This article is a continuation of our look at Theodore Millon’s historical review of dependent personality disorder and how it has been classified by various psychologists and schools of thought. Aaron Beck and his associates, in the 90s, have sought to apply cognitive psychology to the treatment of this personality disorder in identifying specific beliefs which undergird it:
“DPD can be conceptualized as stemming from two key assumptions. First, these individuals see themselves as inherently inadequate and helpless, and therefore unable to cope with the world on their own. They see the world as a cold, lonely, or even dangerous place that they could not possibly handle alone. Second, they conclude that the solution tot he dilemma of being inadequate in a frightening world is to try to ind someone who seems able to handle lie and who will protect and take care o the. They decide that it is worth giving up responsibility and subordinating their own needs and desires in exchange for being taken care of.
In terms of hierarchy o beliefs, their core belief is likely to be “I am completely helpless,” or “I am all alone.” Their conditional beliefs are “I can function only if I have access to somebody competent,” “If I am abandoned, I will die,” “I I am not loved, I will always be unhappy.” The instrumental level consists of imperatives such as “Don’t offend the caretaker,” “Stay close,” “Cultivate as intimate a relationship as possible,” “Be subservient in order to bind him or her.”
Timothy Leary drew on the work of Horney and Fromm. He described what he referred to as the “docile-dependent” personality type in the following words:
“The moderate form of this security operation is expressed as a respectful or poignant or trustful conformity. In its maladaptive intensity it is manifested as a helpless dependency. These subjects in their interpersonal reflexes avoid the expression of hostility, independence, and power. Human beings utilize these security operations because they found that they are least anxious when they are outwardly relying on or looking up to others…These persons…seem to go out of their way to pull sympathy, help, and direction from others; who use their symptoms to communicate a helpless, painful, uncertain, unfrightened, hopeful, dependent personality.”
Benjamin, extending some of Leary’s ideas further, wrote:
“The baseline position is of marked dependentness to a dominant other person who is supposed to provide unending nurturance and guidance. The wish is to maintain connection to that person even if it means tolerating abuse The DPD believes that he or she is instrumentally incompetent,and this means that he or she cannot survive without the other dominant person.”
Costa and Widiger apply the Five actor Model of personality in attempting to articulate dependent personality disorder:
“DEP represents primarily an extreme variant o agreeableness with high levels of neuroticism and low assertiveness. Dependent individuals are characterized by a marked need or social approval and affection and will sacrifice many of their own needs, values, options, pleasures, and other goals to live in accord with the desires o others.”
Cloninger has proposed that this personality type is characterized by high harm avoidance, high reward dependence and low novelty seeking, although apart from this, not any biologically grounded proposals have been proferred with respect to this personality disorder. Cloninger says that this personality tends to be very deferential, submissive, ingratiating, and exhibits a very low threshold for frustration, criticism and punishment.
Theodore Millon argues that the dependent personality consists of four criteria:
“We shall label the central traits of the passive-dependent personality as follows: gentle affectivity (having kind, soft and humanitarian impulses), cognitive denial (showing a Pollyanna-like refusal to admit discomforting thoughts), inadequacy self-image (viewing oneself as inferior, fragile and unworthy) and interpersonal compliance (willing to submit and obligate to others).
Millon worked on the personality subcommittee of the DSM-III Task Force and, in 1975, proposed the relevant criteria:
“This pattern is typified by a passive-dependency, general social naivete and a friendly…temperament. There is a striking lack of initiative and competitveness, self-effacement of aptitudies and a general avoidance of autonomy. Appeasing and conciliatory submission to others is notable, as is a conspicuous seeking and clinging to supporting persons. Except where dependency is at stake, social difficulties are cognitively denied or neutralied by an uncritical and charitable outlook.
Since adolescence or early adulthood at least 3 o the following have been present to a notably greater degree than in most people and were not limited to discrete periods nor necessarily prompted by stressful life events.
1. Pacific temperament (e.g., is characteristically docile and noncompetitive; avoids social tension and interpersonal conflicts).
2. Interpersonal dependentness (e.g., needs a stronger, nurturing figure, and without one feels anxiously helpless; is often conciliatory, placating, and self-sacrificing).
3. Inadequate self-image (.e.g, perceives self as weak, fragile and ineffectual; exhibits lack o confidence by belittling own aptitudes and competencies).
4. Pollyanna cognitive style (e.g., reveals a naive or benign attitude toward interpersonal difficulties; smoothes over troubling events).
5. Initiative deficient (e.g., prefers a subdued, uneventful and passive life style; avoids self-assertion and refuses autonomous responsibilities.”
In a second draft in 1977, Millon wrote a list for review by the DSM-III Task Force associates:
“A. Excessive dependency (e.g., displays a chronic and conspicuous need for supporting or nurturant persons).
B. Isolation anxiety (e.g., cannot tolerate being alone for more than brief periods).
C. Lack of confidence and initiative (e.g., perceives self as weak, belittles aptitudes and is noncompetitive
D. Dependent and socially conciliatory (e.g., avoids sel-assertion, is self-sacrificing and Pollyanna-like).
E. Abdication of responsibilities (e.g., seeks others to assume leadership and direction for one’s affairs).”
There was a shift from the DSM-III to the DSM-III- with respect to DPD but it was only modestly significant. Instead of the core characterization being regarded as lack of self-confidence, the very idea of a fundamental core that constituted the belief was dropped. The ICD-10 is highly influenced by the DSM-IV in its characterization of the personality disorder.
“Among these are such features as encouraging others to make most important life decisions subordination of one’s own needs to those on whom one is dependent, with unnecessary compliance to one’s wishes: an unwillingness to make normal demands upon persons upon which one depends: considerable discomfort when helpless and alone owing to exaggerated fears of one’s inability to take care of oneself: preoccupation with fears of being abandoned by those on whom one depends: and limited capacity to make decisions without excessive advice and reassurance fro others. Associated features may include perceiving oneself as incompetent, helpless, and lacking in stamina.”
The DSM-IV tended to emphasize a pervasive need to be taken care of that results in clinging and dependency behaviors, as well as separation anxiety. …of the eight listed diagnostic criteria existed within the Interpersonal domain whereas two related to problematic self-image issues, with one related primarily to the cognitive sphere.
“In the Interpersonal realm, the following features serve as separate criteria: difficulties in making ordinary or everyday decisions without excessive advice and reassurance: an inclination to passivity by allowing others, often a single person, to assume responsibility for most areas of life: difficulty in voicing independent views or expressing disagreement with significant others owing to a fear of losing their support or approval: a willingness to go to unusual lengths to obtain nurturance and support, even to undertaking unpleasant tasks; and an urgent seeking for relationships to supplant one that may have been terminated. A single Cognitive criterion is recorded, notably an unrealistic and excessive preoccupation with fears of being abandoned and thereby being left alone to take care of oneself. Finally, the two criteria that relate to the Self-image domain include a lack o self-confidence in one’s self (rather than a lack of motivation or energy), resulting n an inability to initiate projects or to undertake independent tasks; and having exaggerated fears of not being competent to take care of oneself, resulting in feelings of helplessness and discomfort when alone.”