Dependent Personality Disorder: A Critical Review

Krystle L. Disney

PII: S0272-7358(13)00131-1
DOI: doi: 10.1016/j.cpr.2013.10.001
Reference: CPR 1347

To appear in: Clinical Psychology Review

Received date: 4 February 2013

Revised date: 24 September 2013
Accepted date: 1 October 2013

Please cite this article as: Disney, K.L., Dependent Personality Disorder: A Critical
Review, Clinical Psychology Review (2013), doi: 10.1016/j.cpr.2013.10.001

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
 ACCEPTED MANUSCRIPT
1

Running head: DEPENDENT PERSONALITY DISORDER

PT
RI
SC
Dependent Personality Disorder: A Critical Review

NU
Krystle L. Disney
MA
Washington University in Saint Louis1
D
P TE
CE
AC

Abstract

1Please send all correspondence to: Krystle L. Disney, M.A., Washington University in Saint Louis, Department
of Psychology, 1 Brookings Drive, Campus Box 1100, Saint Louis, Missouri 63130, or email
kldisney@wustl.edu.
 ACCEPTED MANUSCRIPT
2

Abstract

Dependent personality disorder (DPD) has evolved from an abstract idea rooted in a

historic and psychoanalytic context to a codified diagnosis in the DSM-IV-TR. This

PT
comprehensive review paper chronicles the evolution of DPD through each version of the

RI
DSM. Major topics relevant to the disorder are also investigated, including gender and

cultural considerations, stability and manifestations of DPD across different developmental

SC
stages, comorbidity issues, and others. The purpose of this review is to provide a broad yet

NU
comprehensive examination of the complex angles of maladaptive dependency and to

identify essential next steps in furthering our knowledge of this disorder. The paper
MA
concludes with a discussion of shortcomings in the body of research relevant to DPD, along

with specific suggestions for improvement in this field of study.

D
TE

Keywords: Dependent personality disorder, dependency, personality disorders

P
CE
AC
 ACCEPTED MANUSCRIPT
3

Dependent Personality Disorder: A Critical Review

Dependency to some degree is required throughout existence; humans are social

creatures who rely on others for survival across various stages of the lifespan. However,

PT
dependency in its more extreme forms is classified as a mental illness within the context of

RI
our current diagnostic system. The purpose of this investigative paper is threefold:

1) To examine excessive dependency in the form of a broad and comprehensive

SC
review, with a focus on manifestations that surpass an individual’s cultural expectations

NU
and cause distress or impairment across multiple contexts;

2) To identify gaps in the literature across several specialized research areas of DPD
MA
that will increase our understanding of this disorder and will allow us to come closer to

making an informed decision regarding its validity as a clinically useful construct, and
D
TE

3) To examine evidence for and against the construct validity of DPD within the

literature, the results of which will be discussed throughout the review, as well as to
P
CE

examine specific forms of validity related to its operationalization and assessment.

History of DPD
AC

Dependent personality disorder (referred to hereafter as “DPD”) has historical roots far

preceding the seminal volume of the DSM, and was often discussed in earlier works as a

manifestation of dysfunction originating in the Freudian oral stage of development (Bornstein,

1998a; Chen, Nettles, & Chen, 1999; Loranger, 19962). From its historical roots, DPD has

subsequently evolved over several versions of the DSM. The seminal DSM, published in 1952,

did not contain a distinct category for this disorder. The sole mention of excessive dependency in

this volume was a subtype of passive-aggressive personality titled “passive-aggressive

2 The Reference list is limited to citations discussed within this narrative. Please see the Appendix, available
in the online version of this paper, for references which are briefly cited but not discussed in detail.
 ACCEPTED MANUSCRIPT
4

personality, passive-dependent type,” characterized by “helplessness, indecisiveness, and a

tendency to cling to others as a dependent child to a supportive parent” (p. 37).

The DSM-II, published in 1968, continued to exclude any mention of a personality

PT
disorder based on dependency. The only suggestion of what would eventually become DPD can

be found in the description of the “Hysterical Personality,” which later evolved into Histrionic

RI
PD. The description of these individuals noted that they are often dependent on others. In

SC
addition, the description of the Passive-Aggressive personality also touched on abnormal

NU
dependency. According to the text, passive-aggressive behavior “is one expression of the

patient’s resentment at failing to find gratification in a relationship with an individual or

MA
institution upon which he is over-dependent” (p. 44).

The DSM-III, published in 1980, was the first volume to place personality disorders on
D
TE

Axis II, and was also the first to list DPD as a separate disorder. It was comprised of the

following three criteria: 1) allows others to assume responsibility for important life decisions,
P

along with passivity in interpersonal relationships, 2) subordinates one’s own needs to those of
CE

persons upon whom one depends, and 3) lacks self-confidence. The DSM-III was criticized for a
AC

number of reasons, including its suggestion that DPD and depression were strongly comorbid,

when the literature at that time showed a mixed relationship at best (Bornstein, 1995b).

Considerable changes were made in the transition from DSM-III to DSM-III-R, published

in 1987; most notably, the criteria were dramatically extended. This enabled a broader

conceptualization regarding the various behaviors and emotions prominent in the disorder. In

addition, the prior core criterion, “Lacks self-confidence” was dropped. In this volume, DPD was

characterized primarily by “a pervasive pattern of submissive and dependent behavior, beginning

by early adulthood and present in a variety of contexts” (p. 354). Five of the following nine
 ACCEPTED MANUSCRIPT
5

criteria were to be met in order to qualify for the diagnosis: 1) unable to make everyday

decisions, 2) allows others to make important decisions; 3) agrees with people even if they are

thought to be wrong; 4) difficulty initiating projects; 5) performs unpleasant tasks to obtain the

PT
approval of others; 6) dislikes being alone; 7) devastation when close relationships end; 8)

RI
preoccupation with fears of abandonment; and 9) easily hurt by criticism or disapproval.

The primary feature of DPD in DSM-IV, published in 1994, was modified slightly from

SC
DSM-III-R to “a pervasive and excessive need to be taken care of, which leads to submissive and

NU
clinging behavior and fear of separation” (p. 665). The DSM-IV consists of eight criteria that are

nearly identical to those in the DSM-III-R, with the exception of criterion 9 (being easily hurt),
MA
which was dropped from the DSM-IV due to its overlap with other PDs (Bornstein, 1995a,

1997). DPD was quite nearly deleted from the DSM-5 at the initial recommendation of the
D

Personality Disorders Work Group. However, the American Psychiatric Association’s Board of
TE

Trustees ultimately chose not to approve the proposed changes, and DPD was ultimately
P

included in the DSM-5.

CE

DPD as a construct
AC

Little empirical research has been completed on the construct of DPD in comparison to

other Axis II disorders (Loas, Cormier, & Perez-Diaz, 2011; Loranger, 1996; Smith, Hilsenroth,

& Bornstein, 2009). The core element of this disorder appears to be a view of the self as helpless

and inept, along with a view of others who are seen as strong and competent (Bornstein, 1997;

Gudjonsson & Main, 2008).

PDs are often criticized for their heterogeneity. An individual is required to meet five of

eight criteria for a diagnosis of DPD. Therefore, there are 93 possible combinations of

symptoms. A person could also present with five, six, seven, or all eight symptoms, providing
 ACCEPTED MANUSCRIPT
6

further variety in terms of severity. To investigate this issue further, Gude, Karterud, Pedersen,

and Falkum (2006) studied symptom combinations of 248 individuals diagnosed with DPD in a

clinical sample from Norway. They found that 60 of 93 possible combinations were present, and

PT
that none of the combinations appeared more than seven times. These results suggest that there is

no “core” or “privileged” manner of obtaining or presenting with DPD, and that there is indeed a

RI
variety of DPD presentations that clinicians and researchers may be presented with. The results

SC
of this study could be interpreted as evidence against the construct of DPD, as there are indeed

NU
dozens of ways in which DPD in its current operationalized form can manifest in an individual.

However, this argument can be used for all of the PDs, and some of them (antisocial, for
MA
instance) are even more heterogenous than DPD.

Blashfield and Breen (1989) studied responses in a sample of 61 psychologists and

D
TE

psychiatrists (29 psychologists and 32 psychiatrists) to examine face validity of DPD and other

Axis II criteria in the DSM-III-R. Clinicians were given a randomly-ordered list of all 142 PD
P

criteria that were considered valid at the time of publication and were asked to assign each
CE

criterion to the appropriate parent category. The average clinician placed 66% of the 142 criteria
AC

correctly. Clinicians were able to accurately identify DPD criteria 73% of the time, which was

close to the 80% marker that authors had selected for adequate face validity. However, 12% of

the time, DPD criteria were incorrectly assigned to Borderline PD, and 13% of the time,

Avoidant criteria were incorrectly assigned to DPD. In contrast, DPD criteria were only called

Avoidant 3% of the time. The authors concluded that DPD is not one of the more problematic

PDs, as it outperformed many others in this particular study (Histrionic in particular). Another

similar study (Huprich and Fine, 1996) found that DPD criteria were correctly assigned to the

appropriate parent category 93% of the time. Accordingly, we can conclude that clinicians are
 ACCEPTED MANUSCRIPT
7

able to accurately identify DPD criteria the majority of the time. It is also noteworthy that

avoidant criteria look more dependent than vice versa (see Comorbidity section below for more

information on the relationship between DPD and avoidant PD).

PT
Bachrach, Croon, and Bekker (2012) conducted a literature review of factor-analytic

RI
studies of DPD between 1980 and 2012 and found only two such studies serving this purpose:

one that implemented PCA and one with CFA. PCA is generally considered an inferior method

SC
of factor analysis in PD research, because it assumes the variables are orthogonal; however, we

NU
know from the extensive comorbidity issues within Axis II PDs that they are not independent

from one another. Regardless, both studies found DPD to be a bidimensional construct,
MA
consisting of the domains of incompetence and dysfunctional attachment. There is also factor-

analytic evidence that PDs consist of internalizing and externalizing domains (Kendler et al.,
D
TE

2011; Krueger, McGue, & Iacono, 2001), and that DPD is classified as an internalizing disorder.

Regarding the operationalization of DPD, it is widely agreed that there are problematic
P

DSM-IV criteria within DPD, and external validity of the criteria has been questioned (Smith et
CE

al., 2009). For example, Criterion 2, “Needs others to assume responsibility for most major areas
AC

of his or her life” had never been tested directly at the time of publication of DSM-IV, nor had

Criterion 7, “Urgently seeks another relationship as a source of care and support when a close

relationship ends” (Bornstein, 1997). In addition, two criteria were contradicted by findings at or

near to the time of DSM-IV publication: Criterion 3 (“Has difficulty expressing disagreement

with others because of fear of loss of support or approval”) and criterion 4 (“Has difficulty

initiating projects or doing things on his or her own”). Only four of eight DPD criteria were

empirically supported at the time of publication, which raises questions about the validity of

DPD and identifies particular criteria that may be flawed.

 ACCEPTED MANUSCRIPT
8

Gude et al. (2006) suggest that one way to define sufficient construct validity is for DPD to

demonstrate high correlations among the DPD criteria, low item correlations with other PDs, and

satisfactory internal consistency. They analyzed item correlations between DPD criteria and

PT
other Axis II disorders and found that the first four DPD criteria significantly correlated with

RI
avoidant PD, while the last three were significantly correlated with borderline PD. There was

moderate internal consistency among the DPD criteria (Cronbach’s α = .68). Criterion 3

SC
(Difficulties in expressing disagreement and fear of loss of support or approval) is particularly

NU
positively correlated with Avoidant PD, and criterion 5 (Goes to excessive lengths to obtain

support; volunteers to do unpleasant things) correlated quite weakly with DPD. The authors
MA
concluded that the quality of the DPD construct as it is currently operationalized is low to

moderate overall, and that criteria 3 and 5 are particularly problematic.

D
TE

In addition to examining properties of DPD criteria in the DSM, it is also useful to compare

DPD constructs between the DSM and ICD-10, which overlap a great deal but do not carry
P

identical definitions of DPD. For example, the ICD lists “Unwillingness to make even reasonable
CE

demands on the people one depends on,” as a symptom of the disorder, which is an interesting
AC

behavioral trait that is implied but not specifically listed as a symptom in the DSM-IV.

Prevalence rates of DPD using the ICD-10 classification tend to be lower than with the DSM

(Brieger, Sommer, Blöink, & Marneros, 2000); further exploration of these differences would

yield useful information. To date, however, there is a lack of empirical investigation or

comparison between DPD as it is operationalized in both volumes.

Costa and McCrae’s (1985) popular five-factor model of personality contains five

underlying factors, or domains: Neuroticism, Extraversion, Openness, Agreeableness, and

Conscientiousness, comprised of six facets each. Dependent traits are strongly associated with
 ACCEPTED MANUSCRIPT
9

Neuroticism (Bienvenu & Brandes, 2005; Bornstein, 2011; Brieger et al., 2000; Lowe,

Edmundson, & Widiger, 2009), with relationships in at least four of the six facets therein:

Anxiety, Depression, Self-consciousness, and Vulnerability.

PT
Bornstein & Cecero (2000) conducted a meta-analysis of studies that investigated the

RI
relationship between DPD and the Big Five and found that dependency scores are positively

correlated with Neuroticism and Agreeableness, and are negatively correlated with Extraversion,

SC
Openness, and Conscientiousness. Their findings held regardless of whether the assessment was

NU
conducted via clinical interview or questionnaire. In this meta-analysis, the largest correlation

between the dependency measures and Neuroticism facets was found in Self-Consciousness (r =
MA
.45). Lowe et al. (2009) found that 11 of 13 dependency measures were significantly correlated

with Neuroticism in a clinical sample, with correlations ranging from .23 (3 Vector Dependency
D
TE

Inventory, Exploitation Scale, p < .05) to .53 (MCMI-III, p < .01). The congruence of these

findings indicate that although there may be problems with the current operationalization of
P

DPD, or problems with specific criteria, there is a core factor that maps on to the five-factor
CE

model in a predictable and fairly consistent way. Regarding Openness, dependent individuals are
AC

lower on the Actions facet, but no other remarkable or specific relationships have been

consistently noted in the literature. Congruent with the findings from Bornstein and Cecero’s

meta-analysis, other researchers have also found a relationship between DPD and low levels of

Extraversion. In terms of its facets, DPD features are particularly associated with low levels of

Excitement-Seeking (Brieger et al., 2000).

As one would likely expect, DPD has shown a relationship with Agreeableness (Brieger

et al., 2000; Gudjonsson & Main, 2008). However, the relationship between DPD and this

domain is noticeably less straightforward and powerful when compared to its relationship with
 ACCEPTED MANUSCRIPT
10

Neuroticism. This is surprising, given that clinical wisdom often conceptualizes DPD as a

combination of high Neuroticism and excessively high Agreeableness. However, the relationship

between the two was not as strong as predicted across various studies (Bornstein & Cecero,

PT
2000; Lowe et al., 2009; Miller & Lynam, 2008).

RI
Agreeableness may not demonstrate a consistent relationship with DPD because of the

way the relevant items in the NEO are worded, in that they measure healthy levels of

SC
dependency as opposed to those that are maladaptive (Lowe et al., 2009). These researchers

NU
reworded items of the NEO to assess maladaptive dependency and then re-assessed the strength

of the relationship between DPD and Agreeableness. For example, “I try to be courteous to
MA
everyone I meet” became “I am overly courteous to everyone I meet,” and “I think of myself as a

charitable person” became “I am so charitable that I give more than I can afford.” With this
D
TE

revised NEO Agreeableness scale, a strong relationship between DPD and Agreeableness was

repeatedly found. The authors concluded that the NEO measures adaptive Agreeableness, while
P

their Revised NEO measures maladaptive Agreeableness that more adequately captures the
CE

symptoms of DPD. Accordingly, caution should be used when discussing the relationship
AC

between Agreeableness and DPD as it pertains to the Big Five.

Despite potential flaws in the relationship between Agreeableness and DPD, the Big Five

together explain more than quarter of the variance of all ICD-10 personality pathology (R2 =

.27), 14-17% of the variance in DPD in particular (Brieger et al., 2000), and is a useful and

widely-used model for the conceptualization of DPD.

Etiology/Risk Factors of DPD

There has been particularly little empirical research regarding the etiology of DPD (Baker,

Capron, & Azorlosa, 1996). Family environment, social learning, severe childhood illness, and
 ACCEPTED MANUSCRIPT
11

biological predisposition have all been implicated as playing a role in its development

(Ampollini et al., 1999; Bornstein, 2011). In addition to these variables, specific early traumatic

events such as childhood sexual abuse are often noted in the literature (Alexander, 1993).

PT
However, in a study examining the relationship between childhood sexual abuse and adult PDs

RI
in a sample of adult survivors, it was not the characteristics of sexual abuse but rather attachment

style that best predicted DPD, with Fearful attachment style being the strongest predictor. This

SC
style is associated with a lack of assertiveness as well as high levels of social anxiety.

NU
Attachment theory and DPD are frequently associated in the research literature (Alexander,

1993) though others argue that the relationship between the two is modest at best, and that while
MA
insecure attachment behaviors and DPD are related, they are ultimately separate constructs

(Bornstein, 1995a, 1997, 2012). According to attachment theory, children learn about themselves
D
TE

and the world primarily through seminal relationships with caregivers. These relationships form

the basis of an internal working model, which permeates the individual’s experience into and
P

throughout adulthood. When this attachment operates in a dysfunctional way, such as through
CE

lack of warmth and/or consistency on the part of the caregiver, the child develops insecure
AC

attachment. As a result, the insecurely attached child views him- or herself as inadequate.

Despite findings that seem fairly consistent and are intriguing and compelling in their own right,

one of the primary issues to keep in mind with both the child abuse and attachment literature is

that they both often rely on retrospective self-report, which is not entirely reliable.

Related to attachment theory is parental style. Overprotective and authoritarian parenting

styles have been linked to the development of DPD (Bornstein, 1997, 2012), though this

assertion is largely theory-driven and the result of retrospective self-report as well. Accordingly,

though it is rarely disputed that parental style is an influential factor, there is a lack of solid
 ACCEPTED MANUSCRIPT
12

empirical evidence to support this idea. In terms of the theory behind this assertion, when a child

is reinforced for being excessively compliant, they are likely to present themselves as dependent

or helpless in later relationships (Bornstein, 1995a). In addition, these parenting styles hinder the

PT
child’s mastery and self-efficacy that would otherwise develop through autonomous exploration

RI
of the world. With regard to specific parenting style, children of overprotective parents are taught

that they are fragile and that they will never survive unless they are looked after, while

SC
authoritarian parents teach that the best survival method is to defer to the wishes and

NU
expectations of others who are stronger and more capable.

Separation anxiety disorder (SAD) is a developmental disorder that has been suggested as a
MA
risk factor for adult-onset DPD (American Psychiatric Association, 1994; Mroczkowski et al.,

2011). Loas et al. (2002) examined a sample of 1492 individuals composing large clinical and
D
TE

nonclinical samples and found that DPD was 9.85 times more likely to occur when paired with a

lifetime occurrence of SAD. The authors concluded that while the results are striking, the
P

relationship between DPD and SAD could also be inflated due to fear of separation being a
CE

symptom of both disorders. This is a valid comorbidity issue; however, these disorders are not
AC

the same. They have different developmental stage requirements (SAD requires onset prior to 18

years of age, while DPD doesn’t have to begin until early adulthood), and different symptoms.

However, the relationship between the two is poised as an important area of future exploration.

Cognitive therapy (CT) also examines the role of childhood experience, but rather than

focusing primarily on the relationship between infant and caregiver, supporters of CT take the

stance that childhood schemas underlie maladaptive emotions and behaviors of individuals with

PDs, and that our representations of ourselves, others, and the world around us develop during

childhood as a result of environmental and biological interactions. Maladaptive cognitions lead

 ACCEPTED MANUSCRIPT
13

to a view of the self as being weak and ineffectual (Bornstein, 1998b), and faulty schemas lead to

biased information processing, typically toward the negative (Arntz, Weertman, & Salet, 2011).

The resulting low self-esteem and anxiety continue into adulthood and form the basis of DPD

PT
(Bornstein, 2004).

RI
Cloninger (1987) proposed a well-known biosocial theory of personality relevant to the

etiology of DPD. In his model, three heritable and biologically based characteristics of

SC
personality were proposed: Novelty-Seeking, Harm Avoidance, and Reward Dependence. High

NU
levels of Harm Avoidance are present in individuals with Cluster C disorders (particularly DPD),

as well as high levels of Reward Dependence (Ampollini, Marchesi, Signifredi, & Maggini,
MA
1997; Casey & Joyce, 1999). Harm avoidance is defined in Cloninger’s model as a heritable

characteristic involving the serotonin (5-HT) system that emits an intense aversive response to
D
TE

certain types of stimuli. The individual then learns to avoid not only punishment, but novelty as

well. This manifests in the individual as worry and shyness. Cloninger’s model is unique in the
P

realm of etiological theories of DPD in that it combines personality traits and behaviors with
CE

genetic and biological mechanisms, rather than ignoring those influences entirely, as many other
AC

models and theories do. This focus on biological and physiological mechanisms points is

important in that it includes the often overlooked aspect of anatomical structures and processes

and their involvement in personality.

Assessment of DPD

Personality assessment is notoriously difficult, and even more so in the realm of

personality disorders. Instruments in this area are often criticized for unsuitably low levels of

test-retest reliability and construct validity (Smith et al., 2009). Method of assessment is an

important variable to consider. Loranger (1996) recommends the use of semi-structured

 ACCEPTED MANUSCRIPT
14

interviews over self-report due to the oft-noted shortcomings of self-report in PD assessment.

One major problem with self-report and PDs is the self-serving bias, or a tendency for people to

draw “a friendly picture of themselves” (Leising, Sporberg, & Rehbein, 2006, p. 320). Lowe et

PT
al. (2009) have suggested that gender is important as well in the assessment of DPD, as men

RI
typically score lower on self-report measures. One alternative is to combine self- and peer report,

which addresses the bias present in using either method alone (Casey & Joyce, 1999;

SC
Rodebaugh, Gianoli, Turkheimer, & Oltmanns, 2010). The combination of self-report with a

NU
follow-up clinical assessment has also been recommended in the literature. Instruments that

require assessment by a clinician have the benefit of greater reliability and validity (Jacobsberg,
MA
Perry, & Frances, 1995). However, this is done at the expense of requiring more time per

participant and is not always practical or feasible. Others have argued that self-report can be
D
TE

omitted entirely in personality assessment, and that reports from a variety of persons who know

the person best are most accurate (Hofstee, 1994), as plural observations from informants cancel
P

out idiosyncratic bias that may be present in any one individual.

CE

If possible, use of informant report and/or structured interviews should be used to

AC

overcome the many problems associated with PD diagnosis, such as low reliability and lack of

insight (Baer, Jenike, Ricciardi, & Holland, 1990; Jacobsberg et al., 1995; Klonsky, Oltmanns, &

Turkheimer, 2003). Informant report increases the richness of personality portraits while

overcoming several disadvantages of self-report (Klonsky, Oltmanns, & Turkheimer, 2002;

Vazire, 2006; Vazire & Carlson, 2011). Other methods of assessment surpass self-report as well.

Bornstein (2012) recommended that in lieu of informant report, implicit or performance-based

data should be used to investigate the presence and strength of DPD criteria. Behavior

observation is a form of assessment that is often underutilized, which could potentially reduce
 ACCEPTED MANUSCRIPT
15

error variance associated with retrospective self-report and global judgments (Leising et al.,

2006).

It is also important to note the difference between instruments measuring dependency

PT
(such as the Interpersonal Dependency Inventory or IDI, Hirschfeld et al., 1977), and those that

RI
were specifically constructed to assess for the presence of DPD in DSM-IV-R, such as the

Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1997).

SC
While instruments that measure information on dependency are useful, they are not measuring

NU
identical constructs. Therefore, if they are going to be used, they should be used in addition to

(rather than in lieu of) measures specifically designed to assess Axis II psychopathology. For
MA
detailed information on convergent validity among 13 widely used dependency measures, see

Lowe et al., 2009.

D
TE

There are a number of ways to approach the assessment of DPD, many of which are hotly

debated. One issue with little disagreement is that relying on self-report is no longer satisfactory
P

or accurate. Informant report has been a gold standard for the past decade or two, but there are
CE

also new, promising areas of assessment yet to be developed, such as implicit association tasks
AC

and behavioral observation. One other issue particularly relevant to DPD is to avoid assessment

based primarily on the construct of dependency; though useful, it can cause problems if

instruments that are used to diagnose were not designed with the purpose of detecting the

disorder.

Gender and Cultural Factors in DPD

DPD is diagnosed more frequently in females, and is one of the most hotly debated PDs

in terms of gender. Critics argue that clinicians are biased and view this array of symptoms as

more maladaptive when presenting in females than in males (Anderson, Sankis, & Widiger,
 ACCEPTED MANUSCRIPT
16

2001; Kaplan, 1983). It has also been correctly noted that the DSM PD Work Groups across the

various volumes have been overwhelmingly male (89% male for DSM-III; 84% for DSM-III-R;

78% for DSM-IV, and 82% for DSM-V), and that the criteria for DPD have therefore been

PT
written from a masculine perspective. Many studies are congruent with the DSM-IV and report a

RI
higher prevalence rate of DPD in females (Barzega, Maina, Venturello, & Bogetto, 2001;

Bornstein, 1997, 1998b; Calsyn, Fleming, Wells, & Saxon, 1996; Loranger, 1996; Lowe et al.,

SC
2009; Starcevic et al., 2008), while others have reported no difference (Baer et al., 1990; King,

NU
2000; Lopez-Rodriguez et al., 1999).

Kaplan’s well-known paper (1983) takes particular issue with DPD, focusing first on the
MA
criterion of occupational impairment for general personality disorder. She argues that a woman

who is unemployed but cares for the home and children and a man who works at the expense of
D
TE

spending time with his children would not be labeled as impaired. However, a woman who

neglects her children or a man who cannot hold down a job are both more likely to be considered
P

impaired due to societal sex role expectations. Additionally, if a female excessively conforms to
CE

her traditional gender role, she receives the diagnosis of DPD and possibly Histrionic PD as well.
AC

Conversely, behaving in a stereotypically male fashion (restricted expression of emotion, putting

work before family, or discomfort with intimate conversations, for example) will not. Therefore,

she argues that DSM criteria are biased towards masculinity in terms of what is normal, and

argues that DPD is little more than a caricature of the traditional female role.

Kaplan noted that “Masculinity alone is not clinically suspect; femininity alone is” (p.

791). This assertion was supported in later empirical work by Klonsky, Jane, Turkheimer, and

Oltmanns (2002), in which men and women’s levels of masculinity and femininity were assessed

via informant reports of participants who lived on the same college dorm floor. Men scoring
 ACCEPTED MANUSCRIPT
17

higher on femininity exhibited more features of all PDs with the exception of antisocial PD.

Strikingly, this was found via both peer and self report. DPD traits were also associated with

higher levels of femininity and lower levels of masculinity in women for both self and peer

PT
report as well. These results tell us that features of femininity are associated with personality

RI
pathology in men, and with features of DPD specifically in women. What is still unclear is

whether femininity is truly pathologized, or if it co-occurs with features of personality pathology,

SC
particularly DPD.

NU
Multiple hypotheses for gender bias in DPD have been suggested: One is that the criteria

themselves are biased. The other is that the criteria are not biased, but that clinicians view the
MA
criteria as being more or less maladaptive depending on whether they are present in a male or a

female. Anderson et al. (2001) recruited two samples of clinicians from District 12 of the
D
TE

American Psychological Association to investigate this issue and asked them to rate how 1)

common or rare and 2) how maladaptive PD criteria were in the case of a client being either male
P

or female. Their results showed that clinicians rated DPD as being more common in females, but
CE

that they did not perceive DPD characteristics to be differentially pathological in either sex.
AC

Their findings supported the argument that DPD criteria are gender neutral, contradicting

Kaplan’s earlier assertions: clinicians do not apply the criteria differentially to either gender

based on perceived maladaptiveness, though they do perhaps fall prey to a representativeness

heuristic caused by base rates. However, this study contradicted earlier work showing that DPD

criteria were rated as more maladaptive for females than for males (Sprock, Crosby, & Nielsen,

2001), meaning that whether or not femininity and women are pathologized in the realm of DPD

is still unknown.
 ACCEPTED MANUSCRIPT
18

The area of DPD traits in men is understudied and teeming with interesting results. One

important issue to consider is the relationship between dependency and spousal abuse (Loas et

al., 2011). It has been argued that fear of loss in dependent relationships may lead to physical

PT
violence by the dependent male in order to prevent or reduce risk of abandonment (Berk &

RI
Rhodes, 2005). Men who commit uxoricide (wife murder) commonly have concurrent DPD. In

these men, the perception of imminent abandonment triggers rage responses and ultimately,

SC
physical violence. They may also engage in behaviors such as monitoring their partner’s time or

NU
making direct threats (Dutton, 2002).

DPD may be associated with differential relationships with males in other ways aside
MA
from the potential for abuse. Loas et al. (2005) found that the relationship between suicidal

ideation and DPD was stronger in male drug abusers than in female drug abusers. Bolton, Belik,
D
TE

Enns, Cox, and Sareen (2008) examined Wave 1 of NESARC data to investigate the relationship

between suicide attempts and a number of sociodemographic and psychopathology-related

P

variables in depressed individuals. Personality pathology was the strongest predictor of suicide
CE

attempts over and above age, ethnicity, income, and anxiety and substance use disorders. In
AC

males, DPD was particularly associated with suicide attempts, with a higher association between

lifetime suicide attempts and males with DPD than any of the other six PDs assessed. The

presence of DPD predicted suicide attempts in almost three quarters of depressed males (with a

positive predictive value of 74.3%), though the presence of DPD was also a strong predictor of

suicide attempts in women (with a positive predictive value of 58%), over and above the other

personality disorders in both genders. In contrast to some of the evidence presented above, this is

compelling evidence in favor of the validity of DPD, as it suggests that there is something

particular about this array of symptoms that is associated with suicide attempts in comparison to
 ACCEPTED MANUSCRIPT
19

many other variables, including demographic variables and other PDs. However, as the authors

noted, their results are reliant upon retrospective self-report about a very personal issue.

These results provide important information for further consideration, as the

PT
manifestations and consequences of DPD may ultimately differ for men and women. These

RI
findings are congruent with a growing body of literature identifying DPD as a potential suicide

risk factor for males, and to a lesser extent for females.

SC
Cultural influences are also often overlooked in the assessment and diagnosis of DPD.

NU
Culture shapes how an individual views the relationship between self and others on a spectrum

from individualistic to collectivistic. Individualists see themselves as more differentiated from

MA
family and friends than collectivists. In collectivist cultures, individuals defer their goals to the

goals that best benefit the group, and the focus is on cooperation and alliance with others. This
D
TE

lack of drive toward individual wishes and goals may explain the higher prevalence of DPD

symptoms in collectivist cultures. Caldwell-Harris and Ayçiçegi (2006) studied community

P

individualist and collectivist samples of students in Boston and Istanbul, respectively, and found
CE

that American individuals scoring lower on individualism received significantly higher DPD
AC

scores on the PDQ-R, r = -.35, p < .01. In addition, Americans with collectivist orientations

received significantly higher scores of psychopathology on a number of other Axis I and II

disorders as well. These findings, in which collectivist Americans scored higher on measures of

psychopathology, supported the authors’ hypothesis that a clash between personality and societal

values is a risk factor for psychopathology, and that this risk applies to DPD.

While there is some research on individualist and collectivist cultures and their respective

contributions to dependent symptoms, there is far less research on specific ethnicities within the

U.S., particularly African Americans. One study found that African American participants were
 ACCEPTED MANUSCRIPT
20

significantly less likely to be diagnosed with DPD than Caucasians or Hispanics (Calsyn et al.,

1996), but there is very little else in the way of empirical research about this group of

individuals. This is a grossly neglected area of research needing further exploration.

PT
Stability of DPD

RI
It can be difficult to discern developmental differences in DPD, particularly because

research on PDs in the elderly is lacking (Casey & Joyce, 1999). This is unfortunate, as this is a

SC
particularly important age group in the study of dependency manifestations and transitions.

NU
Symptoms in this stage of life can develop in response to psychological or physical disorders, for

example, and may be exacerbated due to the frightening nature of an illness (Bornstein, 1995b;
MA
Chen et al., 2009). In addition, disrupted social functioning due to the repercussions of disease

may foster or maintain dependency behaviors (Lopez-Rodriguez et al., 1999). Loranger (1996)
D
TE

compared a group of individuals with DPD (n = 342) to a group of individuals with any of the

other PDs (n = 3298), and found that 51.2% of the DPD group was over 40 years of age, whereas
P

this was only true for 25.7% of the non-DPD group (p < .001). The author suggested that this
CE

result could be due in part to declining health, though age 40 is a somewhat early to begin to
AC

attribute personality traits to health problems.

In another study, anxious older adults (M = 66 years) had significantly elevated rates of

DPD compared to a group of anxious younger adults (M = 20.2 years) (Coolidge, Segal, Hook,

& Stewart, 2000). These results suggest that DPD may not remit in middle to later life as other

PDs, such as antisocial and borderline, are widely reputed to do (Grilo et al., 2001), possibly due

in part to the health-related stressors and transitions mentioned above that are generally unique to

later life.
 ACCEPTED MANUSCRIPT
21

Dependent behaviors manifest differently at various points in the lifespan. DPD Criterion

2 reads, “Needs others to assume responsibility for most major areas,” which is not unusual in

adolescents (Grilo et al, 1998). Dependency in adolescents may also manifest as close

PT
relationships with valued peers, rather than with parents. As the person shifts from adolescence

RI
to adulthood, the primary object of dependence may shift again from peers to a mentor or figure

of authority, such as a professor or supervisor (Bornstein, 2012).

SC
One of the trademark diagnostic requirements for a personality disorder is for the

NU
symptom to be present and stable since early adulthood, though there is little data to support this

prerequisite. Grilo et al. (2001) found that DPD scores were significantly lower two years after
MA
baseline in a clinical sample of hospitalized teenage outpatients, suggesting that DPD in

adolescents may not have a typically chronic course, as currently required in the DSM. Grilo et
D

al. (1998) examined PD prevalence groups between adolescents (ages 12 to 17.99 years, M
TE

= 15 years) and adults (ages 18 to 37, M = 23 years). Of the 10 PDs, a significant age
P

difference was only found for DPD, which was significantly more common in the adult
CE

group than in the adolescent group.

AC

Gutiérrez et al. (2012) examined a sample of 1477 patients (aged 15 to 82) over a

six-year period. Using multiple linear regressions and controlling for sex and sex x age

effects, they found that DPD does show a significant decline across increasing age groups,

with a 23.8% reduction in symptom criteria from age 20 to age 50 (R2 = .02, p < .001). The

authors also made the notable point that while we tend to look for disorders that are

increasing or decreasing over time, we should also examine whether each criterion

increases or decreases. Within a disorder, some symptoms may increase over time while

others decrease, which may result in a disorder that appears stable when there is actually
 ACCEPTED MANUSCRIPT
22

quite a bit of movement within the individual criteria. While Cluster C disorders in this

study remained fairly stable until approximately age 35 and then declined to age 50, we are

still left wondering about the years of 50 and beyond, during which time health issues and

PT
other transitions unique to later life may contribute to a reemergence of dependent

RI
symptoms.

Evidence is mixed regarding the stability and course of DPD. What does seem clear,

SC
however, is that the sparse findings in this area are not congruent with the DSM-IV. The

NU
course does not always seem to be chronic, as DPD symptoms, sometimes severe, can arise

later in life. In addition, studies have shown mixed results regarding prevalence rates
MA
across different developmental stages, and manifestations of DPD may be more common

and unique to particular age ranges.

D
TE

Comorbidity of DPD

Examination of the antecedents, correlates, and consequences of DPD is essential, as

P
CE

these personality features may be risk factors for the development or maintenance of other Axis I

and II disorders (Ampollini, et al., 1999; Bornstein, 1995b). Comorbidity issues appear to be a
AC

consistently productive area of research on DPD. However, because of the detrimental impact of

Axis II pathology in various areas of the affected person’s life, more prospective or longitudinal

studies are needed to evaluate causal or temporal relationships among the various disorders.

Many papers leave the reader with the conclusion that DPD is associated with other specific

disorders, but we still need to learn why, when, and how. We will now briefly examine the

disorders most concentrated within the DPD comorbidity literature.

Comorbidity with other PDs

 ACCEPTED MANUSCRIPT
23

DPD has a high overlap with the other PDs in general (Bornstein, 1995b; Gude et al.,

2006), and particularly with the other Cluster C disorders. Studies that report significant results

with DPD often include significant findings for one or both of the other Cluster C disorders as

PT
well, indicating the presence of substantial overlap. While this is what one would expect from

RI
PDs within the same cluster, it can become difficult to determine specificity of the contribution

of any particular disorder when these relationships repeatedly occur in the literature. For

SC
example, one study found that DPD is associated with the onset of postpartum depression within

NU
a few weeks of childbirth. Avoidant and obsessive-compulsive PDs were identified as risk

factors as well (Akman, Uguz, & Kaya, 2007), making Cluster C disorders a unique predictor in
MA
the onset of postpartum depression in new mothers. In keeping with our examination of evidence

for and against the construct of DPD, the excessive overlap between DPD and other PDs could
D
TE

be indicative of a discriminant validity problem in the context of other Cluster C disorders

(Blashfield & Breen, 1989; Bornstein, 1995b).

P

Over and above the relationship among all three Cluster C disorders, dependent and
CE

avoidant PDs overlap in the literature substantially (Bornstein, 1997; Gude et al., 2006).
AC

Researchers have been questioning the overlap between Avoidant and DPD for a quarter of a

century (Trull, Widiger, & Frances, 1987; Reich, 1989). One study found a large correlation of

.66 between symptoms of DPD and Avoidant PD (Bachrach et al., 2012), and the DPD and

Avoidant scales of the SCID-II are substantially and positively correlated as well, at .55 (Leising

et al., 2006). This amount of overlap poses a serious concern to the validity of both disorders; in

the following paragraphs, further differences and similarities between the two will be

highlighted.
 ACCEPTED MANUSCRIPT
24

Avoidant and dependent PDs share an overlap of cognitive styles, with a view of others

as being “better,” more capable, and more competent, and an emphasis on behaviors such as

avoidance and compliance (Arntz et al., 2011; Gudjonsson & Main, 2008). Individuals with both

PT
disorders are concerned with being criticized or rejected, and both are quick to engage in self-

RI
blaming behaviors. For example, individuals with both avoidant and DPD symptoms have shown

higher levels of submissiveness than other PDs when put into an assertiveness role-playing

SC
situation, even after being asked to be as assertive as possible (Leising et al., 2006).

NU
While DPD and Avoidant may overlap due to similar manifestations and social

behaviors, the motivations underlying these similarities are quite different. DPD individuals feel
MA
highly anxious about being left alone or functioning autonomously, and avoidant individuals do

not share this concern. One additional difference between these disorders is that individuals with
D

DPD believe that there are “better” others out there who may come to their aid, whereas avoidant
TE

individuals have no such belief (Arntz et al., 2011). The Big Five differentiate DPD and avoidant
P

PD further; both disorders are associated with elevated Neuroticism, but avoidant PD is also
CE

consistently associated with low levels of Extraversion. This result is not found for DPD to the
AC

same degree (Bienvenu & Brandes, 2005). In terms of Cloninger’s biosocial model of

personality, both DPD and Avoidant individuals score high on Harm Avoidance, but what

differentiates the two is that individuals with DPD also score high on Reward Dependence,

reflecting their deep-seated need for approval (Casey & Joyce, 1999).

Trull et al. (1987) found high correlations between Avoidant and DPD symptoms.

However, these results are not discussed in detail here because they correspond to the disorders

as they were written in DSM-III. However, it is noteworthy that even in their early stages, DPD

and Avoidant PD overlapped a great deal. The authors’ suggestion at the time was to retain both
 ACCEPTED MANUSCRIPT
25

disorders, but to identify criteria that separated each from the other (social withdrawal in the

avoidant but not dependent individual, for example), and to make said criteria a required

symptom to further differentiate the two disorders. This suggestion was never implemented, but

PT
could provide an easy and effective method for reducing overlap common to these two

RI
syndromes.

Finally, functioning and outcomes are important to consider in disentangling these two

SC
common presentations. One study found that DPD features were positively associated with

NU
employment five years after substance use, while avoidant features were associated with

unemployment, p < .001 (Jansson, Hesse, & Fridell, 2009). These results must be interpreted
MA
cautiously, as this was a sample of 1) all women who 2) had undergone mandatory substance use

treatment five years earlier. Nonetheless, further examination of functioning may differentiate
D
TE

DPD and avoidant PD in a way that takes real-world functioning into account. These particular

results are not entirely surprising, given that Avoidant individuals struggle with new social
P

situations, including those in which they are likely to be evaluated (such as in job interviews).
CE

In addition to the well-documented relationships within Cluster C, DPD is correlated with

AC

Cluster B disorders as well, with particular emphasis on borderline and histrionic PDs (Barzega

et al., 2001; Bornstein, 1997; Bornstein et al., 2010; Gude et al., 2006). All three share the

dimension of pathological neediness (Cogswell & Alloy, 2006). Bakkevig and Karterud (2010)

found significant correlations between three Histrionic criteria and DPD: a) use of physical

appearance to draw attention, b) suggestibility, and c) considering relationships to be more

intimate than they are. Their results showed that Histrionic PD criterion 7 (suggestibility)

correlated more strongly with DPD and Avoidant PD than with itself, and concluded that the

construct validity for Histrionic PD was poor.

 ACCEPTED MANUSCRIPT
26

As mentioned, both DPD and borderline PD share high levels of dependency needs

(Bornstein et al., 2010). DPD is noted as a differential diagnosis of borderline in DSM-IV, and it

is remarked that both disorders are “characterized by a fear of abandonment” (p. 653). Regarding

PT
the transient psychotic episodes and dissociation noted in Borderline PD under times of severe

stress, the DSM-IV states “The real or perceived return of the caregiver’s nurturance may result

RI
in a remission of symptoms” (p. 708). Accordingly, the severe reactions sometimes seen in

SC
Borderline occur in response to real or imagined abandonment, which is strongly associated with

NU
dependency. Bornstein et al. (2010) reported that approximately 30-40% of BPD-diagnosed

individuals also receive diagnoses of DPD, and that correlations between the symptoms of the
MA
two disorders are typically in the range of .30 - .40. These comorbidities are exacerbated in

inpatient (as opposed to outpatient) BPD populations.

D
TE

The integration of these findings demonstrate that DPD as it is currently defined has

serious comorbidity issues with other Axis II disorders. There is little debate on that issue. What
P

is unclear, however, is how clinically relevant this overlap is. It is essential to pay more attention
CE

to the motivations underlying similar behaviors in different disorders. For example, inability to
AC

withstand criticism is a feature of several personality disorders. In the paranoid person, it is

because they assume the person criticizing them has sinister intentions and is trying take

advantage of them. In the borderline person, the criticism can lead to splitting and volatile

emotional reactions, accompanied by intense feelings of distress and emptiness. In the avoidant

person, criticism is taken as evidence that the person is inadequate or inferior in some way. This

similar feature is therefore very different when considered in the context of individual drives.

Unfortunately, the current definitions of the respective PDs do not make these motivations a

central feature of the disorders; accordingly, clinical and research-related confusion can and does
 ACCEPTED MANUSCRIPT
27

occur. It is likely that making motivation a more salient criterion of DPD could increase its

clinical usefulness by reducing overlap with the other disorders, such as avoidant, borderline, and

histrionic. Diagnostic distinguishability is an important marker of validity, and can assist in the

PT
decision as to whether or not DPD is unique and separate from the other disorders (Huprich &

RI
Fine, 1996).

Comorbidity with anxiety disorders

SC
Naturally, given that it is the “anxious cluster,” DPD and the rest of Cluster C show high

NU
levels of overlap with anxiety disorders (Bornstein, 1995b). Some have proposed that this could

be the result of a shared etiology. For example, high levels of Neuroticism are found in both
MA
anxiety disorders and DPD (Bienvenu & Brandes, 2005). In addition, most researchers agree that

DPD is one of the most common PDs found in patients with panic disorder (Barlow, 2008;
D
TE

Barzega et al., 2001; Marshall, 1996). Studies consistently indicate that panic disorder

complicated by the presence of comorbid personality pathology leads to poorer response to both
P

medication and cognitive therapy (Iketani et al., 2002). Ampollini et al. (1997) reported a
CE

significant positive relationship between DPD and agoraphobia in two groups of patients with
AC

panic disorder (one group had comorbid mood disorder; one did not). Their findings suggested

that the presence of dependent traits is associated with the severity of panic disorder. Other

studies have found that women with panic disorder and agoraphobia (as opposed to panic

disorder alone) had a higher number of personality disorders as a group, with particular a

emphasis on those in Cluster C (Barzega et al., 2001).

Aside from panic disorder, DPD is also one of the most common PDs diagnosed in

samples of patients with OCD. In a comparison among four groups (Hoarding OCD,

Nonhoarding OCD, other anxiety disorders, and controls), hoarding individuals scored
 ACCEPTED MANUSCRIPT
28

significantly higher for DPD on the PDQ-4 than each of the other three groups, none of which

differed from each other (M=4.1 vs. 1.8, 1.9, and 0.7, respectively; F(3, 96) = 21.7, p < .001)

(Frost, Steketee, Williams, & Warren, 2000). The researchers also found significantly higher

PT
impairment of family relationships in the hoarding group compared to the other three groups.

RI
DPD is well known to be comorbid with some of the anxiety disorders discussed above,

but less so with others, such as GAD and PTSD (McLaughlin & Mennin, 2005). These authors

SC
raised three areas of research that are essential in furthering our knowledge of the relationship

NU
between DPD and anxiety disorders: a) exploring the direction of causality between the two, b)

assessing whether dependency should be considered a risk factor for anxiety (if it is shown to be
MA
causal, is it clinically meaningful?) and c) identifying the mechanisms that lead from one to the

other.
D
TE

Most research shows that DPD and avoidant PD overlap substantially, and that avoidant

PD and social phobia overlap substantially. However, there is not as much research regarding the
P

strength of the relationship between DPD and social phobia (Dyck et al., 2001). A relationship
CE

between the two has been reported (Grant et al., 2005), but it is not as strong or consistent as one
AC

would expect. This indicates that different features of Avoidant PD overlap with both DPD and

social phobia in unique ways, and further information is needed to determine the relationship

among these features.

The DSM warns of a large overlap between DPD and anxiety disorders. However, a

meta-analysis of 53 studies only showed a mean relationship of r = .11 between DPD and the

anxiety disorders. According to these results, the relationship between the two is modest in

magnitude (Ng & Bornstein, 2005). However, some have questioned the results of this study

because of the authors’ selected inclusion criteria. Most of the individuals in this study had pre-
 ACCEPTED MANUSCRIPT
29

occurring anxiety disorders (Holmbeck & Durlak, 2005). The authors suggested that because of

the difference in prevalence rates, it would be more useful to begin with a sample of individuals

with DPD and then assess for comorbid anxiety disorders, which would lead to a higher

PT
comorbidity rate than beginning with a sample of individuals with anxiety disorders and then

RI
assessing for DPD.

Comorbidity with depression

SC
Some researchers argue that depression, dependency, and low self-esteem are associated

NU
(Alnaes, 1989), and that DPD and major depression have a strong relationship. However, others

have concluded that DPD only has a moderate relationship with both dysthymia and depression
MA
(Bornstein, 1995b).

To investigate this issue, Uguz, Akman, Sahingoz, Kaya, and Kucur (2009) completed a
D
TE

follow-up of 34 women in Turkey who had been diagnosed with new-onset post-partum

depression at six weeks post-childbirth. After one year, women who were still depressed were
P

significantly more likely to have comorbid DPD (45.5% of the sample), compared to the group
CE

of women whose depression had remitted, using Fisher’s exact test (p = .008). However, it
AC

should be noted that the sample size of the two groups at one-year follow-up was quite small (n =

11 and n = 23, respectively). Nonetheless, these results are consistent with other findings

suggesting that DPD is particularly associated with postpartum depression in new mothers

(Akman et al., 2007), which is an important area of study.

Reich (1987) found that 31% of a sample of 342 individuals with DPD were also

diagnosed with comorbid major depression, compared to only 19.8% of a group of individuals

with any other personality disorder (p < .001), and a significant result was found for bipolar

disorder as well (present in 12.3% of DPD patients vs. 7.4% of other-PD patients, p < .01). He
 ACCEPTED MANUSCRIPT
30

did not find a difference in the presence of dysthymia between the two groups. It should be noted

that this study was completed with DSM-III criteria and is not entirely generalizable to today’s

standards. Nonetheless, it is informative to note which trends have continued across decades and

PT
different versions of the DSM.

RI
Based on the extant literature, the relationship between DPD and mood disorders does not

seem as striking or consistent as the relationship between DPD and anxiety disorders,

SC
particularly SAD (which is a developmental disorder, but with a central feature of anxiety),

NU
OCD, and panic disorder with or without agoraphobia. It is safe to say that generally speaking,

excessive dependency is more associated with being anxious than it is with being depressed. As
MA
the criteria of DPD touch on anxiety (feeling uncomfortable when alone, feeling afraid to make

decisions on one’s own, etc.), this is unsurprising. However, one might expect that it might be
D
TE

depressing as well to exist in such a manner. Nonetheless, the literature does not suggest a strong

comorbidity issue between these disorders, which indicates that they are largely separate.
P

Comorbidity with other disorders

CE

Comorbidity with DPD is not limited to purely mood disorders or anxiety disorders.
AC

Ampollini et al. (1997; 1999) found that levels of DPD were higher in individuals with panic

disorder and major depression than they were in groups of individuals with only panic or only

depression. This was consistent with other work (Iketani et al., 2002), in which the same result

was found using two measures and methods of personality assessment: DPD was higher across

both measures for the group with both panic disorder and major depression when compared to

groups with panic or depression alone. Individuals with the combination of these disorders

function less well and have poorer prognoses than individuals with only one of the disorders

(Alnaes, 1989).
 ACCEPTED MANUSCRIPT
31

DPD has high levels of comorbidity in classes of disorders aside from mood and anxiety

disorders. For example, DPD has shown a relationship in the literature to eating disorders

(Bornstein, 1995b). Loas et al. (2002) assessed 182 individuals with anorexia and 112 with

PT
bulimia and found prevalence rates of DPD to be 37.4% and 45.5%, respectively. This is far

RI
higher than what is normally found, even in most psychiatric samples. Given these striking

results, more information is needed that focuses specifically on the interplay between these

SC
disorders.

NU
Studies have shown a relationship between DPD and substance use as well (Bornstein,

1995b; Calsyn et al., 1996; Loas et al., 2005), while others have found a significantly lower risk
MA
of substance use in DPD patients compared to those with any other PD (Loranger, 1996).

Substance use is obviously an important issue of study because of its impact on the individual
D
TE

and on public health (Echeburúa, de Medina, & Aizpiri, 2005). These same researchers (2009)

compared personality differences between two groups of alcohol-dependent outpatients (those

P

with concurrent cocaine use and those without), and found that DPD was one of the most
CE

common PDs diagnosed in the alcohol/no cocaine group (9.4%), and the presence of Cluster C
AC

disorders in general was significantly higher in the alcohol/non-cocaine group (31.3%) than in

the alcohol/cocaine group (16.1%). This finding was consistent with their earlier work, which

showed that DPD was the most common PD diagnosis in a group of 30 alcohol-dependent

patients seeking treatment (13.3% of sample) using two measures and methods of personality

assessment. However, the authors noted that the former was a pilot study with a small sample

size; as a result, their results should be interpreted cautiously.

These results, though presented in a brief way, indicate that features of DPD are

associated with a variety of Axis I and Axis II disorders, and some of these relationships are
 ACCEPTED MANUSCRIPT
32

more powerful than others. DPD is associated with some disorders that carry fairly serious health

consequences (such as eating disorders and substance use disorders). It is essential to learn more

about why and how these features may go together, and to do so from an empirical basis, rather

PT
than a solely theoretical basis.

RI
Social Effects of DPD/Behavior in DPD

Much of the literature on DPD remarks on the passivity seen in individuals with this

SC
disorder (Bender, 2005). However, Bornstein has written extensively on this topic (1995a; 1997;

NU
1998a), and argues that individuals with DPD are primarily concerned with obtaining and

maintaining nurturant relationships with others, and that they can and will adapt their behaviors
MA
as needed in order to reach this goal. Individuals with DPD have low self-esteem and believe

they are powerless to navigate life successfully. Accordingly, they are highly motivated to attach
D
TE

themselves to individuals who can provide guidance, support, or protection. Bornstein concludes

that DPD is not inherently passive; rather, DPD is more about a presentation of passivity: a
P

collection of behaviors geared toward maximizing benefits – in this case, the care, protection,
CE

and concern from others. In fact, despite widespread acceptance of the idea that individuals with
AC

DPD are interpersonally rigid in their presentation, the individual with DPD can be quite flexible

in his or her behavior and will self-deprecate or self-enhance where needed. According to

Bornstein’s view, the dependent individual’s repertoire of relationship-facilitating behaviors is

wider than previously thought, and he suggests that active, non-passive behaviors are more likely

to occur under three conditions: 1) when competing with others for the potential support of a

caretaker; 2) when acting assertively might please an authority figure; and 3) when seeking

help/guidance from a potential caretaker (Bornstein, 1995a).

 ACCEPTED MANUSCRIPT
33

Bornstein’s assertions have been contradicted by other work (Leising et al., 2006), which

demonstrated that higher levels of DPD symptoms were correlated negatively with assertive

behavior in short role-plays judged by both the participant and the confederate of the role-play (r

PT
= -.42, p < .001 and r = -.36, p < .001, respectively). This was true even when the participants

RI
were explicitly directed to behave assertively.

Continuing the discussion of outward behavioral manifestations and social tendencies

SC
with DPD, other behaviors or self-presentation strategies often noted are self-deprecation and

NU
simultaneous enhancement of the other person, in addition to various forms of help-seeking,

compliance, cooperativeness, and suggestibility (Bornstein, 1997). After briefly discussing these
MA
behaviors in earlier works, Bornstein (2012) conducted a more thorough and systematic review

of strategies used by the individual with DPD. The first is supplication, in which the individual
D
TE

accentuates his or her own weakness or makes his or her fears salient to the other. With

ingratiation, the person will draw attention to favors s/he has done for the other person, or point
P

out his or her own contributions. In exemplification, the person visibly exaggerates his/her effort
CE

and emphasizes self-sacrifice/difficulty. Self-promotion behavior includes touting his or her

AC

unique skills, and emphasizing his or her accomplishments. And lastly, with intimidation, the

individual may go to such an extent as to threaten self-harm or to behave aggressively. These

studies show that DPD can have a fairly manipulative component and the individual may not be

as compliant, helpless, or submissive as the literature states.

Continuing our discussion of social behavior and effects of DPD, every single published

study examining peer adjustment and dependent behaviors reports a significant negative

correlation between level of dependency and popularity levels reported by peers (r’s ranging

from -.22 to -.64) (Bornstein, 2012), which is congruent with other work stating that DPD traits
 ACCEPTED MANUSCRIPT
34

are socially undesirable (Birtchnell, 1991). Other studies show that while it is widely assumed

that the DPD individual will rely primarily on one figure, they are often dependent on more than

one person and will gravitate toward the individual most likely to provide support and

PT
reassurance at that time (Bornstein, 1997). This suggests that the social networks of individuals

RI
with DPD can be larger than clinical wisdom might suggest.

Individuals with DPD can be quite strong academically (King, 2000). Specifically,

SC
dependent traits are positively associated with classroom attendance and college GPA. These

NU
findings are in contradiction of the relationship with low levels of Conscientiousness noted

above. They also attend to medical problems more quickly than more autonomous individuals,
MA
which also brings the Conscientiousness issue into question. It seems as though self-reported

Conscientiousness has an inverse relationship with DPD traits when self-report is used, but it has
D
TE

a positive relationship when assessed behaviorally. This could be a function of their core belief

that they are incompetent or capable of completing tasks on their own. This belief is likely
P

exaggerated, which explains why the objective behavioral measures indicate otherwise. In
CE

addition, individuals with DPD are exceptionally efficient at reading subtle social cues such as
AC

facial expression, presumably due to their need to be able to behave in a way that maximizes

probability of care (Bornstein, 1998a, 2012). These findings paint a picture of what the

individual with DPD looks like interpersonally and in society: they can be drawn to figures of

authority as young adults, are quite motivated to obtain the care they need, and will engage in a

variety of behaviors (not all of which are submissive or compliant) in order to do so.

Consequences of DPD

So far, topics such as comorbidity, gender and cultural considerations, and the history of

PD have been examined. One important and often overlooked area of the literature to consider
 ACCEPTED MANUSCRIPT
35

revolves around the associated ramifications of this disorder. To clarify the term “consequences,”

this section is not intended to suggest a temporal, causal relationship between DPD and the

variables described here. What is intended is the identification of variables that are associated

PT
with the presence of DPD. Unfortunately, due to the research design of the majority of DPD

RI
research, we are typically unable to identify causal relationships in this area.

There is a surprisingly strong and consistent literature showing a relationship between

SC
DPD and suicidal ideation and attempts. For example, DPD was the strongest predictor of

NU
suicide attempts using Wave 1 NESARC data in depressed individuals. This was particularly true

for men (Bolton et al., 2008). DPD was more strongly correlated with suicide attempts than any
MA
other Axis I or Axis II condition, though it should be noted that borderline PD was not assessed

in NESARC in Wave 1. This is a very notable and important finding. DPD was more associated
D
TE

with suicide attempts than mood disorders and a number of other psychopathology and

demographic variables. Thus, there is something unique about DPD that accounts for this
P

relationship, despite its comorbidity with other syndromes. These features result in an increased
CE

risk of suicide attempts and completion in the literature.

AC

Loas et al. (2005) compared patients with addictive disorders to a control group and

found that suicidal ideation was twice as likely to occur with the presence of dependent

personality disorder, (χ² = 7.20, df = 1, p < .01; OR = 1.99). The risk was even higher with

additional comorbid Axis I pathology. In bulimic patients (both male and female), female

alcoholics, and male drug abusers, the presence of coexisting DPD increased likelihood of

suicidal ideation anywhere from two to nine times in these individuals (OR = 2.65 for bulimic

patients to 9.42 for male drug abusers). Gagnon, Davidson, Cheifetz, Martineau, and Beauchamp

(2009) compared personality pathology in youth (ages 14-25) who had attempted suicide versus
 ACCEPTED MANUSCRIPT
36

those who had completed it, and determined that DPD was significantly higher in the group of

completers. However, they were forced to rely on interviews with a variety of informants for

diagnosis in the group who had completed suicide. Despite the problem with its methodology,

PT
this is the only study to the author’s knowledge that assessed for DPD in individuals who had

RI
completed suicide with the exception of NESARC data, so there is little other choice but to note

these preliminary results which are consistent with the other studies discussed above.

SC
Klonsky et al. (2003) examined a sample of 1,986 military recruits to identify

NU
relationships between personality and deliberate self-harm. Using the Schedule for Adaptive and

Nonadaptive Personality (SNAP; Clark, 1993), participants reporting a history of self-harm

MA
scored significantly higher on both the Dependency trait scale of the self-reported SNAP

(Cohen’s d = .80, p < .0001), as well as the DPD diagnostic scale. Those who deliberately self-
D
TE

harmed also received significantly higher peer nominations for DPD. More specifically, they

were nominated more often for DPD criterion 8 (feeling unrealistically afraid of being left
P

alone). Self-harmers also scored significantly higher on a number of other traits as well,
CE

including those for borderline and avoidant PDs.

AC

The risk of abuse is another area of concern in DPD. Using analysis of variance

(ANOVA), DPD was found to be the most prevalent disorder (21%) in a group of 42 women

who were seeking treatment at a shelter and who had been in multiple abusive relationships, a

rate which was significantly higher than a group of 33 women who had only been in one abusive

relationship, as well as 52 control subjects, F(2, 126) = 6.37, p = .002 (Coolidge & Anderson,

2002).

Continuing our discussion of DPD and various important outcomes, the relationship

between DPD and health should not be overlooked. Individuals with higher levels of DPD
 ACCEPTED MANUSCRIPT
37

features are more likely to embrace the “sick” or “patient” role (Greenberg & Bornstein, 1988).

They also have higher levels of health-related anxiety and medical costs than individuals without

dependent traits (Tyrer, Tyrer, & Barrett, 2012). Doctors frequently overlook personality

PT
pathology in their patients, and Axis II behavior tends to erode the doctor-patient relationship.

RI
Unrecognized PDs contribute to substantial health care costs (Hueston, Werth, & Mainous,

1999), and physicians describe dependent patients as difficult (Bornstein, 2012).

SC
Conversely, symptoms of DPD can be beneficial in certain situations and contexts. Those

NU
with DPD seek medical attention quickly when faced with physical or psychological illness

(Bornstein, 1995a; Greenberg & Bornstein, 1988), and they are particularly compliant with
MA
medical treatment (Bornstein, 2012). In addition, DPD features are positively associated with

employment status in a study on PDs and functioning in a sample of 132 women who had
D
TE

received mandatory substance abuse treatment five years earlier (Jansson et al., 2009). However,

individuals with DPD may also overutilize medical services, have longer hospital stays, and have
P

significantly increased odds of receiving public welfare service (Bornstein, 1995a; Vaughn et al.,
CE

2010). This last finding is congruent with other research showing that DPD is inversely related to
AC

status and wealth (Ullrich, Farrington, & Coid, 2007).

Loas et al. (2011) found that 66.7% of a group of participants with Dependent PD had a

history of somatic disease, which was significantly greater than a group of individuals with no

personality disorder (16.8%) as well as a group that combined all of the other PDs (29.4%), χ² =

18.3, df = 1, p < .0001. Other interesting relationships between health and DPD have been noted

as well. Individuals with DPD have high levels of subjective memory complaints that are

uncorroborated with objective memory assessment (Park et al., 2012). Individuals with DPD

were also found to be 5.54 times more likely to report having peptic ulcers than those without
 ACCEPTED MANUSCRIPT
38

DPD using NESARC data (Schuster, Limosin, Levenstein, & Le Strat, 2010). While the self-

report in this study was not objectively corroborated, the results suggest that individuals with

DPD either rate themselves as being higher in health problems, or they actually have higher

PT
levels of health problems (in this case, gastric or peptic ulcers), both of which has negative

RI
consequences for well-being.

Treatment of DPD

SC
DPD is often treated using Cognitive Therapy, a primary tenet of which is that PDs manifest via

NU
cognitive biases that maintain the disorder. Cognitive Therapy takes the stance that childhood

schemas underlie the maladaptive emotions and behaviors of individuals with PDs (Arntz,
MA
Weertman, & Salet, 2011). Cluster C is considered to be the most ‘treatable’ compared to the

other clusters (Bender, 2005). CT may be particularly effective for DPD because it can focus on
D

patients’ beliefs about themselves, as well as their fear of being judged (Borge et al., 2010).
TE

In treatment, it is important to focus on restructuring cognitions of the self as weak and

P

ineffectual (Bornstein, 1998a). Others, however, have reported that gains from CT for DPD are
CE

modest, and that integrated approaches might be better able to capture the complexity of DPD, as
AC

they conceptualize the individual from multiple perspectives. For example, a CTB/existential

approach might be useful because both approaches tie back to the view of the self as weak and

helpless: CBT through the examination of faulty schemas, and existential theory via an

inauthentic self (Bornstein, 2004). Simon (2009) conducted a meta-analysis of treatment for

Cluster C disorders, and found that social skills training was effective across different settings

and populations, and there was support for CBT and psychodynamic as well.

From a treatment perspective, it is important to consider not only whether an individual

meets criteria for DPD, but to understand the specific contexts under which the criteria manifest.
 ACCEPTED MANUSCRIPT
39

For example, for criteria 1), difficulty making everyday decisions without advice and reassurance

from others, it would do well to discern under what scenarios this criterion is particularly true.

The therapist can particularly motivate the individual with DPD by indicating that active

PT
behavior can enhance the therapeutic relationship, which would likely lead to increased

RI
compliance on behalf of the client (Bornstein, 1995a). Clinicians should also consider DPD to be

a marker for the presence of other psychopathology, particularly anxiety and mood disorders

SC
(Bienvenu & Brandes, 2005).

NU
Cluster C clients may be more inhibited and avoidant of conflict than other clients. They

experience frequent guilt and self-directed blame. Their traits may actually serve to enhance the
MA
therapeutic alliance and they may be more engaged in therapy. They are friendly, complaint, and

less likely to terminate prematurely than individuals with other PDs. One of the drawbacks of
D
TE

being overly compliant, however, is that resistance can manifest in particular ways, such as

withholding important information or changing the subject. It may also be a struggle to find ways
P

to enhance autonomy in these clients (Bender, 2005). DPD clients may also make more requests
CE

for between-session contact than other individuals (Bornstein, 2012).

AC

Treatment of DPD in men requires several unique considerations. Dependent men may be

especially reluctant to discuss their feelings, due to thinking those feelings are unacceptable, or a

fear of being judged by the therapist. Normalizing dependency needs can be helpful for this

population (Berk & Rhodes, 2005). It can also be useful to encourage clients to extend their

support systems beyond their primary support figure(s).

Finally, DPD clients may have difficulty with termination. One way to address these

concerns is to have the client taper treatment gradually, beginning with having sessions weekly

to once every other week (Berk & Rhodes, 2005). Some studies have shown that treatment of
 ACCEPTED MANUSCRIPT
40

Axis I disorders can be helpful for Axis II disorders; accordingly, treatment of panic disorder

using structured CBT, for example, may result in a successive attenuation of DPD symptoms as

the anxiety and panic become more manageable. (Borge et al., 2010).

PT
Future Directions of DPD Research and Conclusions

RI
Dependent personality has received very little empirical attention, despite its presence in

the DSM for the last 32 years (Smith et al., 2009; Loas et al., 2002). The research attention it has

SC
received has quite often been qualitative, anecdotal, methodologically flawed, and/or published

NU
in journals with low impact factors, where it does not receive much attention.

DPD was nearly deleted from DSM-5 before publication, only to be retained at the last
MA
second after much heated debate. After reviewing the literature, it is clear that this was the best

decision. Despite issues with comorbidity, there is something unique and discriminate about this
D
TE

constellation of symptoms that is consistently associated with several maladaptive and serious

outcomes related to health and well-being. However, despite these findings, we are still left with
P

very real questions of diagnostic reliability and validity in DPD. There is very little empirical
CE

information on the validity of DPD as it appears in DSM-IV-TR. Trull et al. (1987) conducted an
AC

extremely informative and thorough analysis of the DPD construct in DSM-III, but because the

criteria have changed so dramatically since that time, the usefulness of those findings are limited.

There have been few to no studies since that time that are equivalent to Trull et al.’s empirical

rigor on DPD for DSM-IV data. What is clear is that DPD overlaps to an excessive degree with

avoidant PD, and to a lesser extent with borderline and histrionic PDs. As mentioned earlier in

the paper, making the motivations behind the behaviors more salient in the criteria could be quite

effective in addressing this issue.

Part of the inconsistency in what we know about DPD stems from excessive levels of
 ACCEPTED MANUSCRIPT
41

variability in the research conducted on DPD: studies vary by research design, modality, settings,

and populations, as well as diagnostic precision and assessment instruments and methods. This

makes replication and generalizing the findings difficult (Simon, 2009). In addition, much

PT
research on DPD is done internationally. As DPD is argued by many to be a Westernized,

RI
culture-bound disorder, studies done in other cultures, while informative, may also not be

generalizable. Prevalence rates may be affected by differing cultural norms.

SC
Much of the research on DPD used data from DSM-III, and these data are often completely

NU
disregarded. It is important to be aware that due to the shifting operationalization and requisite

number of criteria, earlier results may not be valid or even comparable to today’s version of
MA
DPD. However, it is also important to be intimately aware of and familiar with the research upon

which this disorder is based.

D
TE

DPD is one of the lesser-studied personality disorders. It is interesting to consider the source

of this discrepancy. Following publication of DSM-III, there may have been a genuine
P

preference for some PDs over others in terms of interest that was generated. Consequences of
CE

certain PDs tend to draw more attention (borderline and antisocial, for instance), which may have
AC

prioritized those disorders over the others. Researchers may be unaware of the associations

between DPD and suicide. It is also interesting that studies of DPD rarely appear in psychology

or psychiatric journals with high impact factors compared to other disorders. The fact that much

DPD research is problematic is admittedly likely to contribute to this finding. Unfortunately,

however, this lack of research in top journals fails to make the area thrive.

One purpose of this paper was to identify areas in the realm of DPD of which there is little to

no information. After conducting a review of the available literature, several important areas of

further research have been identified. Biological or physiological studies have been noticeably
 ACCEPTED MANUSCRIPT
42

neglected and may be rich sources of information in DPD. To date, no published studies exist

that have examined imaging with DPD (Bornstein, 2011). This type of study may or may not be

informative; however, we are unable to arrive at that conclusion until there is more information.

PT
There is also a dearth of studies examining familiality and probands. Studies that focus more on

RI
physiology could assist us in filling fairly basic but essential gaps in the literature.

One other major methodological problem with the body of work on DPD stems from post

SC
hoc hypotheses and explanations. In other words, researchers often throw in all 10 PDs to see

NU
which one “sticks.” When DPD unexpectedly shows up as significant, it often seems as though

researchers attempt to explain the finding after the fact. This has led to a fragmented knowledge
MA
of DPD – there are theory-driven findings and “accidental” findings. However, PD researchers

are placed in a difficult position, as the exclusion of other Axis II disorders in the study of DPD
D
TE

can lead to faulty results as well. A compromise between the two approaches is recommended: to

include other PDs, but only those with a sufficient theoretical justification for doing so. With
P

regard to etiology, more longitudinal studies regarding SAD as a precursor or risk factor for DPD
CE

are needed.
AC

In terms of culture, the Westernized nature of DPD is important to consider. Importantly, it is

grossly neglected in the empirical literature. As the United States continues to become

increasingly multicultural, more emphasis should be placed on gender and ethnic awareneness

and cultural sensitivity for both clinicians and researchers. DPD does indeed pathologize certain

cultures, particularly those of a collectivist orientation, as well as the individuals within them

who value relatedness over individuation (Chen et al., 2009). In addition, there is a dire need for

information on DPD (or the lack thereof) in African-American samples.

 ACCEPTED MANUSCRIPT
43

Certain age groups within this disorder are understudied or ignored entirely. Additionally, the

criteria need to be more specific to developmental stage. Some of the current criteria are not

abnormal for adolescents, and research has shown not only that DPD symptoms can manifest

PT
well after adolescence, but that if they do occur in adolescence, symptoms may not be chronic

RI
(Grilo et al., 2001). Therefore, the DSM-IV-TR assertion that DPD begins in adolescence and

carries with it a uniform and chronic course is not supported.

SC
Regarding cognitive processes of DPD, further research studies on implicit tasks are

NU
recommended, as salient DPD-relevant responses in personality measures are likely to result in

unwanted social desirability bias. Accordingly, implicit or behavioral measures may be very
MA
useful to include with informant report to avoid the problems inherent in PD self-report. There is

also a lack of longitudinal information regarding comorbidity of DPD with other disorders. It is
D
TE

still unknown whether DPD puts an individual at risk for an Axis I disorder or vice versa

(Bienvenu & Brandes, 2005; Bornstein, 1995b). It is essential to uncover and understand the
P

course of this disorder in tandem with others. Because of its interesting but understudied
CE

relationship with health status, further prospective or longitudinal studies are also needed that
AC

examine DPD as a predisposing factor for health outcomes, and also as a potential consequence

of health issues, particularly in middle to later life.

One other issue to address in the literature is the lack of community samples. Community

samples in PDs are often thought to be an inconvenience or a limitation due to high levels of

positive skew, low prevalence rates, and small mean differences. However, because of the ego-

syntonic nature of PDs, it is surprising that such emphasis has been placed on psychiatric

samples. Some have called for replication of clinical findings in community samples (Loranger,

1996). Additionally, use of psychiatric samples can render the study and its results unclear
 ACCEPTED MANUSCRIPT
44

because the researchers fail to control for Axis I disorders (Gude et al., 2006). Clinical samples

can inflate the prevalence of Axis II pathology (Klonsky et al., 2002) and make it difficult to

identify specific relationships. While one could argue that studies that include various Axis I

PT
comorbidities have more external validity, this practice currently adds chaos and noise to an

RI
already fairly messy and exploratory area of study. This is particularly true when very different

classes of Axis I disorders are included (mood, anxiety, substance, and eating disorders, for

SC
example).

NU
Many consider Borderline PD to be most strongly associated with suicide attempts on Axis

II. However, results discussed in this review suggest that DPD is overlooked as a potentially fatal
MA
condition (Bolton et al., 2008; Loas et al., 2005). Specifically, it appears to have a distinct

possibility of being associated with violence toward the self or others. Women with DPD are
D
TE

more likely to be in multiple abusive relationships, men with DPD have the potential to become

abusive, and any individual with DPD is at elevated risk of suicidal ideation or attempts, and/or
P

an increased association with deliberate self-harm (Klonsky et al., 2003). These are hefty
CE

arguments against the DSM-V Work Group’s prior assertion that DPD has low clinical utility,
AC

and can be considered evidence in favor of the validity of the construct of DPD.

Another overlooked research area is treatment of DPD. However, it is difficult to define a

treatment when we are still unsure exactly what the disorder is. According to Division 12 of the

American Psychological Association (the Society of Clinical Psychology), there is currently no

modality or treatment for DPD considered to have strong or even modest empirical support. In

addition, prevention of PDs is rarely discussed in the literature; prevention of these disorders

would save time and tremendous burden both to the individual and those around him/her.

Finally, individuals with DPD have demonstrated higher levels of accurate self-report than
 ACCEPTED MANUSCRIPT
45

individuals with the other disorders (Jacobsberg et al., 1995; Klonsky, Oltmanns, & Turkheimer,

2002). It is interesting to consider whether features of this disorder are related to insight or self-

reflection in a different way than the other PDs.

PT
This paper covered several major areas relevant to DPD, as well as a thorough investigation

RI
into its past and future. Previous volumes of the DSM have made the mistake of moving forward

largely on the shoulders of clinical wisdom and theoretical-based rationale. A number of specific

SC
areas for research that would bolster our knowledge of this construct were discussed, as well as

NU
methodological limitations typically seen in this area of study. Excessive levels of dependency

are harmful to the self, to relationships, and in a larger way, to our healthcare system and our
MA
culture and society. This paper identified several next steps to take in our continued exploration

of enmeshment and reliance on others at the expense of reliance on the self and mastery of one’s
D
TE

environment.
P
CE
AC
 ACCEPTED MANUSCRIPT
46

References

Akman, C., Uguz, F., & Kaya, N. (2007). Postpartum-onset major depression is associated with

personality disorders. Comprehensive Psychiatry, 48(4), 343-347.

PT
doi:10.1016/j.comppsych.2007.03.005

RI
Ampollini, P., Marchesi, C., Signifredi, R., Ghinaglia, E., Scardovi, F., Codeluppi, S., &

Maggini, C. (1999). Temperament and personality features in patients with major

SC
depression, panic disorder and mixed conditions. Journal Of Affective Disorders, 52(1-3),

NU
203-207. doi:10.1016/S0165-0327(98)00048-2

Ampollini, P. P., Marchesi, C. C., Signifredi, R. R., & Maggini, C. C. (1997). Temperament and
MA
personality features in panic disorder with or without comorbid mood disorders. Acta

Psychiatrica Scandinavica, 95(5), 420-423. doi:10.1111/j.1600-0447.1997.tb09655.x

D
TE

Anderson, K. G., Sankis, L. M., & Widiger, T. A. (2001). Pathology versus statistical

infrequency: Potential sources of gender bias in personality disorder criteria. Journal Of

P

Nervous And Mental Disease, 189(10), 661-668. doi:10.1097/00005053-200110000-

CE

00002
AC

Bachrach, N., Croon, M. A., & Bekker, M. J. (2012). Factor structure of self‐ reported clinical

disorders and personality disorders: A review of the existing literature and a factor

analytical study. Journal Of Clinical Psychology, 68(6), 645-660. doi:10.1002/jclp.21841

Bakkevig, J. F., & Karterud, S. (2010). Is the Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition, histrionic personality disorder category a valid construct?.

Comprehensive Psychiatry, 51(5), 462-470. doi:10.1016/j.comppsych.2009.11.009

 ACCEPTED MANUSCRIPT
47

Barzega, G. G., Maina, G. G., Venturello, S. S., & Bogetto, F. F. (2001). Gender-related

distribution of personality disorders in a sample of patients with panic disorder. European

Psychiatry, 16(3), 173-179. doi:10.1016/S0924-9338(01)00560-0

PT
Blashfield, R. K., & Breen, M. J. (1989). Face validity of the DSM-III—R personality disorders.

RI
The American Journal Of Psychiatry, 146(12), 1575-1579.

Bolton, J. M., Belik, S., Enns, M. W., Cox, B. J., & Sareen, J. (2008). Exploring the correlates of

SC
suicide attempts among individuals with major depressive disorder: Findings from the

NU
National Epidemiologic Survey on Alcohol and Related Conditions. Journal Of Clinical

Psychiatry, 69(7), 1139-1149. doi:10.4088/JCP.v69n071

MA
Bornstein, R. F. (1995a). Active dependency. Journal Of Nervous And Mental Disease, 183(2),

64-77. doi:10.1097/00005053-199502000-00002
D
TE

Bornstein, R. F. (2012). From dysfunction to adaption: An interactionist model of dependency.

Annual Review Of Clinical Psychology, 8291-316. doi:10.1146/annurev-clinpsy-032511-

P

143058
CE

Bornstein, R. F., Becker-Matero, N., Winarick, D. ., & Reichman, A. L. (2010). Interpersonal

AC

dependency in borderline personality disorder: Clinical context and empirical evidence.

Journal Of Personality Disorders, 24(1), 109-127. doi:10.1521/pedi.2010.24.1.109

Bornstein, R. F., & Cecero, J. J. (2000). Deconstructing dependency in a five-factor world: A

meta-analytic review. Journal Of Personality Assessment, 74(2), 324-343.

doi:10.1207/S15327752JPA7402_11

Brieger, P., Sommer, S., Blöink, R., & Marneros, A. (2000). The relationship between Five-

Factor personality measurements and ICD-10 personality disorder dimensions: Results

 ACCEPTED MANUSCRIPT
48

from a sample of 229 subjects. Journal Of Personality Disorders, 14(3), 282-290.

doi:10.1521/pedi.2000.14.3.282

Caldwell-Harris, C. L., & Ayçiçegi, A. (2006). When Personality and Culture Clash: The

PT
Psychological Distress of Allocentrics in an Individualist Culture and Idiocentrics in a

RI
Collectivist Culture. Transcultural Psychiatry, 43(3), 331-361.

doi:10.1177/1363461506066982

SC
Calsyn, D. A., Fleming, C., Wells, E. A., & Saxon, A. J. (1996). Personality disorder subtypes

NU
among opiate addicts in methadone maintenance. Psychology Of Addictive Behaviors,

10(1), 3-8. doi:10.1037/0893-164X.10.1.3

MA
Casey, J. E., & Joyce, P. R. (1999). Personality disorder and the Temperament and Character

Inventory in the elderly. Acta Psychiatrica Scandinavica, 100(4), 302-308.

D
TE

doi:10.1111/j.1600-0447.1999.tb10865.x

Cloninger, C.R. (1987). A systematic method for clinical description and classification of
P

personality variants. Archives of General Psychiatry, 44:573-588.

CE

Coolidge, F. L., & Anderson, L. W. (2002). Personality profiles of women in multiple abusive
AC

relationships. Journal Of Family Violence, 17(2), 117-131. doi:10.1023/A:101500540014

Coolidge, F. L., Segal, D. L., Hook, J. N., & Stewart, S. (2000). Personality disorders and coping

among anxious older adults. Journal Of Anxiety Disorders, 14(2), 157-172.

doi:10.1016/S0887-6185(99)00046-

Costa, P.T.,Jr. & McCrae, R.R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and

NEO Five-Factor Inventory (NEO-FFI) manual. Odessa, FL: Psychological Assessment

Resources.
 ACCEPTED MANUSCRIPT
49

Dutton, D. G. (2002). The neurobiology of abandonment homicide. Aggression And Violent

Behavior, 7(4), 407-421. doi:10.1016/S1359-1789(01)00066-0

Echeburúa, E., De Medina, R., & Aizpiri, J. (2005). Alcoholism and personality disorders: An

PT
exploratory study. Alcohol And Alcoholism, 40(4), 323-326. doi:10.1093/alcalc/agh158

RI
Echeburúa, E., De Medina, R., & Aizpiri, J. (2009). Personality disorders among alcohol-

dependent patients manifesting or not manifesting cocaine abuse: A comparative pilot

SC
study. Substance Use & Misuse, 44(7), 981-989. doi:10.1080/10826080802494735

NU
Frost, R. O., Steketee, G., Williams, L. F., & Warren, R. (2000). Mood, personality disorder

symptoms and disability in obsessive compulsive hoarders: A comparison with clinical

MA
and nonclinical controls. Behaviour Research And Therapy, 38(11), 1071-1081.

doi:10.1016/S0005-7967(99)00137-0
D
TE

Gagnon, A., Davidson, S. I., Cheifetz, P. N., Martineau, M., & Beauchamp, G. (2009). Youth

suicide: A psychological autopsy study of completers and controls. Vulnerable Children

P

And Youth Studies, 4(1), 13-22. doi:10.1080/17450120802270400

CE

Grilo, C. M., Becker, D. F., Edell, W. S., & McGlashan, T. H. (2001). Stability and change of
AC

DSM-III-R personality disorder dimensions in adolescents followed up 2 years after

psychiatric hospitalization. Comprehensive Psychiatry, 42(5), 364-368.

doi:10.1053/comp.2001.26274

Grilo, C. M., McGlashan, T. H., Quinlan, D. M., Walker, M. L., Greenfeld, D., & Edell, W. S.

(1998). Frequency of personality disorders in two age cohorts of psychiatric inpatients.

The American Journal Of Psychiatry, 155(1), 140-142.

Gude, T., Karterud, S., Pedersen, G., & Falkum, E. (2006). The quality of the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition dependent personality disorder

 ACCEPTED MANUSCRIPT
50

prototype. Comprehensive Psychiatry, 47(6), 456-462.

doi:10.1016/j.comppsych.2006.02.007

Gutiérrez, F., Vall, G., Maria Peri, J., Bailiés, E., Ferraz, L., Gárriz, M., & Caseras, X. (2012).

PT
Personality disorder features through the life course. Journal Of Personality

RI
Disorders, 26(5), 763-774. doi:10.1521/pedi.2012.26.5.763

Holmbeck, G. N., & Durlak, J. A. (2005). Comorbidity of dependent personality disorders and

SC
anxiety disorders: Conceptual and methodological issues. Clinical Psychology: Science

NU
And Practice, 12(4), 407-410. doi:10.1093/clipsy/bpi050

Huprich, S.K, & Fine, M.A. (1996). Self-defeating personality disorder: Diagnostic
MA
distinguishability and overlap with dependent personality disorder. Journal of Personality

Disorders, 10, 229-246.

D
TE

Iketani, T., Kiriike, N., Stein, M. B., Nagao, K., Nagata, T., Minamikawa, N., & ... Fukuhara, H.

(2002). Personality disorder comorbidity in panic disorder patients with or without

P

current major depression. Depression And Anxiety, 15(4), 176-182. doi:10.1002/da.10050

CE

Jansson, I., Hesse, M., & Fridell, M. (2009). Influence of personality disorder features on social
AC

functioning in substance-abusing women five years after compulsive residential

treatment. European Addiction Research, 15(1), 25-31. doi:10.1159/000173006

Kaplan, M. (1983). A woman's view of DSM-III. American Psychologist, 38(7), 786-792.

doi:10.1037/0003-066X.38.7.786

King, A. R. (2000). Relationships between CATI personality disorder variables and measures of

academic performance. Personality And Individual Differences, 29(1), 177-190.

doi:10.1016/S0191-8869(99)00186-5
 ACCEPTED MANUSCRIPT
51

Klonsky, E., Jane, J., Turkheimer, E., & Oltmanns, T. F. (2002). Gender role and personality

disorders. Journal Of Personality Disorders, 16(5), 464-476.

doi:10.1521/pedi.16.5.464.22121

PT
Klonsky, E.D., Oltmanns, T.F., & Turkheimer, E. (2002). Informant reports of personality

RI
disorder: Relation to self-reports and future research directions. Clinical Psychology:

Science and Practice, 9, 300-311.

SC
Klonsky, E., Oltmanns, T. F., & Turkheimer, E. (2003). Deliberate self-harm in a nonclinical

NU
population: Prevalence and psychological correlates. The American Journal Of

Psychiatry, 160(8), 1501-1508. doi:10.1176/appi.ajp.160.8.1501

MA
Leising, D., Sporberg, D., & Rehbein, D. (2006). Characteristic interpersonal behavior in

dependent and avoidant personality disorder can be observed within very short
D
TE

interaction sequences. Journal Of Personality Disorders, 20(4), 319-330.

doi:10.1521/pedi.2006.20.4.319
P

Loas, G., Atger, F., Perdereau, F., Verrier, A., Guelfi, J., Halfon, O., & ... Jeammet, P. (2002).
CE

Comorbidity of dependent personality disorder and separation anxiety disorder in

AC

addictive disorders and in healthy subjects. Psychopathology, 35(4), 249-253.

doi:10.1159/000063830

Loas, G., Cormier, J., & Perez-Diaz, F. (2011). Dependent personality disorder and physical

abuse. Psychiatry Research, 185(1-2), 167-170. doi:10.1016/j.psychres.2009.06.011

Loas, G., Guilbaud, O., Perez-Diaz, F., Verrier, A., Stephan, P., Lang, F., & ... Jeammet, P.

(2005). Dependency and suicidality in addictive disorders. Psychiatry Research, 137(1-

2), 103-111. doi:10.1016/j.psychres.2004.06.022

 ACCEPTED MANUSCRIPT
52

Loranger, A. W. (1996). Dependent personality disorder: Age, sex, and Axis I comorbidity.

Journal Of Nervous And Mental Disease, 184(1), 17-21. doi:10.1097/00005053-

199601000-00004

PT
Lowe, J., Edmundson, M., & Widiger, T. A. (2009). Assessment of dependency, agreeableness,

RI
and their relationship. Psychological Assessment, 21(4), 543-553. doi:10.1037/a0016899

McLaughlin, K. A., & Mennin, D. S. (2005). Clarifying the temporal relationship between

SC
dependent personality disorder and anxiety disorders. Clinical Psychology: Science And

NU
Practice, 12(4), 417-420. doi:10.1093/clipsy/bpi052

Ng, H.M., & Bornstein, R.F. (2005). Comorbidity of dependent personality disorder and anxiety
MA
disorders: A meta-analytic review. Clinical Psychology: Science and Practice, 12, 395-

406.
D
TE

Reich, J. (1987). Sex distribution of DSM-III personality disorders in psychiatric outpatients. The

American Journal Of Psychiatry, 144(4), 485-488.

P

Simon, W. (2009). Follow-up psychotherapy outcome of patients with dependent, avoidant and
CE

obsessive-compulsive personality disorders: A meta-analytic review. International

AC

Journal Of Psychiatry In Clinical Practice, 13(2), 153-165.

doi:10.1080/1365150080257097

Sprock, J., Crosby, J. P., & Nielsen, B. A. (2001). Effects of sex and sex roles on the perceived

maladaptiveness of DSM–IV personality disorder symptoms. Journal Of Personality

Disorders, 15(1), 41-59. doi:10.1521/pedi.15.1.41.18648

Trull, T. J., Widiger, T. A., & Frances, A. (1987). Covariation of criteria sets for avoidant,

schizoid, and dependent personality disorders. The American Journal Of Psychiatry,

144(6), 767-771.
 ACCEPTED MANUSCRIPT
53

Uguz, F., Akman, C., Sahingoz, M., Kaya, N., & Kucur, R. (2009). One year follow-up of post-

partum-onset depression: The role of depressive symptom severity and personality

disorders. Journal Of Psychosomatic Obstetrics & Gynecology, 30(2), 141-145.

PT
doi:10.1080/01674820802545818

RI
SC
NU
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
54

Appendix

Alexander, P. C. (1993). The differential effects of abuse characteristics and attachment in the

PT
prediction of long-term effects of sexual abuse. Journal Of Interpersonal Violence, 8(3),

346-362. doi:10.1177/088626093008003004

RI
Alnæs, R., & Torgersen, S. (1989). Clinical differentiation between major depression only, major

SC
depression with panic disorder and panic disorder only: Childhood and personality

disorder. Psychiatria Fennica, SUPPL58-64.

NU
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
MA
(4th ed., text rev.). Washington, DC: Author.

Arntz, A., Weertman, A., & Salet, S. (2011). Interpretation bias in Cluster-C and borderline
D

personality disorders. Behaviour Research And Therapy, 49(8), 472-481.

TE

doi:10.1016/j.brat.2011.05.002
P

Baer, L., Jenike, M. A., Ricciardi, J. N., & Holland, A. D. (1990). Standardized assessment of
CE

personality disorders in obsessive-compulsive disorder. Archives Of General Psychiatry,

47(9), 826-830. doi:10.1001/archpsyc.1990.01810210034005

AC

Baker, J. D., Capron, E. W., & Azorlosa, J. (1996). Family environment characteristics of

persons with histrionic and dependent personality disorders. Journal Of Personality

Disorders, 10(1), 82-87. doi:10.1521/pedi.1996.10.1.82

Barlow, D. H. (Ed.) (2008). Clinical handbook of psychological disorders: A step-by-step

treatment manual. New York: Guilford.

Bender, D. S. (2005). The Therapeutic Alliance in the Treatment of Personality Disorders.

Journal Of Psychiatric Practice, 11(2), 73-87. doi:10.1097/00131746-200503000-00002

 ACCEPTED MANUSCRIPT
55

Berk, S., & Rhodes, B. (2005). Maladaptive dependency traits in men. Bulletin Of The

Menninger Clinic, 69(3), 187-205. doi:10.1521/bumc.2005.69.3.187

Bienvenu, O., & Brandes, M. (2005). The Interface of Personality Traits and Anxiety Disorders.

PT
Primary Psychiatry, 12(3), 35-39.

RI
Birtchnell, J. (1991). The measurement of dependence by questionnaire. Journal Of Personality

Disorders, 5(3), 281-295. doi:10.1521/pedi.1991.5.3.281

SC
Borge, F.M., Hoffart, A., Sexton, H., Martinsen, E., Gude, T., Hedley, L.M., & Abrahamsen, G.

NU
(2010). Pre-treatment predictors and in-treatment factors associated with change in

avoidant and dependent personality disorder traits among patients with social phobia.
MA
Journal of Behavior Therapy and Experimental Psychiatry, 41(3), 212-219.

Bornstein, R. F. (1995b). Comorbidity of dependent personality disorder and other psychological

D
TE

disorders: An integrative review. Journal Of Personality Disorders, 9(4), 286-303.

doi:10.1521/pedi.1995.9.4.286
P

Bornstein, R. F. (1997). Dependent personality disorder in the DSM-IV and beyond. Clinical
CE

Psychology: Science And Practice, 4(2), 175-187. doi:10.1111/j.1468-

AC

2850.1997.tb00108.x

Bornstein, R. F. (1998a). Depathologizing dependency. Journal Of Nervous And Mental Disease,

186(2), 67-73. doi:10.1097/00005053-199802000-00001

Bornstein, R. F. (1998b). Implicit and self-attributed dependency needs in dependent and

histrionic personality disorders. Journal Of Personality Assessment, 71(1), 1-14.

doi:10.1207/s15327752jpa7101_1
 ACCEPTED MANUSCRIPT
56

Bornstein, R. F. (2004). Integrating Cognitive and Existential Treatment Strategies in

Psychotherapy With Dependent Patients. Journal Of Contemporary Psychotherapy,

34(4), 293-309. doi:10.1007/s10879-004-2525-7

PT
Bornstein, R. F. (2011). Reconceptualizing personality pathology in DSM-5: Limitations in

RI
evidence for eliminating dependent personality disorder and other DSM-IV syndromes.

Journal Of Personality Disorders, 25(2), 235-247. doi:10.1521/pedi.2011.25.2.235

SC
Chen, Y., Nettles, M. E., & Chen, S. (2009). Rethinking dependent personality disorder:

NU
Comparing different human relatedness in cultural contexts. Journal Of Nervous And

Mental Disease, 197(11), 793-800. doi:10.1097/NMD.0b013e3181be76a

MA
Clark, L.A. (1993). The Schedule for Nonadaptive and Adaptive Personality (SNAP).

Minneapolis, MN : University of Minnesota Press.

D
TE

Cogswell, A., & Alloy, L. B. (2006). The Relation of Neediness and Axis II Pathology. Journal

Of Personality Disorders, 20(1), 16-21. doi:10.1521/pedi.2006.20.1.16

P

Dyck, I. R., Phillips, K. A., Warshaw, M. G., Dolan, R. T., Shea, M., Stout, R. L., & ... Keller,
CE

M. B. (2001). Patterns of personality pathology in patients with generalized anxiety

AC

disorder, panic disorder with and without agoraphobia, and social phobia. Journal Of

Personality Disorders, 15(1), 60-71. doi:10.1521/pedi.15.1.60.18643

Grant, B. F., Hasin, D. S., Blanco, C., Stinson, F. S., Chou, S., Goldstein, R. B., & ... Huang, B.

(2005). The Epidemiology of Social Anxiety Disorder in the United States: Results From

the National Epidemiologic Survey on Alcohol and Related Conditions. Journal Of

Clinical Psychiatry, 66(11), 1351-1361. doi:10.4088/JCP.v66n1102

Greenberg, R.P., & Bornstein, R.F. (1988). The dependent personality: I. Risk for physical

disorders. Journal of Personality Disorders, 2(2), 126-135.

 ACCEPTED MANUSCRIPT
57

Gudjonsson, G. H., & Main, N. (2008). How are personality disorders related to compliance?.

Journal Of Forensic Psychiatry & Psychology, 19(2), 180-190.

doi:10.1080/14789940701770898

PT
Hirschfeld, R.M., Klerman, G.L., Gouch, H.G., Barrett, J., Korchin, S.J., & Chodoff, P. (1977).

RI
A measure of interpersonal dependency. Journal of Personality Assessment, 41(6), 610-

618. doi: 10.1207/s15327752jpa4106_6

SC
Hofstee, W.K.B. (1994). Who should own the definition of personality? European Journal of

NU
Personality, 8, 149-162. Doi: 10.1002/per.2410080302

Hueston, W. J., Werth, J., & Mainous, A. G. (1999). Personality disorder traits: Prevalence and
MA
effects on health status in primary care patients. International Journal Of Psychiatry In

Medicine, 29(1), 63-74. doi:10.2190/YCKA-HRQ4-U7QV-5H1J

D
TE

Jacobsberg, L., Perry, S., & Frances, A. (1995). Diagnostic agreement between the SCID—II

Screening Questionnaire and the Personality Disorder Examination. Journal Of

P

Personality Assessment, 65(3), 428-433. doi:10.1207/s15327752jpa6503_4

CE

Kendler, K. S., Aggen, S. H., Knudsen, G., Røysamb, E., Neale, M. C., & Reichborn-Kjennerud,
AC

T. (2011). The structure of genetic and environmental risk factors for syndromal and

subsyndromal common DSM-IV axis I and all axis II disorders. The American Journal Of

Psychiatry, 168(1), 29-39. doi:10.1176/appi.ajp.2010.10030340

Krueger, R. F., McGue, M., & Iacono, W. G. (2001). The higher-order structure of common

DSM mental disorders: Internalization, externalization, and their connections to

personality. Personality and Individual Differences, 30(7), 1245-1259.

 ACCEPTED MANUSCRIPT
58

Lopez-Rodriguez, F., Altshuler, L., Kay, J., Delarhim, S., Mendez, M., & Engel, J. R. (1999).

Personality disorders among medically refractory epileptic patients. The Journal Of

Neuropsychiatry And Clinical Neurosciences, 11(4), 464-469.

PT
Marshall, J. R. (1996). Comorbidity and its effects on panic disorder. Bulletin Of The Menninger

RI
Clinic, 60(2, Suppl A), A39-A54.

Miller, J. D., & Lynam, D. R. (2008). Dependent personality disorder: Comparing an expert

SC
generated and empirically derived five-factor model personality disorder count.

NU
Assessment, 15(1), 4-15. doi:10.1177/1073191107306095

Mroczkowski, M. M., Goes, F. S., Riddle, M. A., Grados, M. A., Bienvenu, O., Greenberg, B.
MA
D., & ... Samuels, J. F. (2011). Separation anxiety disorder in OCD. Depression And

Anxiety, 28(3), 256-262. doi:10.1002/da.20773

D
TE

Park, S., Hong, J., Lee, H. B., Samuels, J., Bienvenu, O., Chung, H., & ... Nestadt, G. (2012).

Relationship between personality disorder dimensions and verbal memory functioning in

P

a community population. Psychiatry Research, doi:10.1016/j.psychres.2011.08.012

CE

Pfohl, B., Blum, N. S., & Zimmerman, M. (1997). Structured interview for DSM-IV personality:
AC

SIDP-IV. Washington, DC: American Psychiatric Press.

Rodebaugh, T. L., Gianoli, M., Turkheimer, E., & Oltmanns, T. F. (2010). The interpersonal

problems of the socially avoidant: Self and peer shared variance. Journal Of Abnormal

Psychology, 119(2), 331-340. doi:10.1037/a0019031

Schuster, J., Limosin, F., Levenstein, S., & Strat, Y. (2010). Association between peptic ulcer

and personality disorders in a nationally representative US sample. Psychosomatic

Medicine, 72(9), 941-946. doi:10.1097/PSY.0b013e3181f35e23

 ACCEPTED MANUSCRIPT
59

Smith, S. W., Hilsenroth, M. J., & Bornstein, R. F. (2009). Convergent validity of the SWAP-

200 Dependency Scales. Journal Of Nervous And Mental Disease, 197(8), 613-618.

doi:10.1097/NMD.0b013e3181b08d89

PT
Starcevic, V., Latas, M., Kolar, D., Vucinic-Latas, D., Bogojevic, G., & Milovanovic, S. (2008).

RI
Co-occurrence of Axis I and Axis II disorders in female and male patients with panic

disorder with agoraphobia. Comprehensive Psychiatry, 49(6), 537-543.

SC
doi:10.1016/j.comppsych.2008.02.009

NU
Tyrer, H., Tyrer, P., & Barrett, B. (2013). Influence of dependent personality status on the

outcome and health service costs of health anxiety. The International Journal Of Social
MA
Psychiatry, 59(3), 274-280. doi:10.1177/0020764012438483

Ullrich, S., Farrington, D. P., & Coid, J. W. (2007). Dimensions of DSM-IV personality
D
TE

disorders and life-success. Journal Of Personality Disorders, 21(6), 657-663.

doi:10.1521/pedi.2007.21.6.657
P

Vaughn, M. G., Fu, Q., Beaver, D., DeLisi, M., Perron, B., & Howard, M. (2010). Are
CE

personality disorders associated with social welfare burden in the United States?. Journal
AC

Of Personality Disorders, 24(6), 709-720. doi:10.1521/pedi.2010.24.6.709

Vazire, S. (2006). Informant Reports: A Cheap, Fast, and Easy Method for Personality

Assessment. Journal of Research in Personality, 40, 472-481.

Vazire, S., & Carlson, E.N. (2011). Others sometimes know us better than we know ourselves.

Current Directions in Psychological Science, 20, 104-108

 ACCEPTED MANUSCRIPT
60

Highlights

 Dependent personality disorder is currently one of the most understudied personality

disorders
 DPD is associated with an array of negative outcomes in areas related to suicide, health,

PT
wellbeing, and functioning
 Much of the research this disorder is built on is theory-based rather than empirical, and
is often methodologically flawed

RI
SC
NU
MA
D
P TE
CE
AC