Help Them Get Out of That Relationship - Dealing with Dependent Personality Disorder
Dependent Personality Disorder (DPD) until recently has been predominantly diagnosed in women. It is now thought in the psychology community that Dependent Personality Disorder is more equally distributed among men and women. Why has this changed? What social or cultural factors influence this sexist diagnosis? Have women always been more dependent than men? Has there been a change in the diagnosis criteria? The change warrants deeper look into the diagnosis, cultural influence, and treatment.
What is DPD?
Dependent Personality Disorder is found on Axis II of the DSM-IV under Cluster C. Cluster C is described as anxious or fearful disorders. DPD is “characterized by a person’s pervasive and excessive need to be taken care of, a condition that leads to submissive and clinging behavior and fears of separation” (Durand & Barlow, 2006). The disorder is often characterized as submissive, timid and passive, and those who are diagnosed with DPD have feelings of inadequacy, are sensitive to criticism, and have a need for reassurance. Those with DPD will agree with someone even if their opinion is opposite or different due to fear of rejection (Durand, 2006).
Someone who suffers from Dependent Personality Disorder has a strong desire to be accepted. People with DPD will do anything to gain the approval of those in their relationship; they fear making decisions on their own, and often defer to others to make decisions for them as they fear disapproval. This can go as far as suffering serious abuse and not acknowledging it as a problem because of their intense fear of losing the relationship. They seem to move quickly into relationships after just losing one because of this intense fear of being alone.
Many studies have been conducted on the best way to find the correct diagnosis for people with Personality Disorders, and more specifically DPD. The most common method for measuring dependency, as reported by Cogswell, is self-report instruments (2008). He suggests that the most common of these are the Interpersonal Dependency and the Depressive Experiences Questionnaire. He also goes on to present that women score high on self reports (whereas men do not), but the genders do not differ on indirect indices (which is another way to test). This data suggest that men and women have equivalent needs for dependency but that self-presentational biases function to minimize males’ dependency scores on self-report (2008). As shown by Cogswell, women are more likely to show that they have the traits for dependency than are men. In other words men misrepresent themselves in self-reporting tests. Because self-reporting is the preferred way of testing for DPD men will not usually be tested further, this causes men to be under diagnosed with DPD.
The diagnostic criteria haven’t changed for Dependent Personality Disorder in recent years, yet there is a move in the psychology community toward equity of diagnosis among men and women. This skew in diagnosis is not do to the diagnostic criteria which appears to have no inherent gender bias, but may actually have to do with the cultural influences toward gender stereotyping (Berk & Rhodes, 2005). In western society gender roles typically place men as being independent and women as dependent. This creates social gender bias toward stereotyping. This is considered gender-role socialization (Berk, 2005). In the recent years this notion has slightly changed, which could have an influence on the reasons for dependency being found more in men.
Other cultural factors that may be playing a role in diagnosis of DPD are abuse and men having multiple sexual partners one after another. Psychologists are finding now that some men abuse their spouses and break the law out of fear of losing their relationships (Berk, 2005). These symptoms qualify under the anxious or fearful cluster of Personality Disorders and have the qualifications for Dependent Personality Disorder. People with DPD seem to quickly move into relationships after losing one (Berk, 2005). In Western culture it has been considered a positive for men to have multiple mates. Psychologists are finding that this is occurring for some men because of dependency traits. People who are participating in these activities because of DPD have underlying issues that are not resolved. In both of these examples the person tends to deny the interpersonal conflicts, to maintain the façade that important relationships are never at risk (Bornstein, 1998). Once again because of the shift in the western society this is becoming more evident.
Comorbidity is found often among Personality Disorders and DPD is no exception. The most common comorbid diagnosis with DPD is depression. This tends to be problematic in many ways; the suicide attempt rates for people who suffer from both DPD and depression are as high as those in Cluster A and Cluster B of Personality Disorders. whereas when controlled for depression the rates are below those of both cluster A and Cluster B and have the same rates as the other PD’s in Cluster C (Chioqueta & Stiles, 2004). In other words those who suffer from only DPD are not at a very high risk to attempt suicide. Psychologist suggest because people who suffer from DPD are submissive and passive it is difficult for them to engage in any form of hurting themselves and this is the reason the rates are lower (Chioqueta, 2004 et. Al.). On the other side the suicide attempt rates are higher for those who do suffer from DPD and depression. The reason for this could be they already are unable to meet their own perceived demands of their relationship because of their feelings of inadequacy, and the continual fear of the losing the relationship caused by DPD combined with the negative thought process of depression. This is especially relevant because as Berk and Rhodes report that dependence and depression is higher in men than women. They go on to claim that there is a strong correlation between dependency traits in men and Axis I disorder, particularly depression. While there are many negative correlations with comorbidity there is at least one positive: People suffering from both depression and DPD are more likely to see someone for the problem. This means they will get treatment. However, it can be difficult for the therapist to detect DPD.
Treatment for DPD is difficult. Most cases of DPD start in youth and are chronic. The therapist needs to watch to make sure that the client does not become dependent upon the therapist. The main treatments are psychodynamic, cognitive behavioral therapy (CBT), and schema-focused therapy. Psychodynamic psychotherapy is focused on a specific problem. The Unconscious is emphasized, and the Patient is helped to identify problems and defense mechanisms. Therapist uses an eclectic mixture of tactics where they focus on social and interpersonal relationships. Cognitive behavior therapy is a way of identifying and changing negative ways of thinking and replacing with more positive attitudes. This focuses on adaptive behaviors and coping styles (Durand, 2006). The final is Schema Focused Therapy. This therapy is to modify interpersonal schemata. Schema Focused Therapy especially focuses on beliefs of insecure attachment, fear of rejection, abandonment and works on the submissiveness of the client (Livesley, 2008). Livesley declares that the therapist does not focus on one facet but instead need to integrate the treatments and focus on what the client needs, he writes, “The merits of integrated therapy are more apparent when the relationships between treatment strategies and domains of psychopathology are considered. Although different treatments have been developed to treat personality disorder, most are fairly selective in the way they target the different domains.” He claims that best way to treat PD and DPD is to “select effective interventions from different treatments” that best suit the client (2008). Many different treatments need to be used to address the complexity of the DPD. This takes work by the therapist to make a plan and patience by the client to follow through with the plan addressing each issue individually.
There is sufficient evidence that Dependent Personality Disorder is just as common in men as women. Cogswell has declared that diagnosis of DPD has been gender bias based on the flawed process of self-report as the preferred measurement. Berk and Rhodes claim that DPD has been misdiagnosed because of gender stereotyping. There needs to be an emphasis on strategies for determining DPD in men as the preferred strategy at this time leads to gender bias. Therapists also need to be aware of the cultural influences and gender bias in diagnosing. This is especially true among men that have depression and show symptoms of DPD as the suicide attempt rates are greater for those suffering from DPD coupled with depression as Choiqueta and Stiles have made clear. With emphasis on correctly diagnosing people suffering from Dependent Personality Disorder through correct strategies and without cultural bias in mind, there will be a better chance for those suffering to receive treatment with greater benefits. While treatment is slow and in depth, at least knowing that people are being correctly diagnosed can bring hope.
Berk, S, & Rhodes, B (2005). Maladaptive dependency traits in men. Bulletin of Menninger Clinic, 69, 187-205.
Bornstein, B. (1998).Implicit and self-attributed dependency needs in dependent and histrionic personality disorders.Journal of Personality Assessment. 71, 1-14.
Chioqueta, A, & Stiles, T (2004). Assessing suicide risk in cluster c personality disorders. Crisis, 25, 128-133.
Cogswell, A (2008).Explicit rejection of an implicit dichotomy: Integrating two approaches to assessing dependency. Journal of Personality Assessment, 90, 26-35.
Durand, V.M. & Barlow, D.H. (2009). Essentials of Abnormal Psychology (5th Edition). Thomson/Wadsworth.
Livesley, J (2008).Integrated therapy for complex cases of personality disorders. Journal of Clinical Psychology: In Session, 64, 207-221.