Dependent personality disorder: Perspectives for DSM-IV

The concept of dependency has its roots in psychoanalytic theory, social psychological theory, and ethologic theory (Hirschfeld, Klerman, Chodoff, Korchin, and Barrett, 1976). Psychoanalytic theory emphasizes the attainment of instinctual aims through interaction with social objects, such as the mother, as the source of dependency. Social learning theories consider dependency to be a learned behavior, that is, one acquired in experience rather than being instinctual in the organism. More specifically, dependency refers to a class of behaviors stemming from the infant's initial reliance on the mother; subsequently these learned behaviors generalize to interpersonal relations in general. In ethological theory the concept of attachment has been proposed to refer to the affectional bond that one person forms to another specific individual. This bond is manifested by behaviors fostering proximity to and contact with the love object and by behavioral disruptions if separation occurs. These three sources (psychoanalytic, social learning, and ethological) share certain elements but are far from identical. The psychoanalytic viewpoint emphasizes intrapsychic mechanisms, both motivational and cognitive. Social learning theory emphasizes behavior and is much less concerned with internal events. Also, from the standpoint of social learning theory, dependent behaviors are contingent upon reinforcements and therefore may vary over time and situation. The ethological approach blends both intrapsychic and behavioral aspects. Attachments are intrapsychic but lead to quite specific behavioral manifestations. Attachments are enduring and specific. These theoretical sources have contributed to the concept of dependent personality disorder as defined in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. The essential feature of this mental disorder has been abnormal dependency, which causes subjective distress and/or impairment in functioning for the individual. The definition and criteria of dependent personality disorder have shifted in the different versions of the DSM. In DSM-I (see Table 1) passive-dependent personality was defined as a subtype of passive-aggressive personality and was characterized by helplessness, indecisivenss, and denying behavior. DSM-II relegated passive-dependent personality to ''Other Personality Disorders of Specified Types'' and provided no description. In DSM-III, three criteria were specified: passivity and lack of independence, subordination of one's own needs, and low self-confidence. DSM-III-R expanded the definition to nine criteria. The essential feature became a ''pervasive pattern of dependent and submissive behavior'' with five criteria required for a diagnosis. Most of the criteria are elaborations of the passivity and subordination included in DSM-II. However, lack of self-confidence was dropped, and several criteria reflecting anxious attachment and fear of loss of an important person were added. In addition, a criterion reflecting sensitivity to criticism was added. The criteria for dependent personality disorder are currently under critical examination for possible revision for DSM-IV. The purpose of this paper is to address key issues and to review current thinking with regard to the criteria and diagnosis of this disorder.