Consult-Liaison Education Medicine

Personality Disorders (IX): Definition and Etiology of the Dependent Type.

There is very little data about dependent personality disorder. Psychoanalytic theorists have discussed their ideas about how this condition comes about, but there are few papers that discuss the reasons why it develops and what to do about it.

We’ll go through the DSM-4 criteria for it first:

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:

Yikes. Would you have ever guessed that “clinging” would become a diagnostic criterion?

(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

The thought is that the person will make the “wrong” decision or that the decision will displease other people. The decisions, though, may not appear complicated to most people. (“Which cereal should I eat? You’re not going to be mad if I eat the Cookie Crisp, right? But maybe I should go with Lucky Charms. Which do you think will taste better?”)

(2) needs others to assume responsibility for most major areas of his or her life

Again, this suggests a lack of trust in oneself to make the “right” decisions. (“Which job should I apply for? Where should I live? What kind of food should I eat?”)

(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.

Perhaps this is also a fear of abandonment (see borderline personality disorder). Also note that this criterion includes a caveat about excluding “realistic fears”, whereas in borderline personality disorder, the excessive efforts apply to either “real or imagined” abandonment.

(I suppose it is noteworthy that this criterion refers to “expressing disagreement” and the borderline criterion refers to “excessive efforts”, though both are driven by “fear”.)

(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)

Insecurity is all a matter of degree. Again, this difficulty with initiative must impair function, affect relationships, etc. Conversations like

“Where do you want to eat?”
“I don’t know, where do you want to eat?”

don’t count.

(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

Doormat” is not a clinical term, but this is what often comes to mind.

(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

This is an interesting criterion because it comments directly on emotions rather than behaviors. Sometimes we think people feel uncomfortable or helpless, though they actually feel neither. Sometimes people do feel uncomfortable and helpless, though their behaviors don’t suggest this at all.

(7) urgently seeks another relationship as a source of care and support when a close relationship ends

This criterion, as with the last one, should be taken in conjunction with the other criteria for this diagnosis.

(8) is unrealistically preoccupied with fears of being left to take care of himself or herself

Fear underpins this diagnosis and drives the behaviors that seem like “clinging”.[1. One must be careful when assuming intentions from behaviors alone. You might see me eating a sack of cookies (behavior) and assume that I lack control (intention). I might actually be eating a sack of cookies (behavior) because I hadn’t eaten all day or I don’t want to share my cookies with other people. Maybe the sack is no longer full of cookies, but I am eating quickly because I am running late. The sack may not have cookies inside. You get my point.]

Here is a paper that reports some studies that describe possible etiologies of dependent personality disorder. Some authors found a relationship between “infantile feeding experiences and later dependency”, though the data is inconsistent and subject to the mothers’ reporting bias.

When people studied interactions between infants and parents and parenting styles, they found that parents who are overprotective and authoritarian may have children who ultimately develop dependent personality disorder.

The author correctly notes that parental behavior may actually reinforce dependent behaviors in children and vice versa. If the parent derives some benefit (psychological or otherwise) from a child who shows dependent behaviors, the parent may actually increase the authoritarian and overprotective behavior because the parent “likes” the reactions. This may drive the child to demonstrate even more of these behaviors. And on and on it goes.

These observations are in direct contrast to other hypothesizes about dependent personality disorder (for which there is no data, but only speculation): Some argue that children who lose their parents at an early age (due to death, adoption, etc.) are more likely to develop dependent personality disorder. Others argue that children who have chronic physical illness are also more likely to develop this condition.

One major component to consider is “fit”.[2. To learn more about “fit”, read about attachment theory.] We don’t choose our parents or our children. Sometimes, there just isn’t a “good fit” between parents and children. Some parents are anxious, which leads to overprotectiveness and authoritarian behavior. This may increase the likelihood that the child will develop dependent personality disorder or traits. If the child had different parents, he might have a different temperament as an adult. To be clear, many children do have anxious parents and never develop this condition.

And that’s all I got for dependent personality disorder. Next up is how to manage (not treat!) these conditions in settings like shelters and supportive housing. I shan’t let that task daunt me.