Dependent Personality Disorder

Dependent personality p describes people who have an excessive need to be taken care of by others.
This leads them to be overly submissive and clinging in their relationships and extremely fearful of
separation. People with this disorder find it very difficult to do things on their own. They seek advice in
making even the smallest decision. Children or adolescents with the problem may look to their parents
to select their clothes, diets, schools or colleges, even their friends. Adults with the disorder allow others
to make important decisions for them

After marriage, people with dependent personality disorder may rely on their spouses to make decisions
such as where they should live, which neighbors they should cultivate, how they should discipline the
children, what jobs they should take, how they should budget money, and where they should vacation.
Like Matthew, individuals with dependent personality disorder avoid positions of responsibility. They
turn down challenges and promotions and work beneath their potential. They tend to be overly
sensitive to criticism and preoccupied with fears of rejection and abandonment.

Evidence shows that dependent personality disorder in our culture is diagnosed more frequently in
women than in men . The diagnosis is often applied to women who, for fear of abandonment, tolerate
husbands who openly cheat on them, abuse them, or gamble away the family’s resources. Underlying
feelings of inadequacy and helplessness discourage them from taking effective action. In a vicious cycle,
their passivity encourages further abuse, leading them to feel yet more inadequate and helpless.
Applying the diagnosis to women with this pattern is controversial and may be seen as unfairly “blaming
the victim,” because women in our society are often socialized to dependent roles.

Dependent personality disorder is linked to other psychological disorders, including mood disorders and
social phobia, as well as to physical problems such as hypertension, cardiovascular disorder, and
gastrointestinal disorders like ulcers and colitis. There also appears to be a link between dependent
personality and what psychodynamic theorists refer to as “oral” behavior problems, such as smoking,
eating disorders, and alcoholism . Psychodynamic theorists trace dependent behaviors to the utter
dependence of the newborn baby and the baby’s seeking of nourishment through oral means (suckling).
Food may come to symbolize love, and people with dependent personalities may overeat to ingest love
symbolically.

Obsessive–Compulsive Personality Disorder

The defining features of 9obsessive–compulsive personality disorder include excessive orderliness,

perfectionism, rigidity, difficulty coping with ambiguity, difficulty expressing feelings, and meticu-
lousness in work habits. Estimates of the prevalence of the disorder vary from 2.1% to 7.9% of the
population . The disorder is about twice as common in men as in women. Unlike obsessive–compulsive
anxiety disorder, people with obsessive–compulsive personality disorder do not necessarily experience
outright obsessions or compul-sions. If they do, both diagnoses may be deemed appropriate.

People with obsessive–compulsive personality disorder are so preoccupied with the need for perfection
that they cannot complete work on time. Their efforts inevitably fall short of their expectations, so they
redo their work. Or they ruminate about how to prioritize their work and never seem to start working.
They focus on details that others perceive as trivial. As the saying goes, they fail to see the forest for the
trees. Their rigidity impairs their social relationships; they insist on doing things their way rather than
compromising. Their zeal for work keeps them from participating in, or enjoying, social and leisure
activities. They tend to be stingy with money. They find it difficult to make decisions and postpone or
avoid them for fear of making the wrong choice.

Problems with the Classification of Personality Disorders

Personality Disorders—Categories or Dimensions? Are personality disorders best understood as distinct

categories of psychological disorders marked by particular symptoms or blehavioral features? Or should
we think of them as extreme variations of common personality dimensions found in the general
population? The DSM adopts a categorical model for classifying abnormal behavior patterns into specific
diagnostic categories based on particular diagnostic criteria.

To warrant a diagnosis of antisocial personality disorder, a person must show a range of clinical features
similar . But just how many of the seven features listed in the table need to be present for a diagnosis of
antisocial personality disorder? Three of them, four of them, or perhaps all of them? The answer,
according to the diagnostic manual, is that three or more of these criteria need to be present. Why
three? Basically, this determina-tion represents a consensus of the authors of the DSM. A person may
exhibit two of these features in abundance, but still not be diagnosed with antisocial personality
disorder, whereas someone showing three of the features in a milder form would merit a diagnosis. The
problem of where to draw the line when applying diagnostic categories ripples throughout the DSM
system, raising concerns of many critics that the system relies too heavily on an arbitrary set of cutoffs
or diagnostic criteria.

Another concern with the categorical model is that many of the features associated with personality
disorders and with many other diagnostic categories (e.g., mood disorders, anxiety disorders) are found
to some degree in the general population. Thus, it may be difficult to distinguish between normal
variations of these features (or traits) and abnormal variations.

Another concern with the categorical model is that many of the features associated with personality
disorders and with many other diagnostic categories (e.g., mood disorders, anxiety disorders) are found
to some degree in the general population. Thus, it may be difficult to distinguish between normal
variations of these features (or traits) and abnormal variations.

The developers of the DSM-5 are currently reviewing just how best to diagnose personality in
preparation for the next version of the DSM-5, to be called DSM-5.1. Several alternative models are
under consideration, including a hybrid dimensional-categorical model that is part categorical and part
dimensional. The dimensional model is based on the Big Five personality traits. Under the proposed
plan, a diagnosis of a personality disorder would be based on meeting specified criteria for particular
disorders (the categorical approach) together with ratings of extreme or pathological traits (the
dimensional approach). This hybrid model is consistent with methods used to diagnose medical
illnesses, which rely on both specific criteria (e.g., findings of cancerous cells on biopsies, symptoms of
infectious diseases) and extreme measures on continuous dimensions (e.g., a diagnosis of hypertension
based on high blood pressure readings).
Problems Distinguishing Personality Disorders From OTHER CLINICAL SYNDROMES One nagging
question is whether personality disorders can be reliably differentiated from other clinical syndromes.
For example, clinicians often have difficulty distinguishing between obsessive–compulsive disorder and
obsessive–compulsive personality disorder. Clinical syndromes are believed to be variable over time,
whereas person-ality disorders are held to be generally more enduring patterns of disturbance. Yet the
features of personality disorders may vary over time with changes in circumstances, while some other
clinical syndromes (e.g., dysthymia) follow a more or less chronic course.

Overlap Among Disorders A high degree of overlap exists among the personality disorders. Most people
receiving a diagnosis of a personality disorder meet criteria for more than one . Although some
personality disorders have distinct features, many share common traits, such as problems in
interpersonal relationships. For example, a person may have traits suggestive of both antisocial
personality disorder and borderline personality disorder (e.g., impulsivity, unstable relationship
patterns).

Difficulty in Distinguishing Between Normal and AbnormalBehavior Another problem with the
diagnosis of personality disorders is that they involve personality traits, which, in lesser degrees,
describe the behavior of most normal individuals (Warner et al., 2004). Feeling suspicious now and then
does not mean you have a paranoid personality disorder. The tendency to exaggerate your own
importance does not mean you are narcissistic. You may avoid social interactions for fear of
embarrassment or rejection without having an avoidant personality disorder, and you may be especially
conscientious in your work without having an obsessive–compulsive personality disorder. Because the
defining attributes of these disorders are common personality traits, clinicians should only apply these
diagnostic labels when the patterns are so pervasive that they interfere with the individual’s functioning
or cause significant personal distress. We still lack the evidence we need to determine the particular
points at which personality traits become maladaptive and to justify a diagnosis of a personality
disorder.

Confusing Labels With Explanations Labeling people with disturbing behavior as having personality
disorders overlooks the social and environmental contexts of the behavior. The impact of traumatic life
events, which may occur with a greater range or intensity among members of a particular gender or
cultural groups, is an important underlying factor in maladaptive behavior. However, the conceptual
underpinnings of the personality disorders do not consider cultural differences, social inequalities, or
power differences between genders or cultural groups. For example, many women diagnosed with
personality disorders have a history of childhood physical and sexual abuse. The ways in which people
cope with abuse may come to be viewed as flaws in their character rather than as reflections of the
dysfunctional societal factors that underlie abusive relationships.

Theoretical Perspectives

In this section, we consider theoretical perspectives on the personality disorders. Many theoretical
accounts of disturbed personality derive from the psychodynamic model. We thus begin with a review
of traditional and modern psychodynamic models.
Psychodynamic Perspectives

Traditional Freudian theory focused on problems arising from the Oedipus complex as the foundation
for abnormal behaviors, including personality disorders. Freud believed that children normally resolve
the Oedipus complex by forsaking incestuous wishes for the parent of the opposite gender and
identifying with the parent of the same gender. As a result, they incorporate the parent’s moral
principles in the form of a personality structure called the superego. Many factors may interfere with
appropriate identification and sidetrack the normal developmental process, preventing children from
developing moral constraints and the feelings of guilt or remorse that normally follow antisocial
behavior. Freud’s account of moral development focused mainly on the development of males. He has
been criticized for failing to account for the moral development of females.

Hans Kohut One of the principal shapers of modern psychodynamic concepts is Hans Kohut, whose
theory is labeled self psychology because of its emphasis on processes in the development of a cohesive
sense of self. Kohut believed that people with narcissistic personalities mount a facade of self-
importance to cover up deep feelings of inadequacy. The narcissist’s self-esteem is like a reservoir that
needs to be constantly replenished with a steady stream of praise and attention lest it run dry. A sense
of grandiosity helps people with a narcissistic personality mask their underlying feelings of
worthlessness. Failures or disappointments threaten to expose these feelings and drive the person into
a state of depression, and so as a defense against despair, the person attempts to diminish the
importance of disappointments or failures.

Otto Kernberg Otto Kernberg a leading psychodynamic theorist, views borderline personality in terms
of a failure in early childhood to develop a sense of constancyand unity in one’s image of oneself and
others. From this perspective, borderline individuals cannot synthesize contradictory (positive and
negative) elements of themselves and others into complete, stable wholes. Rather than viewing
important people in their lives as sometimes loving and sometimes rejecting, they shift back and forth
between pure idealization and utter hatred. This rapid shifting back and forth between viewing others as
either “all good” or “all bad” is referred to as splitting.

Margaret Mahler Margaret Mahler, another influential modern psychodynamic theorist, explained
borderline personality disorder in terms of childhood separation from the mother figure. Mahler and her
colleaguesbelieved that during the first year, infants develop a symbiotic attachment to their mothers.
Symbiosis, or interdependence, is a biological term derived from Greek roots meaning “to live together.”
In psychology, symbiosis is a state of oneness in which the child’s identity is fused with the mother’s.
Normally, children gradually differentiate their own identities or senses of self from that of their
mothers. The process, separation-individuation, is the development of a separate psychological and
biological identity from the mother (separation) and recognition of personal characteristics that define
one’s self-identity (individuation). Separation-individuation may be a stormy process.

Learning Perspectives

Learning theorists focus on maladaptive behaviors rather than disorders of personality. They are
interested in identifying the learning histories and environmental factors that give rise to maladaptive
behaviors associated with diagnoses of personality disorders and the reinforcers that maintain them.
Learning theorists suggest that childhood experiences shape the pattern of mal-adaptive habits of
relating to others that constitute personality disorders. For example, children who are regularly
discouraged from speaking their minds or exploring their environments may develop a dependent
behavior pattern. Excessive parental discipline may lead to obsessive–compulsive behaviors.
Psychologist Theodore Millon (1981) suggests that children whose behavior is rigidly controlled and
punished by parents, even for slight transgressions, may develop inflexible, perfectionistic standards. As
these children mature, they strive to develop themselves in an area in which they excel, such as
schoolwork or athletics, as a way of avoiding parental criticism or punishment. But because of overat-
tention to a single area of development, they do not become well rounded. Thus, they squelch
expressions of spontaneity and avoid risks. They may also place perfectionistic demands on themselves
to avoid punishment or rebuke, or develop other behaviors associated with the obsessive–compulsive
personality pattern.

Family Perspectives

Also consistent with psychodynamic theory, family factors such as parental over-protection and
authoritarianism (a “do what I said because I said so” style of parenting) are implicated in the
development of dependent personality traits (Bornstein, 1992). Extreme fears of abandonment may also
be involved, perhaps resulting from a failure to develop secure bonds with parental attachment figures
in childhood due to parental neglect, rejection, or death. Subsequently, these individuals develop a
chronic fear of abandonment by significant others, leading to the clinginess that typifies dependent
personality disorder. Theorists also suggest that obsessive–compulsive personality disorder may emerge
within a strongly moralistic and rigid family environment, which does not permit even minor deviations
from expected roles or behavior.

Biological Perspectives

Genetic Factors Evidence points to genetic factors playing a role in the development of several types of
personality disorders, including antisocial, narcissistic, paranoid, and borderline types. Parents and
siblings of people with personality disorders, such as antisocial, schizotypal, and borderline types, are
more likely to be diagnosed with these disorders themselves than are members of the general
population. Genetic factors also appear to be involved in the development of personality traits that
underlie the psychopathic personality, such as callousness, antisocial behavior, impulsivity, and
irresponsibility. Investigators also report finding genetic indicators in a particular chromosome linking to
features of borderline personality disorder.

Lack of Emotional Responsiveness According to a leading theorist, Hervey Cleckley (1976), people with
antisocial personalities can maintain their composure in stressful situations that would induce anxiety in
most people. Lack of anxiety in response to threatening situations may help explain the failure of
punishment to induce antisocial people to relinquish antisocial behavior. For most of us, the fear of
getting caught and being punished is sufficient to inhibit antisocial impulses. People with antisocial
personalities, however, often fail to inhibit behavior that has led to punishment in the past, perhaps
because they experience little, if any, fear or anticipatory anxiety about being caught and punished.

When people get anxious, their palms tend to sweat. This skin response, called the galvanic skin
response (GSR), is a sign of activation of the sympathetic branch of the autonomic nervous system
(ANS). In an early study, Hare (1965) showed that people with antisocial personalities had lower GSR
levels when they were expecting painful stimuli than normal controls did. Apparently, the people with
antisocial personalities experienced little anxiety in anticipation of impending pain.

The Craving-for-Stimulation Model People with antisocial or psychopathic personalities appear to have
exaggerated cravings for stimulation (Arnett et al., 1997). Perhaps they require a higher-than-normal
threshold of stimulation to maintain an optimum state of arousal. In other words, they may need more
stimulation than other people to maintain interest and function normally.A need for higher levels of
stimulation may explain why people with antisocial personality traits tend to become bored easily and
gravitate to stimulating but potentially dangerous activities, like the use of intoxicants such as drugs or
alcohol, motorcycling, skydiving, high-stakes gambling, or high-risk sexual adventures. A higher-than-
normal threshold for stimulation would not directly cause antisocial or criminal behavior; after all,
astronauts, soldiers, police officers, and firefighters must also exhibit this trait to some respect.
However, the threat of boredom and the inability to tolerate monotony may influence some sensation
seekers to drift into crime or reckless behavior.

Sociocultural Perspectives

Social conditions may contribute to the development of personality disorders. Because antisocial
personality disorder is reported most frequently among people from lower socioeconomic classes, the
kinds of stressors encountered by disadvantaged families may contribute to antisocial behavior
patterns. Many inner-city neighborhoods are beset with social problems such as alcohol and drug abuse,
teenage pregnancy, and disorganized and disintegrating families. These stressors are associated with an
increased likelihood of child abuse and neglect, which may in turn contribute to lower self-esteem and
breed feelings of anger and resentment in children. Neglect and abuse may become translated into a
lack of empathy and a callous disregard for the welfare of others that are associated with antisocial
personalities.

Treatment of Personality Disorders

Psychodynamic Approaches

Psychodynamic approaches are often used to help people diagnosed with personality dis-orders become
aware of the roots of their self-defeating behavior patterns and learn more adaptive ways of relating to
others. However, people with personality disorders, especially those with borderline and narcissistic
personality disorders, often present particular challenges to the therapist. For example, people with
borderline personality disorder tend to have turbulent relationships with therapists, sometimes
idealizing them, sometimes denouncing them as uncaring.

Promising results are reported using structured forms of psychodynamically oriented therapies in
treating personality disorders (e.g., Clarkin et al., 2007; Gunderson, 2011; Paris, 2008). These therapies
raise clients’ awareness of how their behaviors cause problems in their close relationships. The therapist
takes a more direct, confrontational approach that addresses the client’s defenses than would be the
case in traditional psychoanalysis. With borderline personality disorder, the psychodynamic therapist
helps clients better understand their own and other people’s emotional responses in the context of their
close relationships.
Cognitive-Behavioral Approaches

Cognitive behavior therapists focus on changing clients’ maladaptive behaviors and dysfunctional
thought patterns rather than their personality structures. They may use behavioral techniques such as
modeling and reinforcement to help clients develop more adaptive behaviors. For example, when clients
are taught behaviors that are likely to be reinforced by other people, the new behaviors may well be
maintained.

As applied to DBT, the dialectical approach involves the attempt to reconcile the opposites or
contradictions of acceptance and change. DBT therapists recognize the need to show acceptance of
people with borderline personalities by validating their feelings while also gently encouraging them to
make adaptive changes in their behavior. Therapists help patients to recognize how their feelings and
behaviors cause problems in their lives, enable them to learn to regulate their emotions through
cognitive-behavioral and mindfulness techniques, and encourage them to identify alternative ways of
relating to others. The tension between acceptance and mild encouragement of change constitutes the
dialectical approach.

Biological Approaches

Drug therapy does not directly treat personality disorders. However, antidepressant and antianxiety
drugs are sometimes used to treat depression and anxiety in people with personality disorders.
Neurotransmitter activity is also implicated in aggressive behavior of the type seen in individuals with
borderline personality disorder. The neurotrans-mitter serotonin helps put the brakes on impulsive
behaviors, including acts of impul-sive aggression (Carver, Johnson, & Joormann, 2008; Seo, Patrick, &
Kennealy, 2008).

Antidepressants of the selective serotonin reuptake inhibitor (SSRI) class (e.g., Prozac) increase the
availability of serotonin in synaptic connections between neurons and can help temper feelings of anger
and rage. However, we’ve yet to see antidepressant medication produce any substantial benefits
relative to placebo in treating borderline personal-ity disorder (Gunderson, 2011). Atypical
antipsychotics may have benefits in controlling aggressive and self-destructive behavior in people with
borderline personality disorder, but the effects are modest and the drugs carry serious poten-tial side
effects (Gunderson, 2011). Moreover, drugs alone do not target long-standing patterns of maladaptive
behavior that are the defining features of personality disorders.