Day # 140: Dependent Personality Disorder

Today we will continue our current theme of cluster C personality disorders. Today's topic is dependent personality disorder.

Today's Content Level: Beginner and Intermediate

Introduction 1

• Individuals with dependent personality disorder (DPD) have a long-standing pattern of poor self-confidence, feeling helpless, and having an excessive need to be taken care of.

• They may find it very difficult to be alone and often struggle to manage life responsibilities without assistance.

• DPD has historical roots far preceding the first DSM and has been called passive-dependent personality. It was described by Frued as originating in the oral stage of development.

• Common traits/symptoms may include being -> insecure, helpless, passive, idle, suggestible, needy, clingy, pessimistic, fearful.

Diagnostic Criteria 2

• The diagnosis of dependent PD requires a pervasive pattern of an 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.

• ≥5 of the following must also be present: Mnemonic "RELIANCE"

• Reassurance - Dificulty making everyday decisions without reassurance from others

• Expressing disagreement - Dificulty expressing disagreement because of fear of loss of approval

• Life responsibilities - Needs others to assume responsibilities for most areas of his or her life

• Initiative - Dificulty initiating projects because of lack of self-conidence

• Alone - Feels helpless when alone

• Nurturing - Goes to excessive lengths to obtain support/nurturing from others

• Companionship - Urgently seeks another relationship when one ends

• Exaggerated fears - Preoccupied with fears of being left to take care of self

Epidemiology/Pathogenesis 3, 4, 5

• Prevalence is estimated to be 0.5-1% of the general population.

• Women are more likely to be diagnosed than men. Some critics argue that clinicians are biased and may view this pattern of symptoms as more maladaptive when presenting in women than in men. Some studies report similar prevalence rates among men and women.

• As with all personality disorders, the dominant theory suggests dependent PD develops from a combination of genetic vulnerability and environmental stressors.

• There has been little empirical research regarding the etiology and risk factors for DPD. Genetic predisposition, severe or chronic physical illness in childhood, childhood/family environment, and early traumatic events have all been associated. Dependent and avoidant PD likely share common genetic factors. The following parental approaches have also been associated-> self-sufficiency is discouraged, rule-oriented, neglect, and abuse.

Clinical Pearls 4, 5, 6

• History: Dependent PD begins early in life by a pervasive pattern of dependent and submissive behavior. They have difficulty making decisions without an excessive amount of advice and reassurance from others. Occupational functioning tends to be impaired since they cannot act independently without close supervision. They prefer to be submissive and avoid positions of responsibility and become anxious if asked to assume a leadership role. Social relations are limited to those on whom they can depend. The are at risk for depression particularly after the loss of a person on whom they are dependent. Patients do not like to be alone and may frantically seek new relationships when a key relationship is threatened. An abusive, unfaithful, or alcoholic partner may be tolerated for long periods to avoid disturbing the sense of attachment. Regression (going back to a younger age of maturity) is often seen in these patients. Many people with debilitating illnesses can develop dependent traits, however, to be diagnosed with DPD, the features must manifest in early adulthood.

• Mental status exam: Patients will likely appear compliant and make an effort to be cooperative and welcome specific questions, guidance, and advice. As you get to know the patient you may observe their speech reflects their self-doubt, passivity, and pessimism. Frequent intersession contact is common.

• Optional personality questionnaires: Dependent Personality Questionnaire (DPQ), Dependent Personality Inventory (DPI), Personality Assessment Inventory (PAI), Minnesota Multiphasic Personality Inventory (MMPI).

• Differential diagnosis: Dependent traits are found in many psychiatric disorders. Dependence is a prominent feature in patients with histrionic and borderline personality, but may be more manipulative and/or have difficulties maintaining long-lasting relationships. Dependent behavior may also occur in patients with significant anxiety or agoraphobia. Also, keep in mind that the degree to which dependent behaviors are considered appropriate varies substantially across different age, gender, and sociocultural groups. Some societies place an emphasis on passivity, deferential treatment, and politeness and may be misinterpreted as traits of DPD. Dependent behavior should only be considered when clearly in excess of the individuals cultural norms.

Treatment 7, 8, 9

• General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

• Psychotherapy: Cognitive behavioral therapy (CBT) is effective for cluster C personality disorders including dependent PD. This treatment is based on the tenet that maladaptive emotions and behaviors manifest from cognitive biases and childhood schemas. It may be particularly effective in dependent PD because it can focus on a patient's beliefs about their need to be taken care of, help them become more active and independent, and learn to form healthy relationships. Insight-oriented therapies, such as psychodynamic psychotherapy, involves a close examination into certain past relationships in which their dependent behavior was encouraged. Schema therapy (ST) has also been used successfully. This approach brings together elements from CBT, psychoanalysis, attachment theory, and emotion-focused therapy, among others. Behavioral therapy, assertiveness training, social skills training, family therapy, and group therapy have all been used, with successful outcomes in many cases.

• Pharmacotherapy: There are no FDA approved medications or randomized control trials for dependent PD. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment. Comorbid anxiety (such as separation anxiety and panic disorder) and depressive disorders should be treated accordingly (see treatment of depression; treatment of anxiety).

Conclusion

• Next lesson we will cover obsessive-compulsive personality disorder. If you want more learning resources then check out our recommended resources page.

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• Resources for today's post include: First Aid for Psychiatry, Kaplan and Sadock’s Synopsis of Psychiatry, DSM-5, Pocket Psychiatry, and the articles referenced above.