Dependent Personality Disorder

Clinical Description

Individuals with this disorder have an excessive need to be taken care of by others. As such, they are characteristically submissive, clinging, and needy, ever fearful of being alone. They are reluctant to make even minor decisions, relinquishing this responsibility to others or only doing so after receiving excessive advice and reassurance. Chronically feeling inadequate, dependent individuals desperately need others to assume responsibility for them. They lack confidence in their abilities and have difficulty initiating tasks or doing things independently. Although often characterized as passive and indecisive, people with this disorder are not without their own opinions or beliefs, but if challenged, they will quickly retreat to prevent the loss of support or approval.

Individuals with Dependent Personality Disorder can be excessively self-sacrificing, willing to take on onerous or demeaning tasks as a way to secure the affection of others. In many cases, they are taken advantage of by others, yet they tolerate mistreatment and often remain in unhealthy or abusive relationships because their fear of being alone overrides their desire to be treated decently. They are also likely to be unassertive and unwilling to make demands on others, seeing themselves as not worthy of expressing themselves and also fearing disapproval. Their predominant self-perception is that of being helpless and unable to negotiate life successfully without assistance. As a result, people with this disorder typically are preoccupied with maintaining relationships and experience a constant overwhelming fear of being abandoned or cast off to fend for themselves.

When important relationships end, dependent individuals will go to great lengths to secure another supportive relationship as quickly as possible. Their fear of being alone outweighs their fear of rejection. (This ability to seek out new relationships at all costs contrasts starkly with the avoidant type who goes to great lengths not to seek out relationships.) Finally, the dependent individual tends to consider other people as being more important and competent than he or she is, responding by appeasing others and acting submissively. Table 4.2 lists the DSM-IV-TR diagnostic criteria for Dependent Personality Disorder.

Potential Age-Bias of Criteria

Two criteria for Dependent Personality Disorder may be problematical in the later-life context, especially where a dementing

Table 4.2 DSM-IV-TR Diagnostic Criteria for Dependent Personality Disorder (Code: 301.6)

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 area 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 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

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

Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.

illness is present. Older persons with cognitive impairment may show deficits in their abilities to make reasonable decisions for themselves, display previously held good judgment, and initiate constructive behaviors (lack of initiation is a classic sign of frontal lobe impairment). In these cases, it would be incorrect to conclude that the person has met the threshold for Criterion 1 (has difficulty making everyday decisions without an excessive amount of advice and reassurance from others) and Criterion 4 (has difficulty initiating projects or doing things on his or her own [because of lack of self-confidence in judgment or abilities rather than a lack of motivation or energy]), especially if these behaviors are not lifelong traits or can be accounted for by organic changes in the brain.

Criterion 6 (feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself) and Criterion 8 (is unrealistically preoccupied with fears of being left to take care of himself or herself) may not apply well in situations where the older person is extremely frail or disabled and has significant anxieties about being left alone and not receiving adequate care and support from others. At issue here is how reasonable the person's fears and concerns are. If the fears about having to care for oneself are not exaggerated or unrealistic, then it would be incorrect to see the person as exhibiting traits of Dependent Personality Disorder. If the fears are excessive and disproportionate (even in physically frail older adults), then dependency may be a core issue for the person.

Theorized Pattern in Later Life and Possible Impact of Aging The most onerous age-related stressor among individuals with dependent personality is widowhood. Severe problems are likely to arise for the dependent older person whose spouse dies, leaving the person in the threatening (and unfamiliar) position of having to depend on him- or herself. After such a loss, dependent older adults commonly appear helpless, unable to perform the most mundane functions after decades of relying excessively on their partners. Feeling lost and vulnerable, these older adults often turn to their adult children to fill the void left by the deceased spouse on whom they depended. In many cases, their excessive needi-ness quickly becomes burdensome and arduous, frequently leading to their children feeling overwhelmed and annoyed.

A dramatic example of this pattern was observed in one of our patients, a 74-year-old woman, whose husband had died several months before the consultation. One of the patient's daughters reported that the patient was unable to change out of her pajamas in the morning because her husband was no longer there to tell her which outfit to wear. On taking the patient grocery shopping, the daughter discovered that she was unable to make even basic decisions (e.g., which cereal to buy). Although her name had been on the checkbook for many years, it also became apparent that the patient did not know how to write a check, and a stack of unpaid bills accumulated in her house. The children in this family had been aware that for many years their father had taken care of their mother, but they did not realize the degree of her dependency until after he died.

Older persons with Dependent Personality Disorder are also likely to actively seek out and overly rely on other supportive individuals and services, easily becoming burdensome. Facing retirement, the older adult with Dependent Personality Disorder may welcome the occurrence and the concomitant freedom from those responsibilities. In contrast to the other personality disorders we have already discussed, increased dependency is not particularly challenging for the aging dependent type. In fact, quite the contrary, the dependent type may enjoy such opportunities for greater dependence in later life, relishing increased opportunities to receive the care and nur-turance of others. A key distinction to make is between older adults who are dependent on others due to unfortunate life circumstances (e.g., illness) and those whose dependence is excessive to the current situation.

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