By Mark Zimmerman, MD, Rhode Island Hospital
Dependent personality disorder is characterized by a generalized and excessive need to be taken care of, leading to submission and slimy behaviors. Diagnosis is by clinical criteria. Treatment is with psychotherapy and possibly antidepressants. (See also Overview of Personality Disorders.) In patients with dependent personality disorder, the need to be cared for results in the loss of their autonomy and interests. Because they are intensely anxious about taking care of themselves, they become overly dependent and submissive. It is estimated that less than 1% of the US population generally has dependent personality disorder. It is diagnosed more often in women, but in some studies, the prevalence between men and women was similar. Comorbidities are common. Patients often also have depressive disorder (major depressive disorder or persistent depressive disorder), anxiety disorder, alcoholism, or another personality disorder (eg, borderline, histrionic). Etiology of dependent personality disorder Information on the causes of dependent personality disorder is limited. Cultural factors, negative early experiences, and biological vulnerabilities associated with anxiety are thought to contribute to the development of dependent personality disorder. Family traits such as submission, insecurity, and low-key behavior can also contribute.
Signs and symptoms of dependent personality disorder Patients with dependent personality disorder do not feel that they can take care of themselves. They use submission to try to get other people to take care of them. Patients with this disorder often require a lot of reassurance and advice when making common decisions. They often let others, often a single person, take responsibility for many aspects of their lives. For example, they may depend on their spouse to tell them what to wear, what kind of work to look for, and who 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 can agree to something they know is wrong rather than risk losing the help of others. Even when irritation is appropriate, they don't get angry with friends and co-workers for fear of losing their support. As 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 in need of constant help and reassurance. When assured that a competent person is supervising and approving them, these patients tend to function properly. But they don't want to look too competent lest they be abandoned. As a result, their careers can be jeopardized. They perpetuate their dependence because they tend not to learn independent living skills. These patients will go to great lengths to obtain care and support (eg, performing unpleasant tasks, submitting to unreasonable demands, tolerating physical, sexual, or emotional abuse). Being alone makes them feel extremely uncomfortable or scared because they fear they can't take care of themselves. Patients with dependent personality disorder tend to interact socially with only a few people they depend on. When an intimate relationship ends, patients with this disorder immediately try to find a replacement. Because of their desperate need to be taken care of, they do not discriminate when choosing a replacement. These patients fear abandonment by those they depend on, even when there is no reason to do so.
Diagnosis of dependent personality disorder · Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) For the diagnosis of dependent personality disorder, patients must have · Persistent and excessive need to be cared for, resulting in submission and attachment This persistent need is manifested by the presence of ≥ 5 of the following: · Difficulty making daily decisions without an excessive amount of advice and reassurance from others · Need to make others responsible for many important aspects of their lives · Difficulty expressing disagreement with others because they fear losing 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 do anything (eg, perform unpleasant tasks) to gain support from others · Feelings of discomfort or helplessness when they are alone because they fear they cannot take care of themselves · Urgent need to establish a new relationship with someone who will provide care and support when an intimate relationship ends · Unrealistic preoccupation with fear of being abandoned to fend for themselves In addition, symptoms must have occurred in early adulthood.
Differential diagnosis Several other personality disorders are characterized by hypersensitivity to rejection. But they can be distinguished from dependent personality disorder on the basis of characteristic features, as follows: · Borderline Personality Disorder: Patients with this disorder are very afraid 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 submission and angry hostility. · Avoidant Personality Disorder: Patients with this disorder are also very afraid to undergo the same degree of control that patients with dependent personality disorder undergo. Patients with avoidant personality disorder stay away until they are sure they will be accepted without criticism; in comparison, those with dependent personality disorder seek out and 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 exuberant and actively seek attention; those with dependent personality disorder are discreet and shy. Dependent personality disorder must be distinguished from dependence that is present in other psychiatric disorders (eg, depressive disorders, panic disorder, agoraphobia).
Treatment of dependent personality disorder · Cognitive behavioral therapy · Psychodynamic psychotherapy · Possibly antidepressants The general treatment of dependent personality disorder is similar to that for all personality disorders. Psychodynamic psychotherapy and cognitive behavioral therapy that focus on examining independence fears and difficulties with assertiveness can help patients with dependent personality disorder. Physicians must be careful not to promote dependence in the therapeutic relationship. There is little evidence about drug therapy for dependent personality disorder. Monoamine oxidase inhibitors (MAOIs), which are effective in avoidant personality disorder, can be effective, as can selective serotonin reuptake inhibitors (SSRIs). Benzodiazepines are not used because patients with dependent personality disorder are at greater risk for drug dependence.
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