacotherapy of personality disorders |pages=[https://archive.org/details/treatingpersonal0000unse/page/43 43–63] |editor1-first=David A. |editor1-last=Adler |title=Treating Personality Disorders |location=San Francisco |publisher=Jossey-Bass |isbn=978-1-55542-811-2 |chapter-url=https://archive.org/details/treatingpersonal0000unse/page/43 }}
• {{cite book |editor1-first=David A. |editor1-last=Adler |year=1990 |title=Treating Personality Disorders |location=San Francisco |publisher=Jossey-Bass |isbn=978-1-55542-811-2 |url-access=registration |url=https://archive.org/details/treatingpersonal0000unse }}
• {{cite book |first1=Henry Jay |last1=Richards |year=1993 |title=Therapy of the Substance Abuse Syndromes |location=New York |publisher=Jason Aronson |isbn=978-0-87668-539-6 |url-access=registration |url=https://archive.org/details/therapyofsubstan0000rich }}
• {{cite book |first=Mark |last=Zimmerman |year=1994 |title=Diagnosing DSM-IV-R Psychiatric Disorders in Primary Care Settings: An Interview Guide for the Nonpsychiatrist Physician |publisher=Psych Products |isbn=978-0-9633821-3-9}}
• {{cite book |first=Sharon |last=Ekleberry |year=2014 |chapter=Dependent Personality Disorder (DPD) |chapter-url=https://books.google.com/books?id=ySsiAwAAQBAJ&pg=PT63 |pages=63–64 |title=Treating Co-Occurring Disorders |publisher=Routledge |isbn=978-1-317-82549-4}}
• {{cite book |first1=John M. |last1=Oldham |first2=Lois B. |last2=Morris |year=1990 |title=The Personality Self-portrait: Why You Think, Work, Love, and Act the Way You Do |publisher=Bantam |isbn=978-0-553-05757-7 |url=https://archive.org/details/personalityself000oldh }}
• {{cite book |first=Len |last=Sperry |year=1995 |title=Psychopharmacology and Psychotherapy: Strategies for Maximizing Treatment Outcomes |publisher=Psychology Press |isbn=978-0-87630-787-8 |url-access=registration |url=https://archive.org/details/psychopharmacolo0000sper }}
• {{cite book |first=Michael H. |last=Stone |year=1993 |title=Abnormalities of Personality: Within and Beyond the Realm of Treatment |publisher=Norton |isbn=978-0-393-70127-2}}
• {{cite book |first=Lorna Smith |last=Benjamin |year=1993 |title=Interpersonal Diagnosis and Treatment of Personality Disorders |publisher=Guilford Press |isbn=978-0-89862-990-3 |url-access=registration |url=https://archive.org/details/interpersonaldia0000benj }}
• {{cite book |first=Lorna Smith |last=Benjamin |year=1996 |chapter=Dependent Personality Disorder |chapter-url=https://books.google.com/books?id=esvC9po1cIgC&pg=PA221 |pages=[https://archive.org/details/interpersonaldia0000benj/page/221 221–239] |title=Interpersonal Diagnosis and Treatment of Personality Disorders |publisher=Guilford Press |isbn=978-0-89862-990-3 |url=https://archive.org/details/interpersonaldia0000benj/page/221 }}

• J. Christopher Perry, M.P.H., M.D., 2005 ([http://www.health.am/psy/more/dependent_personality_disorder_pro/ Dependent Personality Disorder])
• [https://web.archive.org/web/20140713022001/http://www.mentalhealth.com/dis/p20-pe09.html Diagnostic Features, Complications, Prevalence, Associated Laboratory Findings]
• [https://www.nlm.nih.gov/medlineplus/ency/article/000941.htm MedlinePlus Medical Encyclopedia: Dependent personality disorder]

{{ICD-10 personality disorders}}

{{Medical resources

| ICD10 = {{ICD10|F|60|7|f|60}}

| ICD9 = {{ICD9|301.6}}

| MeshID = D003859

| MedlinePlus = 000941

}}

{{Authority control}}

Category:Cluster C personality disorders