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* This is the Professional Version. *

Dependent Personality Disorder (DPD)

By Lois Choi-Kain, MD, Gunderson Residence of McLean Hospital;Harvard Medical School

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Dependent personality disorder is characterized by a pervasive, excessive need to be taken care of, leading to submissiveness and clinging behaviors. Diagnosis is by clinical criteria. Treatment is with psychotherapy and possibly antidepressants.

In patients with dependent personality disorder, the need to be taken care of results in loss of their autonomy and interests. Because they are intensely anxious about taking care of themselves, they become excessively dependent and submissive.

About 0.7% of the general population are estimated to have dependent personality disorder; it is more common among women.

Comorbidities are common. Patients often also have a depressive disorder (major depressive disorder or dysthymia), an anxiety disorder, an alcohol use disorder, or another personality disorder (eg, borderline, histrionic).

Etiology

Information about the causes of dependent personality disorder is limited. Cultural factors, negative early experiences, and biologic vulnerabilities associated with anxiety are thought to contribute to the development of dependent personality disorder. Familial traits such as submissiveness, insecurity, and self-effacing behavior may also contribute.

Symptoms and Signs

Patients with dependent personality disorder do not think they can take care of themselves. They use submissiveness to try to get other people to take care of them.

Patients with this disorder typically require much reassurance and advice when making ordinary decisions. They often let others, often one person, take responsibility for many aspects of their life. For example, they may depend on their spouse to tell them what to wear, what kind of job to look for, and whom to associate with.

These patients consider themselves inferior and tend to belittle their abilities; they take any criticism or disapproval as proof of their incompetence, further undermining their confidence.

It is difficult for them to express disagreement with others because they fear losing support or approval. They may agree to something they know is wrong rather than risk losing the help of others. Even when anger is appropriate, they do not get angry at friends and co-workers for fear of losing their support.

Because these patients are sure that they cannot do anything on their own, they have difficulty starting a new task and working independently, and they avoid tasks that require taking responsibility. They present themselves as incompetent and needing constant help and reassurance. When reassured that a competent person is supervising and approving of them, these patients tend to function adequately. However, they do not want to appear too competent lest they be abandoned. As a result, their career may be harmed. They perpetuate their dependency because they tend not to learn skills of independent living.

These patients go to great lengths to obtain care and support (eg, doing unpleasant tasks, submitting to unreasonable demands, tolerating physical, sexual, or emotional abuse). Being alone makes them feel extremely uncomfortable or afraid because they fear they cannot take care of themselves.

Patients with this disorder tend to interact socially with only the few people they depend on. When a close relationship ends, patients with this disorder immediately try to find a replacement. Because of their desperate need to be taken care of, they are not discriminating in choosing a replacement.

These patients fear abandonment by those they depend on, even when there is no reason to.

Diagnosis

  • Clinical criteria ( Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5])

For a diagnosis of dependent personality disorder, patients must have a persistent, excessive need to be taken of, resulting in submissiveness and clinging, as shown by ≥ 5 of the following:

  • Difficulty making daily decisions without an inordinate amount of advice and reassurance from other people

  • A need to have others be responsible for most important aspects of their life

  • Difficulty expressing disagreement with others because they fear loss of support or approval

  • Difficulty starting projects on their own because they are not confident in their judgment and/or abilities (not because they lack motivation or energy)

  • Willingness to go to great lengths (eg, do unpleasant tasks) to obtain support from others

  • Feelings of discomfort or helplessness when they are alone because they fear they cannot take of themselves

  • An urgent need to establish a new relationship with someone who will provide care and support when a close relationship ends

  • Unrealistic preoccupation with fears of being left to take care of themselves

Also, symptoms must have begun by early adulthood.

Differential diagnosis

Several other personality disorders are characterized by hypersensitivity to rejection. However, they can be distinguished from dependent personality disorder based on characteristic features, as follows:

  • Borderline personality disorder: Patients with this disorder are too frightened to submit to the same degree of control as patients with dependent personality disorder. Patients with borderline personality disorder, unlike those with dependent personality disorder, vacillate between submissiveness and rageful hostility.

  • Avoidant personality disorder: Patients with this disorder are also be too frightened to submit to the same degree of control as patients with dependent personality disorder. Patients with avoidant personality disorder withdraw until they are sure they will be accepted without criticism; in contrast, those with dependent personality disorder seek out and try to maintain relationships with others.

  • Histrionic personality disorder: Patients with this disorder seek attention rather than reassurance (as do those with dependent personality disorder), but they are more disinhibited. They are more flamboyant and actively seek attention; those with dependent personality disorder are self-effacing and shy.

Dependent personality disorder should be distinguished from the dependency that is present in other psychiatric disorders (eg, mood disorders, panic disorder, agoraphobia).

Treatment

  • Cognitive-behavioral therapy

  • Psychodynamic psychotherapy

  • Possibly antidepressants

General treatment of dependent personality disorder is similar to that for all personality disorders.

Psychodynamic psychotherapy and cognitive-behavioral therapy that focus on examining fears of independence and difficulties with assertiveness can help patients with dependent personality disorder. Clinicians should be careful not to promote dependency in the therapy relationship.

Evidence about drug therapy for dependent personality disorder is sparse. Monoamine oxidase inhibitors (MAOIs), which are effective in avoidant personality disorder, may be effective, as may SSRIs.

Benzodiazepines are not used because patients with dependent personality disorder have an increased risk of drug dependency.

* This is the Professional Version. *