Dependent Disorder and Comorbidity

Dependent Disorder and Its Comorbidity

As I have said in other chapters, I reject the term comorbidity within the field of personality disorders. However, we have no choice but to continue using this word.

Overlaps with Other Personality Disorders

The representation below is intended to illustrate a frequently occurring constellation of overlapping symptoms from the anxious (avoidant) PD F60.6 and the obsessive-compulsive PD F60.5. The degree of severity of the respective overlapping symptoms varies, as with Borderline Personality Disorder.

Obsessive-Compulsive Personality Disorder (F60.5)

Obsessive-compulsive personality disorder is characterised by:

• Feelings of doubt
• Perfectionism
• Excessive conscientiousness
• Constant checking
• Stubbornness
• Caution and rigidity
• Persistent and unwanted impulses (which do not reach the severity of obsessive-compulsive disorder)

Exclusion

Obsessive-compulsive disorder F42.x

Symptoms Often Found in Dependent Disorder

• Constant preoccupation with details, rules, lists, order, organisation
• Perfectionism that hinders the completion of tasks
• Excessive conscientiousness
• Disproportionate focus on performance to the neglect or even abandonment of one’s own needs, pleasures, and/or interpersonal relationships
• Excessive pedantry and adherence to social conventions

Anxious Personality Disorder (F60.6)

Anxious personality disorder is a disorder characterised by the following features:

• Feelings of tension and apprehension
• Insecurity and inferiority
• Persistent longing for affection and acceptance
• Hypersensitivity to rejection and criticism
• Restricted capacity for relationships
• Overemphasis on potential dangers or risks of everyday situations to the point of avoiding certain activities

Symptoms Often Found in Dependent Disorder

• Conviction of being unattractive or inferior compared to others
• Excessive worry about being criticised or rejected in social situations
• Avoidance of social activities involving significant interpersonal contact, out of fear of criticism or rejection

Shifting of Symptoms

Thus, in dependent disorder, an emotional instability may well be present. Dependent disorder is generally accompanied by a disturbance of the self-image, regardless of which symptoms of other PDs are also present.

The regulation of the self-image, however, is entirely different from, for example, that in Borderline Personality Disorder.

Suicide Risk

When abandoned, tendencies toward suicide (then caused by the low self-esteem, feelings of inferiority, and depressiveness) are not uncommon, as the dependent personality believes they cannot survive without their partner.

The Problem of Multiple Diagnoses

As you can see, the individual symptoms — here of the anxious and the obsessive-compulsive PD — can shift to varying degrees within dependent disorder. Nevertheless, it remains a dependent personality.

If one merely adds up the items of the individual PDs — against which explicit warnings are issued, yet which is done time and again — it is no wonder that an affected person receives 3, 4, 5, or even more diagnoses.

But there actually exists for this the combined personality disorder F61. What is remarkable, however, is that hardly anyone is found with an F61 diagnosis.

Recommended Diagnostic Approach

Accordingly, as in the representation above, the diagnosis should read:

Core diagnosis:

• Dependent disorder F60.7

Secondary diagnosis:

• a) Strongly pronounced structures of obsessive-compulsive PD, F60.5
• b) Less strongly pronounced structures of anxious PD, F60.6

Criticism of the Current System

In no other field of science is there such a jumbling together of items with subsequently attempted demarcation and separation (comorbid with…) as in the field of personality disorders.

A Comparison

An example: We go and designate a certain group of apes as “human apes.” Well great — and what is that now? An ape? A human? Both? More ape than human? More human than ape?

Then we should also go ahead and designate ourselves as “ape-humans.”

Summary

Dependent disorder frequently shows overlaps with:

• Anxious-avoidant personality disorder
• Obsessive-compulsive personality disorder
• Depressive episodes
• Anxiety disorders

These overlaps should not lead to an inflation of diagnoses but should rather be understood as a spectrum within the underlying dependent disorder.