Dependent Personality Disorder - A Review of Etiology and Treatmen
Dependent Personality Disorder - A Review of Etiology and Treatmen
Dependent Personality Disorder - A Review of Etiology and Treatmen
Volume 1
Article 7
Issue 2 Spring 2009
3-1-2009
Recommended Citation
Faith, Chasidy (2009) "Dependent Personality Disorder: A Review of Etiology and Treatment," Graduate Journal of Counseling
Psychology: Vol. 1: Iss. 2, Article 7.
Available at: http://epublications.marquette.edu/gjcp/vol1/iss2/7
Faith: Dependent Personality Disorder: A Review of Etiology and Treatmen
Dependent Personality Disorder: A Review of
Etiology and Treatment
Chasidy Faith
Abstract: Dependent personality disorder (DPD) is one of the most common personality
disorders seen in mental health clinics. Those with DPD tend to cling to others and have an
extreme need to be taken care of. Many of the diagnostic issues involve the comorbidity of
DPD, especially with avoidant personality disorder. There are a wide range of theories that
attempt to explain the etiology and treatment of DPD including: biological, environmental,
social learning, and cognitive perspectives. Future research in process and outcome would
benefit DPD, along with information about the comorbidity and cultural views for DPD. This
paper will briefly examine the diagnostic concerns, ideas about etiology and treatment, and
some of the historical and contextual issues related to DPD.
We have all been completely dependent on another person during our
lifetime, although for many of us this only occurred during our younger
years. Bornstein (1992) makes an important statement, “A few life
experiences are so widely shared by people of different backgrounds that
they transcend the boundaries of culture, gender, and ethnicity” (p. 3).
Dependency is one of these experiences. Even when we have grown‐up, we
still show some degree of dependency on others and have a need for
support, guidance, and approval from others, especially during stressful
times (Bornstein, 1996). Dependency becomes a form of psychopathology
when there is abnormal dependency and it causes personal distress and/or
functional impairment (Sperry, 2003).
Personality disorders are enduring patterns in our behaviors and with
dependent personality disorder (DPD) this pattern involves submissive,
clinging behavior in which a person has an extreme need to be taken care
of (American Psychiatric Association [APA], 2000; Perry, 2005). This
pattern begins by early adulthood. These individuals may down play their
assets and refer to themselves as stupid (APA, 2000). Sperry (2003)
comments there is generally a lack of self‐confidence, great discomfort in
being alone, self‐doubting, and approval seeking found with DPD. People
with DPD may easily be taken advantage of because they are so compliant,
agreeable, and trusting of others (Ansell & Grilo, 2007; Sperry, 2003).
DPD is part of the Cluster C personality disorders, along with avoidant
and obsessive‐compulsive personality disorders, which are all considered
the anxious and fearful type (APA, 2000; Seligman & Reichenberg, 2007).
Being among the most commonly diagnosed personality disorder, DPD is
found in about 14% of people who have personality disorders and about
2.5% of the general population (Seligman & Reichenberg, 2007; Sperry,
2003). Other estimates have shown a median prevalence rate of 20%, with
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a range from 2% to 55% (Fossati, et al., 2006). Although Cluster C
personality disorders, including DPD, show high base rates they still have
been studied less than other personality disorders (Endler & Kocovski,
2002; Fossati, et al., 2006; Gude, Hoffart, Hedley, & Ro, 2004).
In order to diagnose a person with DPD, they must exhibit five or
more of the eight criteria that are listed in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition Text Revision (DSM‐IV‐TR,
APA, 2000). These criteria include the ideas and concepts to follow. First,
making simple everyday decisions is a great challenge, especially when
others are not giving advice or reassurance. Second, a person with DPD
wants others to be responsible for decisions involving the major areas in
his or her life such as what career to follow, where to live, or possibly even
when to have children. According to Sperry (2003) this is the optimal
criterion, meaning using this criterion in diagnosing DPD has been shown
to be the most useful. Third, they may say they agree with others when in
reality they do not. The agreement is preferred because of a fear they will
otherwise lose peoples’ support. Fourth, due to a great lack in self‐
confidence it becomes very difficult to begin projects on their own. The
fifth criterion states that a person will go to extreme lengths and endure
unpleasant events. These events could be minor, such as going to a
restaurant they do not particularly care for, or severe such as tolerating
physical and/or sexual abuse (APA, 2000). Sixth, many times being alone
is just simply not an option and is very uncomfortable. Therefore, the
seventh criterion says that when one relationship comes to end another
quickly begins. People with DPD believe they cannot function on their
own. Finally, the eighth criterion notes that because of a belief that they
are dependent on others’ advice and help there is a fear of abandonment
which will mean they will have to care for themselves.
Diagnostic issues have been noted, especially involving the
comorbidity of DPD. For example, 43% of the people diagnosed with
avoidant personality disorder (APD) also met the criteria for DPD; 59% of
patients with DPD met criteria for APD (Fossati, et al., 2006). This leaves
one to question if these two criteria sets are distinguishable from one
another. Fossati et al. (2006) made an important finding regarding criteria
1 thru 5 for DPD and criterion 4 with APD diagnoses. These criteria,
“…were not efficient indicators of the respective latent variables” (p. 200).
This raises a big issue with DPD because 62.5% of the diagnostic
identifiers are involved in criteria 1 thru 5. An example is given comparing
criterion 3 for DPD, difficulty expressing disagreement, and criterion 4 for
APD, excessive fear of being criticized. The criterion for DPD may be
related to either a great need for dependency or to this fear of being
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Faith: Dependent Personality Disorder: A Review of Etiology and Treatmen
criticized. Therefore, Fossati et al. (2006) argue that the convergent and
within‐cluster discriminant validity needs further consideration.
DPD has also been shown to be comorbid with mood and anxiety
disorders, such as depression, phobias, obsessive‐compulsive, and alcohol
abuse (APA, 2000; Bornstein, 1992; Ng & Bornstein, 2005). Ansell and Grilo
(2007) state that patients have poorer outcomes when they have the
combination of mood and/or anxiety disorder along with dependency
traits. Since DPD is so often co‐occurring with other disorders, it is
important to understand what effects comorbidity has on individuals. Yet,
there is little known about how comorbidity affects DPD or the treatments
that may be more useful for these individuals.
Etiology
Many ideas have been developed about the etiology of DPD. Early
studies of dependent personality traits were looked at psychoanalytically
(Bornstein, 1992, 1996). These traits were associated with breastfeeding
and weaning. Those who became fixated at the oral stage would remain
dependent on others for support. It was thought that high levels of
dependency came from either frustration or overgratification during the
oral stage, although research in this area has shown inconclusive results
(Bornstein, 1996).
Studies have determined two parenting styles that lead to high levels
of dependency in children (Bornstein, 1996). First, authoritarian parenting
may create dependency. This is partly because this style of parenting
prevents children from learning through trial‐and‐error, which is one way
children develop autonomy and feelings of self‐efficacy. Secondly,
overprotective parenting can lead to high levels of dependency. Similar to
authoritarian parenting, overprotective parenting makes children believe
they cannot function on their own without the help, guidance, and
support of others. It is important to note that studies have also shown
dependent behaviors in children may encourage and reinforce parents’
overprotectiveness and increase their demandingness (Bornstein, 1992).
In response to these early experiences within the family, cognitive
structures are formed (Bornstein, 1992, 1996; Sperry, 2003). Children may
develop beliefs and mental representations about their own self‐efficacy
and the power of others. Perry (2005) noted that a cognitive
conceptualization has been created by some people who suggest these
individuals first believe they are inadequate and helpless, followed by
thinking that the best strategy to fix this is to find someone who may be
able to deal with the world and protect them. Therefore, these children
may be developing mental representations of themselves being helpless,
inadequate, and failing on their own. This then leads them to seek out
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other people to depend on in order to survive. Eskedal and Demetri
(2006) discuss information on biological issues that may influence the
development of DPD. Infants who have fearful, withdrawing, or sad
temperaments and those with prolonged health issues during childhood
may force parents to become overprotective, which in turn may lead to
DPD. Interestingly, endomorphic and ectomorphic body types, which are
common for dependent people, may also create more concern from
parents (Eskedal & Demetri, 2006). These body types have low energy
thresholds, which may create concern in parents.
Another view on the etiology of DPD is from social learning, simply
stating people learn to be dependent (Bornstein, 1992). Initially it was
believed that dependency was an acquired drive, although the importance
of social reinforcement then became evident. People develop DPD because
their dependency was or still is rewarded. One of the issues involved in
this view is that children are experiencing conflict because they are taught
to obey authority figures and to depend on these people for guidance and
protection, yet they are also being taught to be creative and autonomous
(Bornstein, 1992).
Historical and Contextual Issues Related to DPD
While there does not seem to be much research on culture and DPD,
it is noted that consideration needs to be made regarding one’s culture
(APA, 2000; Perry, 2005). The diagnostic criteria need to be considered in
light of the person’s cultural norms because some cultures value
characteristics such as passivity. Similarly, diagnosing DPD needs to be
used with great caution, and perhaps not at all, with children and
adolescents. It is essential to distinguish dependent behaviors that are
developmentally appropriate from those that are not (APA, 2000).
More research and time has been spent looking at the differences that
genders exhibit with DPD. Usually, DPD has been found to be more
prevalent in females, although how much more prevalent is still up for
debate (Bornstein, 1992; Eskedal & Demetri, 2006; Fossati, et al., 2006;
Klonsky, Jane, Turkheimer, & Oltmanns, 2002; Loranger, 1996; Perry,
2005). Fascinatingly, when using projective measures of dependency,
versus self‐report, the typical finding is that men and women show similar
levels of dependency (Bornstein, 1992; Eskedal & Demetri, 2006).
Bornstein (1992) has postulated a theory about why males and females
may show similar findings when the test is projective and not a self‐report.
In general, self‐report measures of dependency will ask direct questions
about dependent traits, feelings, and behaviors. Males will be less likely
than females to recognize and admit these dependent traits. When using
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Faith: Dependent Personality Disorder: A Review of Etiology and Treatmen
projective measures, the client is asked to respond to ambiguous stimuli,
often being asked to provide open‐ended descriptions. The client is
unaware of what is exactly being looked for, so they will not distort their
responses on the basis of what is socially desirable (Bornstein, 1992).
Another captivating trend regarding gender and prevalence rates is
that longitudinal studies show little if any difference during early
childhood in boys and girls dependency levels, however there is an
increase in dependency differences as a child’s age increases (Bornstein,
1992). This change in the prevalence of dependency may be accounted for
by the traditional sex role that socialization practices. In general, boys are
discouraged from expressing their feelings and needs of dependency, but
girls are usually encouraged to do so (Bornstein, 1992). Role models, such
as parents, teachers, siblings, etc. encourage this behavior even through
subtle messages. The extent that men and women play out these
socialized sex roles may also determine if they will develop psychopathic
dependency. It has been shown that married women who follow the
traditional sex role receive significantly higher scores on the dependency
scale (Dy) for the Minnesota Multiphasic Personality Inventory (MMPI)
versus women reporting that they live a reversal of the traditional sex roles
in their marriage (Bornstein, 1992). In addition, Klonsky et al. (2002)
found that higher femininity and lower masculinity were both associated
with dependent traits, regardless of one’s actual gender.
Treatment of DPD
When working with DPD it is important to keep in mind a few things
throughout the treatment planning and intervention processes. First,
these clients depend on others and therefore may view their therapist as
another person to rely on (Seligman & Reichenberg, 2007). This reliance
may initially be seen in their lack of communication if the therapist does
not direct or ask the client what to discuss (Sperry, 2003). They may work
very hard to please the therapist, which can be used to develop rapport
and encourage an increased independence. Also, to develop rapport it is
important to demonstrate a lot of support and acceptance. It may be
helpful to begin in a directive and structured manner in order to give
sessions a focus. Seligman and Reichenberg (2007) note the overall goal is
to promote a clients’ self‐reliance, self‐expression, and autonomy in the
safety of counseling and to then transfer these characteristics outside of
the sessions. Terminations may be difficult and caution needs to be taken
so the client does not feel abandoned. Therapists must be aware that
clients with DPD, more than any other client, are more apt to develop a
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romantic attachment to the therapist (Seligman & Reichenberg, 2007).
Therefore, setting clear boundaries are of the utmost importance.
There are a variety of treatment approaches for DPD, although there is
concern because few, if any, controlled treatment outcome studies have
been completed (Sperry, 2003). Much of the treatment literature contains
case descriptions, uncontrolled studies, and some controlled trials that
contain a mixture of personality disorders (Perry, 2005). Keeping the lack
of research in mind, psychodynamic is one approach that may be used.
Psychodynamic therapy attempts to help clients better cope with object
losses and/or previous separations (Eskedal & Demetri, 2006; Sperry,
2003). Transference is thus important and the client is allowed to see the
therapist as this lost object or relationship. When a good therapeutic
relationship has been developed, the transference is recognized and
provides insight into the client’s problems while helping resolve the
client’s therapeutic issues (Eskedal & Demetri, 2006; Perry, 2005; Sperry,
2003).
Time‐limited psychodynamic therapy has been said to be the
treatment of choice for clients with DPD (Eskedal & Demetri, 2006;
Sperry, 2003). Long‐term psychodynamic therapy will allow a greater
transference to occur which can be used to promote emotional growth,
although this can take three or more years (Sperry, 2003). Today, this
amount of time is not likely to be spent in therapy for a variety of reasons.
Clients who have limited ego strength or a great degree of separation
anxiety may not benefit from either short or long term psychodynamic
therapy as much as they would from something else, such as a supportive
treatment approach (Eskedal & Demetri, 2006). One last thing to note
with psychodynamic therapy is the possibility of countertransference
toward the client, often of contempt or disdain because of the dependency
the client has on the counselor (Eskedal & Demetri, 2006).
Cognitive‐behavioral therapy (CBT) is also used for DPD, with the
goal of increasing a person’s autonomy and self‐efficacy (Sperry, 2003).
Allowing some dependence initially is important so the client becomes
engaged. As this relationship is formed, the therapist may challenge
dichotomous beliefs, such as the need to either be dependent or
independent with no in‐between. Therapists should note what triggers a
client. For example, situations in which a client faces being alone may
trigger the client’s maladaptive patterns, which then causes anxiety
(Eskedal & Demetri, 2006; Perry, 2005). Knowing these triggers will allow
the client to learn more adaptive ways to deal with difficult situations. The
behavioral techniques used involve techniques such as assertiveness
training or dating skills, homework, relaxation training, and role playing
(Perry, 2005; Sperry, 2003).
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Group psychotherapy has also been demonstrated to be successful in
treating DPD (Sperry, 2003). However, group therapy is not advised for
those with severe impairment or a lack of prosocial behavior. In addition,
it should be determined if the client should be placed in a group that only
targets dependency issues, or a group with mixed personality disorders
(Sperry, 2003). Caution should be used so the client does not become lost
in mixed groups. Furthermore, it should be noted that DPD homogeneous
groups establish cohesion more quickly, offer instantaneous support, and
may provide relief of symptoms at a greater pace (Eskedal & Demetri,
2006). A group setting will allow clients to try out adaptive behaviors
while still being in a supportive setting (Eskedal & Demetri, 2006).
Although it may make sense that marital and family therapy may be
very helpful, because DPD involves being dependent on someone,
professional literature on these interventions is basically nonexistent
(Sperry, 2003). Perry (2005) states that there are no studies that examine
using only family therapy for DPD. When the dependency involves a
family member or members, it may be helpful to include them to facilitate
the client’s progress outside of counseling. Doing so may reduce the
amount of time it takes to help the client and also give support to the
family members (Perry, 2005; Sperry, 2003). The therapist needs to
identify what in the family or relationship is encouraging the dependency
and help the family develop workable goals (Perry, 2005).
Day and residential therapies are used with clients who require a high
level of support and treatment intensity (Perry, 2005). These patients
often have other co‐occurring Axis I and Axis II disorders. The therapy
used with these particular individuals generally includes a mixture of
individual and group therapy, and possibly other services such as
occupational or expressive therapies (Perry, 2005). The duration for day
treatment programs may range from 18 weeks to a year or more, while
residential programs are more long term and for those who have not
improved or have deteriorated with outpatient therapy or while living on
their own (Perry, 2005). Day and residential therapies are said to be
helpful, but there are not a great number of studies noted to support this
statement.
Medications may be used in combination with therapies, although
there are cautions in doing this. Often people diagnosed with DPD also
have Axis I diagnoses, such as depression and anxiety, which may benefit
from medication (Sperry, 2003). If a client is not diagnosed with an Axis I
disorder along with DPD, medication should probably not be used
because it may be abused (Eskedal & Demetri, 2006; Sperry, 2003).
Interestingly enough, because of dependent client’s help‐seeking
behaviors, physicians will often prescribe medications because of the
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client’s persistent complaints (Eskedal & Demetri, 2006). To support this
idea, Eskedal and Demetri (2006) note one study found that DPD patients
in a hospital setting received nearly 50% more medications as compared to
nondependent patients with similar Axis I diagnoses, possibly due to this
help‐seeking behavior.
With all of these treatments listed, there still seems to be a need for
studies on the effectiveness of each. There is some support for most of the
treatments, but the lack of research on effective treatments has been
surprising. During this review, there were not any studies found
examining what exactly makes therapy work, for example the mediators
and moderators of therapy. Dependency itself and the etiology of
dependency seem to have a large amount of literature, including
perspectives of different theories. However, DPD would benefit from more
empirical support for treatments, with a focus on process and outcome
research. With that being said, the prognosis for DPD seems to be
relatively good (Perry, 2005; Seligman & Reichenberg, 2007; Sperry, 2003).
Some reasons for this prognosis include: clients with DPD can form
relationships and make commitments, they can ask for help, and they are
trusting (Seligman & Reichenberg, 2007). This good prognosis may take a
significant amount of time, such as months or years, but it can be reached
(Perry, 2005).
During treatment there may be some great obstacles to overcome,
which may affect the amount of time therapy will take. One of these
obstacles involves the client experiencing a significant loss or separation in
their personal support (Perry, 2005). With the need to depend on others,
suddenly not having this other person available may overwhelm the client
and result in a regression in therapy for the skills that have been learned.
Perry (2005) notes that it is important for the therapist in this situation to
be supportive, offering some suggestions and direction, while at the same
time accepting the interruption or delay in the client’s growth.
Perry (2005) discusses five other challenges that may often arise in
treating a client diagnosed with DPD. First, as is characteristic of DPD, a
client who begins therapy may make many requests for advice and help
that the therapist is unable to give. Second, clients may place the therapist
in a role of the dominant person who should take responsibility for
decisions and tell the client how to run his or her life. The third challenge
entails the client not making changes outside of therapy in order to keep
the emotional attachment with the therapist. Fourth, it may be difficult
when a client has punitive and unsatisfying relationships. Hearing
repeated stories about mistreatment may make a therapist have a desire to
either control the client’s self‐defeating pattern or punish them, perhaps
unknowingly, for not changing. The client may then feel torn between
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pleasing the therapist and being punished by his or her partner in the
relationship outside of counseling. Finally, there are clients who avoid
dealing with their separation issues in therapy. This may lead to
difficulties during termination if the therapist does not address this
avoidance. All of these issues can produce great obstacles in treatment.
Conclusion
In summary, DPD is a common issue seen in therapy. It is important
to be knowledgeable about its etiology and treatment options in order to
better serve clients. With the great range of ideas about the etiology and
treatment of DPD, along with the lack of research available, there
continues to be many unanswered questions. Studies that are better
designed and more controlled would benefit the DPD literature, because
there is a current lack of evidence‐based treatments for this disorder.
Fortunately, there seems to be a good prognosis for individuals diagnosed
with DPD. Part of this may be because these clients are generally easier to
develop a rapport with since they lean on others for support. Therapists
can use this to their advantage, as long as they keep clear boundaries and
help clients become more independent with time.
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Chasidy Faith
Chasidy Faith received her BA from the University of Wisconsin‐Stevens
Point, double majoring in Psychology and Spanish. She is currently working
on her MA degree in counseling at Marquette University. She plans to
continue her education to pursue a PhD in order to be a practicing
psychologist and teach at the university level.
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