Dependent Personality Disorder
The essential feature of Dependent Personality Disorder is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. This pattern begins by early adulthood and is present in a variety of contexts. The dependent and submissive behaviors are designed to elicit caregiving and arise from a self-perception of being unable to function adequately without the help of others.
Individuals with Dependent Personality Disorder have great difficulty making everyday decisions (e.g., what color shirt to wear to work or whether to carry an umbrella) without an excessive amount of advice and reassurance from others (Criterion 1). These individuals tend to be passive and to allow other people (often a single other person) to take the initiative and assume responsibility for most major areas of their lives (Criterion 2). Adults with this disorder typically depend on a parent or spouse to decide where they should live, what kind of job they should have, and which neighbors to befriend. Adolescents with this disorder may allow their parent(s) to decide what they should wear, with whom they should associate, how they should spend their free time, and what school or college they should attend. This need for others to assume responsibility goes beyond age-appropriate and situation-appropriate requests for assistance from others (e.g., the specific needs of children, elderly persons, and handicapped persons). Dependent Personality Disorder may occur in an individual who has a serious general medical condition or disability, but in such cases the difficulty in taking responsibility must go beyond what would normally be associated with that condition or disability.
Because they fear losing support or approval, individuals with Dependent Personality Disorder often have difficulty expressing disagreement with other people, especially those on whom they are dependent (Criterion 3). These individuals feel so unable to function alone that they will agree with things that they feel are wrong rather than risk losing the help of those to whom they look for guidance. They do not get appropriately angry at others whose support and nurturance they need for fear of alienating them. If the individual's concerns regarding the consequences of expressing disagreement are realistic (e.g., realistic fears of retribution from an abusive spouse), the behavior should not be considered to be evidence of Dependent Personality Disorder.
Individuals with this disorder have difficulty initiating projects or doing things independently (Criterion 4). They lack self-confidence and believe that they need help to begin and carry through tasks. They will wait for others to start things because they believe that as a rule others can do them better. These individuals are convinced that they are incapable of functioning independently and present themselves as inept and requiring constant assistance. They are, however, likely to function adequately if given the assurance that someone else is supervising and approving. There may be a fear of becoming or appearing to be more competent, because they may believe that this will lead to abandonment. Because they rely on others to handle their problems, they often do not learn the skills of independent living, thus perpetuating dependency.
Individuals with Dependent Personality Disorder may go to excessive lengths to obtain nurturance and support from others, even to the point of volunteering for unpleasant tasks if such behavior will bring the care they need (Criterion 5). They are willing to submit to what others want, even if the demands are unreasonable. Their need to maintain an important bond will often result in imbalanced or distorted relationships. They may make extraordinary self-sacrifices or tolerate verbal, physical, or sexual abuse. (It should be noted that this behavior should be considered evidence of Dependent Personality Disorder only when it can clearly be established that other options are available to the individual.) Individuals with this disorder feel uncomfortable or helpless when alone, because of their exaggerated fears of being unable to care for themselves (Criterion 6). They will "tag along" with important others just to avoid being alone, even if they are not interested or involved in what is happening.
When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), individuals with Dependent Personality Disorder may urgently seek another relationship to provide the care and support they need (Criterion 7). Their belief that they are unable to function in the absence of a close relationship motivates these individuals to become quickly and indiscriminately attached to another person. Individuals with this disorder are often preoccupied with fears of being left to care for themselves (Criterion 8). They see themselves as so totally dependent on the advice and help of an important other person that they worry about being abandoned by that person when there are no grounds to justify such fears. To be considered as evidence of this criterion, the fears must be excessive and unrealistic. For example, an elderly man with cancer who moves into his son's household for care is exhibiting dependent behavior that is appropriate given this person's life circumstances.
Associated Features and Disorders
Individuals with Dependent Personality Disorder are often characterized by pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to themselves as "stupid." They take criticism and disapproval as proof of their worthlessness and lose faith in themselves. They may seek overprotection and dominance from others. Occupational functioning may be impaired if independent initiative is required. They may avoid positions of responsibility and become anxious when faced with decisions. Social relations tend to be limited to those few people on whom the individual is dependent. There may be an increased risk of Mood Disorders, Anxiety Disorders, and Adjustment Disorder. Dependent Personality Disorder often co-occurs with other Personality Disorders, especially Borderline, Avoidant, and Histrionic Personality Disorders. Chronic physical illness or Separation Anxiety Disorder in childhood or adolescence may predispose the individual to the development of this disorder.
Specific Culture, Age, and Gender Features
The degree to which dependent behaviors are considered to be appropriate varies substantially across different age and sociocultural groups. Age and cultural factors need to be considered in evaluating the diagnostic threshold of each criterion. Dependent behavior should be considered characteristic of the disorder only when it is clearly in excess of the individual's cultural norms or reflects unrealistic concerns. An emphasis on passivity, politeness, and deferential treatment is characteristic of some societies and may be misinterpreted as traits of Dependent Personality Disorder. Similarly, societies may differentially foster and discourage dependent behavior in males and females. This diagnosis should be used with great caution, if at all, in children and adolescents, for whom dependent behavior may be developmentally appropriate. In clinical settings, this disorder has been diagnosed more frequently in females, although some studies report similar prevalence rates among males and females.
Dependent Personality Disorder must be distinguished from dependency arising as a consequence of Axis I disorders (e.g., Mood Disorders, Panic Disorder, and Agoraphobia) and as a result of general medical conditions. Dependent Personality Disorder has an early onset, chronic course, and a pattern of behavior that does not occur exclusively during an Axis I or Axis III disorder.
Other Personality Disorders may be confused with Dependent Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Dependent Personality Disorder, all can be diagnosed. Although many Personality Disorders are characterized by dependent features, Dependent Personality Disorder can be distinguished by its predominantly submissive, reactive, and clinging behavior. Both Dependent Personality Disorder and Borderline Personality Disorder are characterized by fear of abandonment; however, the individual with Borderline Personality Disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline Personality Disorder can further be distinguished from Dependent Personality Disorder by a typical pattern of unstable and intense relationships. Individuals with Histrionic Personality Disorder, like those with Dependent Personality Disorder, have a strong need for reassurance and approval and may appear childlike and clinging. However, unlike Dependent Personality Disorder, which is characterized by self-effacing and docile behavior, Histrionic Personality Disorder is characterized by gregarious flamboyance with active demands for attention. Both Dependent Personality Disorder and Avoidant Personality Disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals with Avoidant Personality Disorder have such a strong fear of humiliation and rejection that they withdraw until they are certain they will be accepted. In contrast, individuals with Dependent Personality isorder have a pattern of seeking and maintaining connections to important others, rather than avoiding and withdrawing from relationships.
Dependent Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).
Many individuals display dependent personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Dependent Personality Disorder.
Diagnostic criteria for 301.6 Dependent Personality Disorder
A pervasive and 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, as indicated by five (or more) of the following:
(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 his or her life
(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.
(4) has difficulty initiating projects or doing things on his or her 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 himself or herself
(7) urgently seeks another relationship as a source of care and support when a close relationship ends
References* Morrison, James. DSM-IV Made Easy: The Clinician's Guide to Diagnosis. New York: The Guilford Press, 1995.
* Gale Encyclopedia of Psychology, 2nd ed. Gale Group, 2001.
* Bornstein, Robert F. "Implicit and Self-Attributed Dependency Needs in Dependent and Histrionic Personality Disorders." Journal of Personality Assessment, no. 1 (1998): 1-14.
* Bornstein, Robert F. "Histrionic Personality Disorder, Physical Attractiveness, and Social Adjustment." Journal of Psychopathology and Behavioral Assessment, no. 1 (1999): 79-94.
* Hilsenroth, Mark J., Daniel, J. Holdwick, Jr., Frank D. Castlebury, and Mark A. Blais. "The Effects of DSM-IV Cluster B Personality Disorder Symptoms on the Termination and Continuation of Psychotherapy." Psychotherapy, no. 2 (Summer 1998): 163-176.