Dependent Personality Disorder

or: Hope is their best friend

I include the anxious (avoidant) personality disorder here, as overlaps frequently arise in the comorbidity of dependent personality disorder.

F60.6 Anxious (Avoidant) Personality Disorder

A personality disorder characterised by feelings of tension and apprehension, insecurity and inferiority. There is a persistent longing for affection and acceptance, a hypersensitivity to rejection and criticism, with a restricted capacity for relationships. The affected person tends to overemphasise potential dangers or risks of everyday situations to the point of avoiding certain activities.

Diagnostic Criteria

A. The general criteria for a personality disorder (F60) must be met.

B. At least four of the following characteristics or behaviours must be present:

Persistent and pervasive feelings of tension and apprehension
Conviction of being socially inept, unattractive, or inferior compared to others
Excessive worry about being criticised or rejected in social situations
Restricted lifestyle due to the need for physical security
Avoidance of occupational or social activities involving significant interpersonal contact, out of fear of criticism, disapproval, or rejection

F60.7 Dependent (Asthenic) Personality Disorder

Persons with this personality disorder passively rely on other people for minor or major life decisions. The disorder is further characterised by great separation anxiety, feelings of helplessness and incompetence, a tendency to subordinate oneself to the wishes of elders and others, and a failure to meet the demands of daily life. The weakness may manifest in the intellectual or emotional sphere; when difficulties arise, there is a tendency to shift responsibility to others.

Diagnostic Criteria

A. The general criteria for a personality disorder (F60) must be met.

B. At least four of the following characteristics or behaviours must be present:

Encouraging or allowing others to make most of the important decisions for one’s own life
Subordination of one’s own needs to those of the person on whom one is dependent, and excessive compliance with their wishes
Unwillingness to make even reasonable demands on persons on whom one depends
Uncomfortable feeling or helplessness when alone, from exaggerated fear of being unable to care for oneself
Frequent preoccupation with the fear of being abandoned and having to fend for oneself
Limited ability to make everyday decisions without extensive advice and reassurance from others

Associated terms:

Asthenic personality disorder
Inadequate personality disorder
Passive personality disorder
Self-defeating personality disorder

Dependent Disorder as a Complementary Disorder

Since dependent disorder stands as a complementary disorder to Borderline Personality Disorder and Narcissistic Personality Disorder and very frequently presents with a pronounced manifestation of anorexia/bulimia, let us examine it more closely.

As already mentioned in the chapter on Borderline Personality Disorder, 70% of all borderline personalities suffer from eating disorders, 60% from substance abuse, and 80% from dependent disorder. But the numbers are not only high here. Dependent disorder as such, but also in conjunction with eating disorders and substance abuse, is probably the most commonly occurring disorder — particularly among women.

Important Distinction

The attentive reader will have noticed the brackets I placed in the heading. The reason is that a dependent personality is by no means necessarily disordered or personality-disordered. Even strong dependent structures need not necessarily lead to a disorder.

Comorbidity and Cascade Disorder

As I have also already mentioned, one speaks of comorbidity when one or more disorders can be diagnosed alongside an existing one. Personally, I hold nothing of the term comorbidity in the case of Borderline Personality Disorder, as in my opinion there is only a cascade disorder here.

That is, when one disorder is layered on top of the existing, underlying one (Borderline Personality Disorder).

Emotional Dependency vs. Dependent Disorder

Borderline personalities often believe they suffer from dependent disorder (especially since they frequently also receive the additional diagnosis F60.7). This is not the case, even though some symptoms overlap.

From the perspective of the borderline personality, this is entirely understandable and comprehensible. They believe, at least at the beginning, that they love excessively, do everything for their partner, and hold on to the relationship even though they should not. The person with Borderline describes their frequent separations as attempts to free themselves from their dependency, and the separation is then the victory.

The Nature of Dependent Disorder

As the name says — dependent = reliant — this disorder always involves a dependency, typically on close persons such as father, mother, or partner. Fundamentally, it is an emotional dependency.

Frequent Accompanying Phenomena

Dependent disorder does not necessarily occur alone. It often appears in conjunction with:

ADD/ADHD
Mixed personality disorder
Eating disorders
Recurrent (recurring) depression
Particularly with substance dependency or abuse thereof

Psychosomatic disorders also very frequently occur as a consequence of their maladaptive adjustment or separation conflicts.

Dependency Displacement

As mentioned, a dependency displacement often sets in. This results in a high vulnerability to dependency in all areas of life.

The displacement can take many forms:

Relationships
Alcohol
Drugs
Medication
Work (workaholism)
Gambling
Sports
Co-dependency

The transition to addiction is frequent. With dependent disorder, misdiagnoses are also common, as it often goes entirely unrecognised.

Development of the Disorder

One cannot say that dependent disorder is an early childhood disorder. Rather, it is a developmental disorder. There is also, in contrast to other disorders, no so-called expression of the disorder. The development and change of state is fluid and gradual.

A crucial role in the development of this disorder is played by the adolescent phase (separation phase, transition from child to adult, puberty):

For girls from the age of 10
For boys from the age of 12
Until the age of 18/20

The Significance of Separation

We already know that separation from the mother is not a point in time that begins at age 10 or 12, but much earlier, from age 2 to 3. From this time onward, the child draws its circles around the mother ever wider through its striving for autonomy, and returns.

The mother must allow this, must support the child in an age-appropriate manner, the most important thing being that the child is given the trust that they can and may return at any time. The child’s inevitably arising fear of loss is thus taken away.

Attachment Behaviour

It should be clear that a dependent disorder is unlikely to develop from a secure attachment. The four categories of attachment behaviour from age 2 onward are:

Secure attachment
Dismissive-secure attachment
Ambivalent-insecure attachment
Disorganised-insecure attachment

Characteristic Features

It is therefore characteristic that people with dependent disorder have displaced or shifted their dependency through an unsuccessfully managed separation process.

Fear of Loss

All affected individuals possess strong fears of abandonment. This is probably also the reason for the “addictions.” They cover these fears, keep them “under control” — at least that is what the affected person believes.

The fears are rooted in childhood. One could say that the dependent personality is, at least in relationships, stuck in the role patterns of childhood.

They have never learned to cope with or come to terms with the loss of close persons or relationships. The loss need not be death here; it can be a simple separation.

Cannot Say “No”

Dependent personalities, male and female alike, all have a speech defect: they cannot say “NO.” When they do manage to say “No,” they are immediately plagued by feelings of guilt.

As adults, they do almost anything in relationships to avoid being abandoned. The reason lies in the fears of loss from childhood, which are not necessarily consciously experienced or definable by those affected.

Ego and Superego

The ego and superego of the dependent personality are well developed and fully integrated. The superego even too well. Both functions are relatively stable. They become unstable, for example, through “wrong” partners or through alcohol, drug, or medication abuse.

The ego of the dependent personality is excellently suited for the borderline personality. Here, the borderline personality can dock on optimally and, through the dependent personality’s lack of ego boundaries, take it over.

For the narcissistic personality as well, the development and stability of the ego and superego of the dependent personality are ideally suited — that is, the dependent structure with its altruism, its fears of abandonment, and its low self-esteem.

Self-Esteem

In contrast to the narcissistic personality, the dependent personality tends to deny their self-esteem to themselves — not to others — which logically produces feelings of inferiority. The reason for the denial is proportional to the strength of the dependency.

Similar to the borderline personality, the dependent personality lacks basic trust. The difference in basic trust between the two is that the former has none at all, while the dependent personality merely has a deficit.

Susceptibility to Emotional Blackmail

Through their fear of rejection, which activates separation anxieties, and through their personality structure, they are very receptive to emotional blackmail. In this respect too, they are particularly well suited for the narcissistic personality and the speciality of the borderline personality.

Even when those affected by dependent disorder recognise the destructiveness of their relationship, they can hardly extricate themselves from such a relationship without help “from outside.” They often stay until the bitter end.

Treatment and Prognosis

Without outside help, the dependent personality is scarcely able to recognise, let alone change, their behavioural patterns and role behaviour. Only the identification of root causes and, as mentioned, therapy — potentially in combination with antidepressants — can help here.

Joining a self-help group can also be very beneficial.

Dependent disorder is, in contrast to other disorders, depending on its extent and severity, relatively easy and straightforward to treat.