Dependent personality disorder
Threatened by self-reliance, they take shelter in submission.
To be sure, people need people. We survive as social creatures. Mental health is partly defined by strong emotional attachments to the people we love and a supple interdependence. Any of us may become perturbed when important people disappoint us. But for some, the relationship becomes one-sided and fraught. Although the distinction between normal and unhealthy dependence may be a matter of degree, psychiatrists have identified a personality disorder associated with such one-sided relationships.
People with dependent personality may submit to the will of others in a misguided attempt to extract a promise of care and protection. They may think of themselves, or present themselves, as unable to cope with everyday life on their own. At the same time, they may fear that a show of confidence or competence will lead to rejection and abandonment. They demand advice and reassurance when making even minor decisions. They take no initiative and let others assume responsibility for their lives — even, sometimes, where to live and what jobs to take. Because they intensely fear disapproval, they may be excessively ingratiating. They find it difficult to disagree or refuse requests, especially from anyone they depend on. They allow themselves to be intimidated and avoid even justified anger for fear of alienating others. To gain the support they think they need, they may volunteer for unpleasant tasks, submit to unreasonable demands, and tolerate verbal, physical, or sexual abuse.
Dependency in psychiatric disorders
Personality disorders have overlapping symptoms, and a person who fulfills the diagnostic requirements for one will often fulfill the requirements for others. Dependent personality belongs to a group of anxious or fearful disorders that also includes avoidant personality — painfully shy, inhibited, and withdrawn. But it also has characteristics in common with histrionic personality — self-dramatizing, suggestible, seductive, and constantly starved for attention. In histrionic personality, the need for approval and protection appears to be directed at the world in general rather than at individuals.
Personality disorders also heighten vulnerability to a variety of psychiatric illnesses. Personality has been compared loosely to the immune system and psychiatric disorders to other medical illnesses. Just as a poorly functioning immune system opens the door for many diseases, so may dependent personality. The diagnosis is particularly intimately associated with depression; separation anxiety, the fear of being apart from a loved person; somatoform disorders, unexplained physical symptoms with an emotional basis; and social anxiety disorder, the crippling dread of personal encounters and social situations.
People with dependent personality disorder develop separation anxiety because they feel abandoned when not in the presence of those they rely on. They are at risk for social phobia because they don't like to leave familiar people and surroundings. They may use physical symptoms as a way to receive sympathy, protection, and care. All of us feel some distress when we don't receive the support we believe we require, when we lose a close relationship, or when we must assume responsibilities for which we feel unprepared. But the risk of depression is much higher in people with dependent personality, especially if they lack the social skills needed to maintain relationships with others.
The seed of personality is temperament — biological dispositions with a hereditary basis. People with dependent personality have usually shown a tendency to caution and fear of novelty since childhood. In their families, there is a high rate of generalized anxiety disorder and phobias, as well as avoidant personality.
But as we are often warned, genes are not destiny. What turns a temperamentally shy or fearful child into an adult with a personality disorder is uncertain. The most popular explanations are psychodynamic and behavioral.
Psychodynamic theorists and therapists believe that unconscious emotional conflicts — experiences and feelings out of awareness — and the unconscious defenses we erect against them shape personality traits. Disorders are thought to arise if, for example, problems in early relationships lead a person to develop defenses that are not effective, adaptive, or useful. According to one psychodynamic theory, dependent personalities are defending themselves against unconscious hostility. They need to ward off this emotion, which was originally directed against overbearing parents, so they submit to others as a way to avoid showing or even acknowledging anger.
For many years, the psychodynamic understanding of personality disorders has been influenced by object relations theory, which emphasizes the power of internalized images of persons who matter to us, especially parents. It is also influenced by the theory of attachment, the biological need for comfort and support embodied in the relationship between parents and young children. Establishing healthy early attachments and retaining comforting psychological images of reliable caretakers provide a solid base from which to explore the world and achieve a balance between independence and closeness to others. If parents are unresponsive, inconsistent, or abusive, children may develop a fearful or insecure form of attachment, which they internalize as a model and adopt in later relationships. They also have more trouble soothing or calming themselves when they are frustrated, angry, or anxious. One result of this pattern of development is dependent personality.
According to behavioral and social learning theory, children develop the habits that constitute a personality through two kinds of learning: conditioning (automatic associations) and reinforcement (reward and punishment). In this model, a child who is rewarded for making excessive demands for care can develop a dependent personality. Others develop expectations that reinforce the tendency toward dependence. If parents are inconsistent, children may learn that they cannot control their lives. A child who has never been rewarded for independent action may avoid it even when it would be valued because the early lesson has been learned too well.
Cognitive psychology views dependency as a result of the way people think about themselves and others. Dependent personalities tell themselves that they are powerless and others are powerful and effective. Parents may provide a model for this kind of thinking by subtly conveying to children that they will be abandoned and alone unless they submit.
One possibility is that dependent personality begins with a gentle and easily frightened temperament that evokes protective feelings. Overanxious parents who discourage independence, or a bullying brother or sister, reinforce the tendency. Constantly sheltered, the submissive child becomes still more passive, and others develop expectations that make the behavior and attitudes difficult to change. It then reappears repeatedly in later childhood and adult relationships.
Bornstein RF. "The Dependent Personality: Developmental, Social, and Clinical Perspectives," Psychological Bulletin (July 1992): Vol. 112, No. 1, pp. 3–23.
Bornstein RF. "The Complex Relationship between Dependency and Domestic Violence: Converging Psychological Factors and Social Forces," American Psychologist (September 2006): Vol. 61, No. 6, pp. 595–606.
Gude T, et al. "The Quality of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Dependent Personality Disorder Prototype," Comprehensive Psychiatry (November–December 2006): Vol. 47, No. 6, pp. 456–62.
Leising D, et al. "Characteristic Interpersonal Behavior in Dependent and Avoidant Personality Disorder Can Be Observed within Very Short Interaction Sequences," Journal of Personality Disorders (August 2006): Vol. 20, No. 4, pp. 319–30.
Luyten P, et al. "Dependency and Self-Criticism: Relationship with Major Depressive Disorder, Severity of Depression, and Clinical Presentation," Depression and Anxiety. Published online December 1, 2006, at www3.interscience.wiley.com.
Tyrer P, et al. "The Dependent Personality Questionnaire: A Screening Instrument for Dependent Personality," International Journal of Social Psychiatry (March 2004): Vol. 50, No. 1, pp. 10–17.
For more references, please see www.health.harvard.edu/mentalextra.
Kinds of dependency
Considering only what people say about themselves, one might conclude that girls and women show more dependent traits and dependent personality than boys and men. Some think that the social roles imposed on the sexes account for this difference; men in our society are not encouraged to admit dependence. Others think that dependent traits create the sex roles. But dependency in men (and some women) may take less obvious forms, just as depression may masquerade as alcoholism or abusive violence. Men who do not acknowledge dependence may show their need in other ways.
Some students of dependent personality separate the symptoms defined by the American Psychiatric Association (see sidebar) into two categories. The first five symptoms reflect problems in assuming responsibility, making decisions, and showing disagreement. The last three involve fears of being abandoned and helpless. These fears may rule men who do not have difficulty asserting themselves and therefore do not receive a diagnosis of dependent personality.
Dependent personality disorder defined
Excessive need for care that leads to clinging and submissive behavior, as indicated by five or more of the following:
Has difficulty making everyday decisions without excessive advice and reassurance.
Needs to have others assume responsibility for most aspects of his or her life.
Has trouble expressing disagreement because of fear of losing approval or support.
Rarely initiates projects or does anything on his or her own because of low self-confidence.
Goes to great lengths to get care from others.
Feels uncomfortable or helpless when alone.
Urgently seeks another relationship whenever a close relationship ends.
Is unrealistically preoccupied with fear of being left to take care of himself or herself.
Adapted from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000.
This kind of dependency is compatible with a surprising degree of aggression. The need for care and support can lead to abusive behavior, intimidation, and violence. A jealous man who abuses his wife or partner may be displaying this kind of dependency. Dependent men are especially at risk of becoming abusers when they fear that the partner is about to leave or getting too close to another person. Some think that therapists treating abusive men need to confront the issue of dependency more often.
Despite what many assume, studies have not found a high rate of dependent personality among abused women in general. Many of these women show apparent dependent traits mainly because they are terrorized, isolated, economically dependent, or worried about their children. But when the most severely abused women are taken as a separate group, there is some evidence that dependent personality is more common — perhaps because such women are more vulnerable to begin with, or find it more difficult to leave even when that would be the best choice.
Dependent personality in action
An experiment has shown that it's possible to observe the signs of dependent personality even in a brief encounter with a stranger. Nearly 100 women, half of them psychology students and the other half recruited by advertisements requesting people who "often experienced problems with other people," answered standard interview questions designed to diagnose personality disorders. Then they were asked to participate in an improvised skit in which they confronted a waitress who brought the wrong order, a friend angling for a loan, and a persistent door-to-door salesman. Observers judging how well they stood up for themselves found that both dependent and avoidant personality traits were linked to low assertiveness, but for different reasons. Women with avoidant personality traits treated their own needs as unimportant; those with dependent traits were afraid they would not be liked.
People with dependent personality disorder may seek treatment when they lose a close relationship or if they are obliged to assume unaccustomed responsibilities. The most common approaches to treatment are psychodynamic and behavioral.
In psychodynamic therapy, patients explore past relationships that fostered dependent behavior and learn how these are reflected in internalized images of themselves and others and in the relationship with the therapist. Cognitive therapists question the patient's thinking, exposing and correcting unrealistic judgments based on false implicit beliefs. They emphasize that the opposite of submission is not control over others but independence and confidence. They examine and question self-denigrating internal monologues and thoughts of helplessness.
Behavioral therapists try to alter cause-effect relationships and incentives that promote compulsive care-seeking. They identify features of the patient's environment that appear to reward displays of incompetence and try to provide the patient with the skills needed to cope in other ways. Role-playing and homework may help, along with correction in which the patient's relationship with the therapist is used as a model.
People with dependent personality can be rewarding to treat because they need personal contact and are open to discussing their problems. They are usually conscientious and cooperative; they don't miss sessions and rarely quit therapy prematurely. Because they want to please authority figures, they respond well to therapists and may confirm a therapist's optimistic expectations.
But there are also obstacles to the treatment of people with dependent personality. They may be passive and make unrealistic demands; it may seem that they can never get enough support or reassurance. Suggestibility and respect for authority can also create problems. The therapist must avoid the temptation to become a guru and tell these patients how to run their lives. It's also important to establish other boundaries to avoid involvement in the patient's life that might impede emotional growth. Often sustaining the relationship indefinitely is necessary and appropriate, but reducing the frequency of meetings over time may help the patient to become more independent.
People rarely come to a psychotherapist to have their characters transformed; they mostly want solutions to specific problems in their lives. Being dependent is normal. We are all born totally dependent on others, and human interdependence continues throughout life. Close ties with others make us feel more secure, and wanting to share experience is normal. People with strong dependent traits are particularly sensitive to the feelings of others and want to perform well, if only to please. They can lead better lives if they are helped to cultivate social skills and the capacity to show their need for guidance and protection in appropriate instead of compulsive and submissive ways. A therapist may be able to help them just enough so that a personality disorder becomes a personality type — polite, agreeable, thoughtful, disliking solitude, respectful of others' opinions, and preferring to be a follower rather than a leader.