The Oxford Handbook of Personality Disorders
Chapter 23
Dependent personality disorder

Introduction

Dependent personality disorder is associated with an array of negative outcomes. It is also associated with increased adaptation in a variety of areas 1) sensitivity to subtle interpersonal cues 2) decreased delay in seeking medical help following symptom onset 3) conscientious adherence to medical and psychological treatment regimes.

The evolution of dependent personality disorder

Descriptive psychiatry and psychoanalysis

In classical psychoanalytic theory, dependency is inextricably linked to events that occur during the first months of life (the oral state). Frustration or over gratification during the infantile, oral phase was thought to result in oral fixation and an inability to resolve the developmental issues that characterize this period (conflicts regarding dependency and autonomy). Research regarding this has produced weak results.

Current diagnostic frameworks

DSM-IV/DSM-IV-R

The essential feature of dependent personality disorder in the DSM-IV and DSM-IV-R is ‘a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning in early adulthood and present in a variety of contexts’.

The DSM-IV list eight specific symptoms. The patient must meet criteria for five of these symptoms to qualify for a dependent personality disorder diagnosis. 1) difficulty making everyday decisions without excessive advice and reassurance 2) needing other people to assume responsibility for most major areas in life 3) difficulty expressing disagreement because of fear of loss of support or approval 4) difficulty initiating projects or doing things on one’s own 5) going to excessive lengths to obtain nurturance and support from others 6) feeling uncomfortable and helpless when alone 7) urgently seeking another relationship as a source of care and support when a close relationship ends 8) being unrealistically preoccupied when fears of being unable to care for oneself

Empirical evidence regarding these criteria is mixed. And none of the symptoms include mention of the central cognitive feature of dependency, a perception of oneself as powerless and ineffectual.

The PDM

In the Psychodynamic diagnostic manual, dependent personality disorder is described in terms of dependent individuals’ tendency to ‘define themselves mainly in relation to others and seek security and satisfaction predominantly in interpersonal contexts’. Dependency must be evaluated with sensitivity to cultural and subcultural contexts.

The PDM is descriptive. It does not enumerate fixed symptom criteria that must be met to qualify for a dependent personality disorder diagnosis. It goes not to describe dependent individuals as 1) feeling ineffectual when left to fend for themselves 2) regarding other people as comparatively powerful and confident 3) organizing their lives with a view to maintaining nurturant and supportive relationships.

Dependent personality disorder patients are cooperative and complaint.

DPD assessment methods

Assessment of dependent personality disorder typically involves administration of questionnaires and/or structured interviews.

No dependent personality disorder questionnaires or interviews have been developed and validated in clinical settings.

Problematic dependency is often quantified via trait dependency scales in addition to formal measures.

Epidemiology, differential diagnosis, and comorbidity

Dependent personality disorder rates are generally in the range of 5-15% in inpatient units, and 0-10% in outpatient clinics. In the general population, the rate is 1-2%.

Women receive dependent personality disorder diagnosis at higher rates than men do.

The differential diagnosis for dependent personality disorder are: mood disorders, panic disorder, agoraphobia, borderline PD, histrionic PD and avoidant PD.

Dependent personality disorder is associated with increased prevalence of eating disorders, anxiety disorders and somatization disorder.

Contemporary theoretical perspectives

About one-third of the variability in adult dependency is attributable to genetic factors.

The psychoanalytic perspective

The object relations model of dependency emphasized the internalization of mental representations of parents and other significant figures as critical developmental tasks of infancy and early childhood. The dependent personality traits result from the internalization of a mental representation of the self as vulnerable and weak. This leads the individual to 1) look to others to provide protection, guidance and support 2) become preoccupied with fears of abandonment 3) adopt a help-seeking stance.

Behavioural and cognitive models

People exhibit dependent behaviour because those behaviours are rewarded. Dependency was initially conceptualized as an acquired drive, the impetus for which was the reduction of basic, primary drives within the context of the infant-caregiver relationship.

Even if dependent behaviour was first acquired in the child’s early interactions with parents and other caregivers, this behaviour must be reinforced in other relationships. Intermitted reinforcement of dependent behaviour plays a key role in the interpersonal dynamics of dependency.

Contemporary cognitive frameworks emphasize the role of the self-concept, beliefs regarding other people, and expectations regarding self-other interactions in the etiology and dynamics of dependency and dependent personality disorder. Beck argued that the core belief of the dependent individual is ‘I am completely helpless’, coupled with the sense that ‘I can function only if I have access to somebody competent’. Dependent persons see the world as cold, lonely, or even dangerous place that they could not possibly handle alone.

Trait models

Contemporary trait models of interpersonal dependency can be traced in part to Leary’s two dimensional (love-hate, dominance-submission) matrix for classifying personality styles. Dependency was thought to occupy the love/submission quadrant.

Three distinct dependency subtypes that occupy unique positions on the interpersonal circumplex are: submissive dependency, exploitable dependency and love dependency.

The five-factor model classifies personality traits in five broad dimensions: neuroticism, extraversion, openness to experience, agreeableness and conscientiousness.

The FFM specifies the underlying facets (the more specific behavioural patterns and predispositions) that combine to compose the five broad trait factors. The FFM dimensions most strongly related to dependency are neuroticism, and a negative correlation with openness to experience.

The humanistic-existential perspective

A key tenet of the humanistic perspective on dependency is that various familial and societal factors can cause the developing person to construct a ‘false’ (inauthentic) self.

The false self leads the individual to deny feelings and urges that are incompatible with parental expectations and societal norms. To the degree that parents’ conditional positive regard was contingent upon the child obeying rules without question and complying passively with external demands, the child comes to view autonomy as unacceptable and creates a false self centered on pleasing other people. Eventually, dependency is no longer a choice.

Defences aimed at obviating alternative ways of perceiving the world become entrenched. The dependent person’s experiences narrow to the point that other-centered behaviour is the sole means of managing anxiety and gaining approval.

Parental authoritarianism plays a role in the etiology of dependency.

The existential perspective on dependency focuses on the core motivation power of existential dread. Awareness of death and eventual nonexistence can be overwhelming, and as a result people devote enormous energy to deneying their own mortality. One key strategy involves externalizing responsibility for choices. The person comes to see him- or herself as a powerless entity controlled by outside forces.

An integrated model

The etiology of dependent personality disorder lies in two areas 1) overprotective, authoritarian parenting, foster dependency by preventing the child from developing a sense of autonomy and mastery following successful learning experiences. They play a key role in the construction of a mental representation of the self as ineffectual and weak. 2) gender-role socialization. Foster the development of a ‘dependent self-concept’ in girls.

Cognitive structures formed in response to early experiences within the family affect the motivations, behaviours and affective responses of the dependent person in predictable ways. A perception of the self as powerless and ineffectual will have motivational effects. The person is motivated to seek guidance, support, protection and nurturance. These motivations produce particular patterns of dependent behaviours. It can have affective consequences like fear of abandonment.

Research support this model.

Treatment strategies

Psychodynamic approaches

Psychodynamic treatment has the assumption that many features of conscious experience are rooted in unconscious conflicts. 1) some reflect clashes between incompatible beliefs, fears, wishes and urges 2) compromise formations, distorted end products of impulses and defences against those impulses.

The myriad rules and restrictions of childhood coupled with society’s expectations of increased self-reliance, causes experiences of ambivalence regarding autonomy and dependency.

The aim of psychoanalytic therapy with dependent patients is not to ameliorate these conflicts, but make them accessible to consciousness, where they can be examined critically and acted upon mindfully.

Core conflictual relationship theme (CCRT) may be helpful for disentangling dependency-related conflicts and dynamics.

The underlying context: a supportive-expressive frame

The first task is to build a collaborative working relationship through empathic communication on the part of the therapist. This may help minimize anxiety and defensiveness.

Insight through analysis of CCRTs

CCRTs are derived from patient narratives that centre on relationship episodes. As patterns emerge in relationship episodes are analysed in three areas: 1) the patient’s wishes, intentions and fears 2) the response of the other person 3) the patient’s reaction to the other person’s response.

The dominant needs and defences are made explicit, and trait-like aspects of dependency become clear. By examining inconsistencies, the contextual specificity of a patient’s behaviour can be understood.

Obstacles to progress: ambivalence in the therapeutic alliance

As the dependent patient becomes increasingly attached to the therapist, anxiety regarding abandonment increases, and behaviours designed to minimize the possibility of relationship disruption begin to dominate. If not managed properly, patient and therapist fears may feed each other.

The emotional undercurrent: transference and countertransference

One way to prevent dependent-related fears form undermining treatment is to explore the patient’s transference reaction and the therapist’s countertransference response.

Common transference patterns in dependent patients include: idealization, possessiveness and projective identification.

Common therapist responses to these transference reactions include: frustration at the patient’s insatiable neediness, hidden hostility, overindulgence and pleasurable feelings of power and omnipotence.

Behavioural approaches

Dependency is conceptualized as a set of responses aimed at obtaining help and support, which are acquired and maintained through a combination of conditioning and learning processes. Dependent persons are responsive to subtle social cues and are more easily conditioned.

The behavioural treatment model is based on the premise that dependent responses persist because they are positively reinforced in at least some relationships, and negatively reinforced as they enable avoiding anxiety-producing situations.

Extinguishing problematic dependency

Therapist and patient identify specific behaviours to be reduced. The components of a patient’s self-defeating dependency are broken into discrete responses so the contingencies that support each response can be identified.

A behaviour management program is created aimed at decreasing the frequency of undesired dependency-related responses. This is enhanced if contingency change first takes place within the context of the patient-therapist relationship.

Replacing dependency with autonomy

At the same time dependency-related responding is reduced, efforts are made to increase the frequency of alternative responses that are incompatible with underside behaviours.

Autonomous behaviours that are rewarded must be specific, identifiable, and within the patient’s behavioural repertoire. To facilitate this, therapist and patient first identify potentially problematic situations, then delineate adaptive responses to these challenges. Role-play techniques can be used to increase patient confidence and maximize the likelihood that the newly acquired responses will produce the desired consequences in vivo.

Using desensitization to facilitate behaviour change

To the degree that a patient’s dependent behaviour is exacerbated by concerns regarding embarrassment, abandonment, or rejection, systematic desensitization techniques should eb implemented to help manage this anxiety and facilitate change.

Maintaining behaviour change post treatment

When autonomous behaviour becomes self-reinforcing, the likelihood that new behaviour patterns will be maintained increases.

Four techniques are useful: 1) choosing target behaviours that lead to positive outcomes in the patient’s natural environment 2) doing in vivo training in settings that resemble those wherein the newly acquired behaviours must be exhibited 3) varying training conditions to reinforce different expression of the target behaviour and increase generalizability 4) gradually reducing the frequency of reinforcement during the later stages of therapy so reward dynamics approximate those of the patient’s social milieu.

Cognitive approaches

Cognitive approaches emphasize effecting behaviour change by altering the patient’s characteristic manner of thinking about, perceiving, and interpreting the world. This focuses on maladaptive schemas.

The primary goals is cognitive restructuring, altering dysfunctional thought patterns that foster self-defeating dependent behaviour. Initially, it focuses on strengthening the dependent patient’s self-efficacy beliefs. The therapist detoxify flawed performance, and provide alternative ways of managing negative feedback.  

Therapist and patient explore the development of the patient’s maladaptive dependency-related schema’s, the processes that maintain these schema’s over time, the avoidance strategies and the compensatory strategies.

The four-stage model is based on the premise that problematic dependency is rooted in active avoidance of autonomy which stems from the patient’s belief that she is doomed to fail without guidance and protection of others.

Stage 1: active guidance

Early in treated, patients are though behavioural skills that enable them to make meaningful changes quickly, thereby increasing motivation and commitment. The therapist takes an active approach in helping the patient delineate long-term therapeutic goals. Techniques here are: 1) assertiveness training 2) behavioural assignments 3) stimulus control.

Stage 2: enhancement of self-esteem

This begins with exploration aimed at uncovering the roots of the patient’s negative self-view and gradually incorporates various cognitive restructures designed to change this thought pattern. Patients are provided with coping self-statements that bolster their self-efficacy and enable them to manage negative affect on their own.

Stage 3: promotion of autonomy

As patients begin to show evidence of enhanced self-esteem, the focus of therapy shifts to increasing autonomous behaviour within and outside therapy, and reducing the patient’s dependence upon the therapist. The therapist encourages the patient to take increasing responsibility for structuring the interaction.

Stage 4: prevention

The patient is taught to anticipate potential problems and reframe setbacks so they are not magnified into global failure experiences. High-risk situations are identified and patients are taught alternative ways of responding.