para>Illness (acute and chronic) may cause regression resulting in dependent behaviors. With DPD, illness and aging are likely to intensify fearfulness and helplessness.
Pediatric Considerations
Diagnosis is rarely made for children/adolescents and may not be appropriate due to the necessary dependency of children/adolescents. Other psychiatric disorders must be ruled out as well as behavior related to a general medical condition or to the developmental cycle of the child. For diagnosis, baseline behaviors must be representative of DPD for at least 1 year.
Pregnancy Considerations
Physical and social changes may induce stress or increase fears, which may result in increased dependent behaviors. Distinguish this disorder from increased dependency due to pregnancy (e.g., when support system is inadequate).
EPIDEMIOLOGY
- Predominant age: onset no later than adolescence or early adulthood (may go undiagnosed for years)
- Predominant sex: female > male
Prevalence
Prevalence of DPD is ~0.6% (3).
ETIOLOGY AND PATHOPHYSIOLOGY
- A combination of hereditary temperamental traits and environmental/developmental factors
- One study found that genetics account for 66% of the variance in DPD-related factors (4).
RISK FACTORS
- Chronic or severe illness or disability in children
- Childhood/adolescent separation anxiety
- Parenting style that does not encourage age-appropriate independence
GENERAL PREVENTION
Children with chronic illness or handicap may be more susceptible to DPD. Foster appropriate independence in the face of disability.
COMMONLY ASSOCIATED CONDITIONS
- Co-occurring personality disorders are common, especially borderline, avoidant, and histrionic personality disorders.
- Increased risk with mood, anxiety, and adjustment disorders
- Increased risk for alcohol and drug abuse (5)[B]
- Associated with psychological complications in first-time mothers (6)[B]
- Increased risk of peptic ulcer disease (7)[B]
- Patients may contribute to, or prolong, underlying illness to get attention.
DIAGNOSIS
Due to high co-occurrence with other psychiatric disorders, assess suicide ideation and self-harm behavior.
HISTORY
DSM-5 criteria require a pattern beginning by early adulthood characterized by five or more of the following (1):
- Difficulty making everyday decisions without an excessive amount of reassurance from others
- Needs others to assume responsibility for most major areas of his or her life
- Has difficulty expressing disagreement with others because of fear of loss of support or approval
- Has difficulty initiating projects or doing things on his or her own because of a lack of self-confidence
- Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
- Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
- Urgently seeks another relationship as a source of care and support when a close relationship ends
- Is unrealistically preoccupied with fears of being left to take care of himself or herself
DIFFERENTIAL DIAGNOSIS
Other psychiatric conditions, such as:
- Mood disorders
- Consider baseline behaviors when considering DPD versus mood disorder.
- Anxiety disorders
- With DPD, chronic baseline behaviors will suggest personality disorder (i.e., they don't occur only at moments of stress or due to another psychiatric disorder).
- Adjustment disorder
- Dependence may be related to a distinct stressor and not chronic.
- Other personality disorder
- High co-occurrence of DPD and other personality disorders, especially borderline, histrionic, and avoidant
- General medical condition (GMC)
- Traits may emerge due to the effect of a GMC on the central nervous system.
- Chronic substance abuse
DIAGNOSTIC TESTS & INTERPRETATION
- Consider age of onset. To meet criteria for DPD, dependent pattern will be present from early adulthood.
- If symptoms begin later than early adulthood or are related to trauma (e.g., after a head injury), a GMC, or substance use, consider other diagnoses.
- Consider referring patient for formal psychological testing.
- Diagnostic accuracy may be improved through use of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) (8)[B]. An updated version known as the SCID-5-PD is in development.
Diagnostic Procedures/Other
- It is important to obtain collateral information (i.e., from family or partner) about behaviors.
- Always ask about substance abuse.
TREATMENT
- Outpatient psychotherapy can improve functioning and quality of life and reduce symptoms in patients with DPD (9,10)[A].
- Short-term inpatient therapy can be considered for severe cases (11)[A].
- Inpatient hospital services for conditions related to DPD should be limited and of short duration to decrease dependence (decreasing likelihood of behavior change).
- Hospitalization should be considered for the following:
- Adjustment of medications
- Implementation of psychotherapy for crisis intervention
- Stabilization of the patient facing significant psychosocial stressors
- If suicidal, may need suicide watch and appropriate psychiatric care
GENERAL MEASURES
- Focus on patient management rather than fixing or curing behaviors.
- Schedule follow-up at each visit to relieve patient stress.
- Meet with, and rely on, treatment team to avoid burnout and to provide opportunity for team to discuss issues with patient.
- As necessary, refer patient to mental health therapist.
- Patient's needs may become exhausting to providers-avoid hostile rejection of the patient.
MEDICATION
- There are no specific medications for treating DPD.
- Treat symptoms and comorbid psychiatric disorders.
- Consider an SSRI for depression or anxiety.
ISSUES FOR REFERRAL
Psychotherapy and psychiatry referrals should be considered.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Refer to inpatient or outpatient mental health specialist if harm to self or others is expressed by the patient and/or suspected by the primary care provider.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Schedule routine follow-up with patient (relieves patient anxiety about medical care relationship with physician).
- Set limits to availability: Keep to regularly scheduled visits.
- Nurses can be helpful in managing the patient and calling the patient as needed (contact with the patient helps relieve patient stress).
- Focus should be on medical conditions and comorbid psychiatric disorders.
PROGNOSIS
- Medical focus is on patient management and caring for medical and comorbid psychiatric disorders.
- With appropriate treatment, including mental health services, patient is viewed as treatment-responsive.
REFERENCES
11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.22 Herold E, Connors E, Moore T. American Psychiatric Association Board of Trustees Approves DSM-5 [news release]. Arlington, VA: American Psychiatric Association; 2012. http://psychnews.psychiatryonline.org/doi/abs/10.1176/appi.pn.2012.12b22. Accessed 2014.33 Lenzenweger MF, Lane MC, Loranger AW, et al. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;62(6):553-564.44 Gjerde LC, Czajkowski N, R ¸ysamb E, et al. The heritability of avoidant and dependent personality disorder assessed by personal interview and questionnaire. Acta Psychiatr Scand. 2012;126(6):448-457.55 Grant BF, Stinson FS, Dawson DA, et al. Co-occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States: results from the National Epidemiologic Survey on alcohol and related conditions. Arch Gen Psychiatry. 2004;61(4):361-368.66 Montmasson H, Bertrand P, Perrotin F, et al. Predictors of postpartum post-traumatic stress disorder in primiparous mothers [in French]. J Gynecol Obstet Biol Reprod (Paris). 2012;41(6):553-560.77 Schuster JP, Limosin F, Levenstein S, et al. Association between peptic ulcer and personality disorders in a nationally representative US sample. Psychosom Med. 2010;72(9):941-946.88 First MB, Gibbon M, Spitzer RL, et al. Structured Clinical Interview for DSM-IV Axis II Personality Disorders, (SCID-II). Washington, DC: American Psychiatric Press; 1997.99 Matusiewicz AK, Hopwood CJ, Banducci AN, et al. The effectiveness of cognitive behavioral therapy for personality disorders. Psychiatr Clin North Am. 2010;33(3):657-685.1010 Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA. 2008;300(13):1551-1565.1111 Bartak A, Spreeuwenberg MD, Andrea H, et al. Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorders: results of a large prospective multicentre study. Psychother Psychosom. 2010;79(1):20-30.
CODES
ICD10
F60.7 Dependent personality disorder
ICD9
301.6 Dependent personality disorder
SNOMED
Dependent personality disorder
CLINICAL PEARLS
- DPD is characterized by an excessive and pervasive need to be taken care of, leading to submissive and clingy behavior and fear of separation.
- To determine if a patient has a DPD versus dependent behavior from another psychiatric or substance-related disorder or from a GMC, note that personality disorders are chronic, so look at baseline behavior. Patients with DPD must have developed the personality disorder traits during adolescence or early adulthood.
- In the outpatient setting, frequent, short visits help patients with DPD to calm their fears of losing support and help providers with time management. When possible, always have an appointment scheduled so patients can look forward to their next visit.
- To feel less overwhelmed when seeing a DPD patient, have an agenda ready for the visit. Be cordial-they deserve the same professionalism as any patient gets. Address one to two issues per clinic visit.
- Many patients will benefit from additional psychotherapy treatments that target thoughts and behaviors associated with client's underlying dependency needs.