Evidence-Based Reviews

Dependent personality disorder: Effective time-limited therapy

Current Psychiatry. 2007 January;6(1):37-45

References

1. Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.

2. Bornstein RF, Languirand MA. Healthy dependency: leaning on others without losing yourself. New York, NY: Newmarket Press; 2003.

3. Bornstein RF. The dependent personality. New York: Guilford Press; 1993.

4. Bornstein RF. The dependent patient: a practitioner’s guide. Washington, DC: American Psychological Association; 2005.

5. Pincus AL, Wilson KR. Interpersonal variability in dependent personality. J Pers 2001;69(2):223-51.

6. Pincus AL, Gurtman MB. The three faces of interpersonal dependency: structural analysis of self-report dependency measures. J Pers Soc Psychol 1995;69(4):744-58.

7. Overholser JC. The dependent personality and interpersonal problems. J Nerv Ment Dis 1996;184(1)1:8-16.

8. Bornstein RF. The complex relationship between dependency and domestic violence: converging psychological factors and social forces. Am Psychol 2006;61(6):595-606.

9. Coen SJ. The misuse of persons: analyzing pathological dependency. Hillsdale, NJ: Analytic Press; 1992.

10. Overholser JC, Fine MA. Cognitive-behavioral treatment of excessive interpersonal dependency: a four-stage psychotherapy model. Journal of Cognitive Psychotherapy 1994;8(1):55-70.

11. Turkat ID. The personality disorders: a psychological approach to clinical management. New York, NY: Pergamon Press; 1990.

12. Bornstein RF. Criterion validity of objective and projective dependency tests: a meta-analytic assessment of behavioral prediction. Psychological Assessment 1999;11(1):48-57.

13. Birtchnell J. The measurement of dependence by questionnaire. Journal of Personality Disorders 1991;5(3):281-95.

14. Nietzel MT, Harris MJ. Relationship of dependency and achievement/autonomy to depression. Clinical Psychology Review 1990;10:279-97.

15. Bornstein RF. Dependent personality disorder in the DSM-IV and beyond. Clinical Psychology: Science and Practice 1997;4(2):175-87.

16. Ryder RD, Parry-Jones WL. Fears of dependence and its value in working with adolescents. J Adolesc 1982;5(1):71-8.

17. Tait M. Dependence: a means or an impediment to growth? British Journal of Guidance and Counselling. 1997;25(1):17-26.

18. Black DW, Monahan P, Wesner R, et al. The effects of fluvoxamine, cognitive therapy, and placebo on abnormal personality traits in 44 patients with panic disorder. Journal of Personality Disorders. 1996;10(2):185-94.

19. Rathus JH, Sanderson WC, Miller AL, Wetzler S. Impact of personality functioning on cognitive behavioral treatment of panic disorder: a preliminary report. Journal of Personality Disorders 1995;9(2):160-8.

20. Bornstein RF. Integrating cognitive and existential treatment strategies in psychotherapy with dependent patients. Journal of Contemporary Psychotherapy 2004;34(4):293-309.

21. Abramson PR, Cloud MY, Keese N, Keese R. How much is too much? Dependency in a psychotherapeutic relationship. Am J Psychother 1994;48(2):294-301.

Three principles guide the diagnosis of DPD.

Dependency, as noted, is not always characterized by passivity. Dependent patients may use active, dramatic self-presentation strategies—such as breakdown threats or parasuicide attempts—to protect themselves from being abandoned.^4,8
Self-reports do not always give a true picture. Because dependency may be viewed as a sign of weakness and immaturity, many adults—especially men—are reluctant to acknowledge dependent thoughts and feelings.¹² Interviewing knowledgeable informants can be enlightening.
Dependency’s severity varies over time and across situations. Depressive episodes are associated with temporary increases in self-reported dependency. Even modest mood changes can amplify dependency.^13,14

Assessment tools. When formal assessment is warranted to confirm a tentative diagnosis or distinguish DPD from a similar Axis II disorder, administer a validated instrument for quantifying DPD symptoms. The 3 interviews used most often to quantify DPD symptoms are the Structured Clinical Interview for DSM Personality Disorders, International Personality Disorder Examination, and Structured Interview for Diagnosis of Personality-Revised. Diagnostic interviews enable you to follow-up on patients’ responses and obtain additional information.

Questionnaires do not allow you to probe and follow-up, but paper-and-pencil tools are relatively inexpensive and efficient. They also avoid reliability problems that can occur with structured interviews. The 2 self-report instruments used most often to diagnose DPD are:

Differential diagnosis

DPD must be distinguished from Axis I and II syndromes with often-overlapping symptoms and similar presentations. These include:

mood disorders, panic disorder, agoraphobia, and dependency arising from one or more general medical conditions
borderline personality disorder, histrionic personality disorder, and avoidant personality disorder.¹

Comorbidity studies suggest that DPD can be associated with a broad range of Axis I and II syndromes. On Axis I, DPD is comorbid with mood disorders, anxiety disorders, eating disorders, adjustment disorder, and somatization disorder. On Axis II, DPD co-occurs with most other personality disorders, including some—such as antisocial or schizoid personality disorder—that bear little resemblance to DPD.^4,15

Axis II comorbidity patterns likely reflect the generalized, nonspecific nature of personality pathology and the fact that patients may show personality disorder symptoms in one or more diagnostic categories.

DPD Treatment

Dependency is associated with patient cooperativeness and conscientiousness.^3,4,16,17 Compared with nondependent patients, those with dependent personalities:

delay less time before seeking treatment for psychological or medical symptoms
adhere more conscientiously to psychotherapeutic and psychotropic regimens
miss fewer therapy sessions
show higher rates of treatment completion in outpatient individual and group therapy.

Medication. No class of medications—including antidepressants, anxiolytics, and antipsychotics—is consistently more effective than placebo in reducing DPD symptoms.¹⁸

Psychotherapy. Traditional psychotherapies—psychodynamic, cognitive, behavioral—modestly improve DPD symptoms.¹⁹ Most effective has been psychotherapy that combines various modalities.^2,4,20 Five interventions (Table 3) have been shown to:

help the patient and therapist identify aspects of the patient’s environment that propagate dependent behavior
provide the patient with coping skills needed to more effectively control dependency-related impulses.

These methods—which integrate aspects of psychodynamic, cognitive, and behavior therapies—can help patients gain insight into problematic dependency and the behaviors by which it is expressed.

Table 3

5 useful psychotherapeutic methods for dependent patients

Explore key relationships from the patient’s past that reinforced dependent behavior; determine if similar patterns occur in present relationships
Examine his or her ‘helpless self-concept,’ dependency’s key cognitive component (Tip: Asking the patient to write a selfdescription can be useful)
Make explicit any self-denigrating statements that propagate the patient’s feelings of helplessness and vulnerability; challenge these statements when appropriate
Help the patient gain insight into the ways he or she expresses dependency needs in different situations (and more-flexible, adaptive ways he or she could express these needs)
Use in-session role play and betweensessions homework to help the patient build coping skills that will enable him or her to function more autonomously

Limitations and caveats

Clinical work with DPD patients traditionally has focused on diminishing problematic dependency. Recent research suggests, however, that expressing dependency strivings in a flexible, situation-appropriate manner can strengthen interpersonal ties and facilitate adaptation and healthy psychological functioning.^2,5 Thus, the most effective interventions emphasize replacing unhealthy, maladaptive dependency with flexible, adaptive dependency.

Beyond the strategies summarized in Table 3, several other considerations—such as setting limits—are important in managing DPD and in minimizing therapeutic obstacles and impasses.

Set firm limits on after-hours contact early in treatment. Unless you set firm limits at the outset of therapy, dependent patients tend to have a higher-than-average number of “pseudo-emergencies” and make frequent requests for between-sessions contact.

In inpatient settings, patients with DPD receive more consultations and psychotropic medications than do non-DPD patients with similar demographic and diagnostic profiles, and their treatment costs can become excessive.²¹