Prof. Joseph Levine

Conversation 66: Dependent personality disorder in the light of the Self-model we develop, the sensitivity channels and the targeted treatment in the reference groups

By Prof. Levine & Dr. Salganik

Dependent personality disorder is a common psychological condition characterized by an excessive need to depend and lean on others leading to submissive and clingy behavior.

Dependent personality disorder is defined by the DSM-5 as a personality disorder from the C disorder cluster characterized by an extensive and excessive need to depend on another manifested in early adulthood and present in a variety of contexts.

DSM-5 criteria:

According to the DSM-5, dependent personality disorder is diagnosed based on the presence of a pervasive and excessive need for dependence leading to submissive and clingy behaviors and fears of separation, as characterized by at least five of the following:

1. Difficulty making daily decisions without excessive advice and reassurance from others.

2. Needing others to take responsibility for most of the main areas of their lives.

3. Difficulty expressing disagreement with others because of fear of losing their support or approval.

4. Difficulty initiating projects or doing things independently due to a lack of confidence in self-judgment or self-abilities.

5. The person makes excessive efforts to receive nurturing, approval and support from others, to the point of volunteering to do things that are not pleasant to him.

6. The person feels uncomfortable or helpless when alone because of exaggerated fears of not being able to act on their own.

7. The person urgently seeks another relationship as a source of affirming nurturing and support when an existing close relationship ends.

8. The person is unrealistically preoccupied with fears that will make them worry about themselves.

Etiology

The etiology of dependent personality disorder is multifactorial, involving genetic, environmental and psychological factors. Early childhood experiences, such as overprotective parenting or conversely neglect, may cause people to develop dependent behaviors. Cognitive theories offer maladaptive schemas about self-worth and interpersonal relationships as contributing factors.

Genetics

While specific genetic markers for dependent personality disorder have not been adequately identified, family studies suggest the existence of a hereditary component. Twin studies suggest that personality traits associated with addiction, such as neuroticism and agreeableness, may have genetic underpinnings. Genetic research continues to identify specific sites and their role in dependent personality disorder in the genome.

Epidemiology

Dependent personality disorder is relatively rare, with an estimated prevalence of 0.49% to 1.5% in the general population. It is diagnosed more often in women, although this may reflect gender biases in diagnosis. Cross-cultural studies indicate variation in prevalence, perhaps influenced by social norms regarding dependence and independence.

Clinical manifestations

People with dependent personality disorder exhibit:

• Difficulty making daily decisions without excessive advice from others and reassurance.

• Tendency to allow others to take responsibility for key areas of their lives.

• Fear of abandonment and separation Urgent search for new relationships when a close relationship ends.

• Difficulty expressing disagreement from the other for fear of losing support.

• Inability to initiate projects or do things independently due to lack of confidence in personal ability.

• Tendency to exert too much effort to receive nurturing and support, even volunteering for unpleasant tasks.

The distinction between dependent personality disorder and a person who is dependent on their boss or a religious authority figure requires an understanding of the criteria for dependent personality disorder and the context in which the dependency occurs.

This is how we distinguish between the two:

The nature of the dependency

Dependent personality disorder: This is a clinical condition characterized by extensive and excessive reliance on others for decision-making, emotional support and guidance in all areas of life. People with dependent personality disorder have difficulty making decisions on their own, fear rejection or dissatisfaction, and may have low self-esteem. This dependence is not limited to one relationship and extends across many areas of their lives.

Example: A person with dependent personality disorder may have difficulty making even small decisions, constantly seek approval or guidance from others, and may feel helpless without constant reinforcement or direction.

Boss Dependence: A person who is dependent on their boss at work usually relies on their boss for professional guidance, feedback and career advancement. This can be common in hierarchical work environments and does not necessarily reflect a personality disorder. This type of dependence may be professional, limited to work, and does not indicate general dependence in personal life.

Example: An employee may often seek guidance from their boss on work-related tasks, but outside of work, they may still function independently in other areas of life.

Dependence on a religious figure (rabbi): In the case of a religious Jew or any person who relies on their religious leader (such as a rabbi for spiritual advice or guidance), this dependence is usually related to faith, tradition and cultural norms. Such a relationship is often seen as spiritually enriching and important for personal growth and decision-making in the religious context. This dependence is more specific to religious or spiritual matters and is not generally considered pathological.

Example: A person regularly consults his rabbi for guidance on religious or ethical issues, but his ability to make decisions in other areas of life (such as career, family) is not impaired by this reliance.

Emotional and psychological impact

Dependent Personality Disorder: People with dependent personality disorder may experience significant distress, anxiety and difficulty forming independent opinions or making decisions. Their self-esteem and sense of self-worth is often tied to the opinions of others, and they may fear being abandoned or rejected.

Dependence on the boss: A person who trusts their boss may not experience distress outside of work if they feel secure in their other relationships. This dependence is usually situational and does not cause wider emotional problems.

Religious dependence: In the case of religious dependence, the individual may find comfort, stability and meaning in his relationship with the Rebbe. This dependence usually does not cause emotional distress or impair their functioning in other areas of life.

In conclusion, dependent personality disorder is a common pathological condition that affects all areas of life, while dependence on a boss or a religious figure is usually situational and specific to certain aspects of life, such as work or religion, without harming general functioning or emotional well-being.

The main differences therefore lie in the extent of dependence, the emotional impact and how it affects a person's general functioning.

Below is a representative example of a clinical case:

A 32-year-old woman, known as [fictitious name and age] Ms. Renana Cohen, came to the mental health clinic with feelings of extreme anxiety to be alone and inability to make decisions without consulting a partner. Ms. Cohen reported a history of overprotective parenting and difficulty coping recently after breaking up with a significant other.

She described persistent fears of abandonment and an urgent need to find a new partner to provide emotional support. She was offered cognitive behavioral therapy (CBT): the sessions focused on challenging Ms. Cohen's maladaptive beliefs about self-worth and dependence, building assertiveness and fostering independence in decision-making.

At the same time Ms. Cohen participated in a support group where she practiced expressing opinions and taking initiative in a safe environment. She was also offered medication.

She was prescribed ciprofloxacin to treat underlying anxiety symptoms that exacerbated her addictive behaviors. After this treatment, at the end of six months, Ms. Cohen reported an increasing confidence in managing daily decisions and a reduced reliance on others for her comfort. She also successfully initiated a new job and described an improvement in interpersonal relationships.

Differential diagnosis

Dependent personality disorder must be distinguished from:

Avoidant Personality Disorder: While both share a fear of criticism, people with avoidant personality disorder avoid relationships, while dependent people seek them out.

Borderline Personality Disorder: Dependent personality disorder lacks the emotional instability and impulsivity characteristic of borderline personality disorder.

We note that there is a dependent personality disorder and those who demonstrate lines of this personality disorder but do not meet all the criteria for diagnosis.

Interestingly throughout history, there have been notable figures in history and relationships that reflect dynamics that could be interpreted as being along the lines of Dependent Personality Disorder, even if such diagnoses were not made at the time, as the disorder was not yet officially recognized.

In many of these historical cases, one partner exhibited a significant level of emotional dependence on the other, which is the hallmark of dependent personality disorder. Here are some examples:

1. Queen Victoria and Prince Albert:

Queen Victoria of the United Kingdom is a well-known historical figure whose relationship with her husband, Prince Albert, exhibits many characteristics that could indicate dependent behaviors. Queen Victoria became very dependent on Prince Albert, both emotionally and politically. She relied on him for decision-making and governance, and after his death in 1861, she entered a prolonged period of mourning, which marked the end of her public life for years. While her emotional connection to Albert was clearly deep, it was also characterized by an overreliance on his presence and judgment, a central characteristic of dependent personality disorder.

2. Catherine the Great and Grigory Potemkin:

Catherine the Great, Empress of Russia, had a long and close relationship with Grigory Potemkin, who was not only her lover but also her trusted advisor.

While Catherine was a powerful control, she was emotionally dependent on Potemkin. His influence on her decision-making was profound, and she often sought his approval and advice on matters of state. Some historians suggest that Catherine's dependence on Potemkin could reflect the traits of dependent personality disorder, although there is no official diagnosis. Their relationship was characterized by Catherine's intense need for Potemkin's presence, which lasted until his death.

P. Scott Fitzgerald and Zelda Sayre:

The relationship between the American writer P. Scott Fitzgerald and his wife Zelda is often seen as a relationship of emotional dependence and instability. Zelda was devoted to Fitzgerald and often struggled with her own identity, as it was largely defined by her relationship with him. Fitzgerald, for his part, depended on her for emotional support, although their relationship was also characterized by mutual dependence and emotional volatility.

Zelda's behavior, including her meltdowns and her need for constant reinforcement from Fitzgerald, can also be seen through the lens of dependent personality disorder, although formal diagnoses were not available at the time.

Treatment:

Psychotherapy

Cognitive behavioral therapy (CBT): focuses on identifying and changing maladaptive thinking patterns and increasing assertiveness and building self-efficacy.

Psychodynamic therapy: explores unconscious conflicts arising from early attachment experiences.

Group Therapy: Provides a supportive environment for practicing independent behaviors.

Medication: While there are no medications specifically approved for dependent personality disorder, medication may treat co-occurring conditions such as anxiety or depression. Selective serotonin reuptake inhibitors and anxiolytics are commonly used.

Psychoeducation: Educating patients and their families about the disorder can reduce stigma and foster a supportive environment.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bornstein, R. F. (2012). Dependent personality disorder. In T. A. Widiger (Ed.), The Oxford handbook of personality disorders (pp. 505–526). Oxford University Press

Beitz, K., & Bornstein, R. F. (2006). Dependent Personality Disorder. In J. E. Fisher & W. T. O'Donohue (Eds.), Practitioner's guide to evidence-based psychotherapy (pp. 230–237). Springer Science + Business Media.

Livesley WJ, Jang KL, Jackson DN, Vernon PA. Genetic and environmental contributions to dimensions of personality disorder. Am J Psychiatry. 1993 Dec;150(12):1826-31.

Paris J. Personality disorders over time: precursors, course and outcome. J Pers Disord. 2003 Dec;17(6):479-88.

Disney KL. Dependent personality disorder: a critical review. Clin Psychol Rev. 2013 Dec;33(8):1184-96.

Hansen BJ, Thomas J, Torrico TJ. Dependent Personality Disorder. 2024 Aug 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 39163425.

In our model, the self includes the elements of the human mental organiztion. The model first assumes the existence of the "primary self", which is in fact the basic biological core consisting of several innate structures and subject to increasing development during life, this self includes the instinctive emotional and cognitive parts of the person.

The primary self uses the reservoirs and mechanisms of emotion, memory and cognitive abilities and it contains primary nuclei for the future development of other mental structures.

Let's first refer to the primary self (Biological Predestined Core): the primary self consists of innate biological structures and instincts that form the innate basis of the parts of the personality and it also included the cognitive processes and the emotional processes. This primary self has its own dynamics during a person's life and is subject to changes with age, following diseases, traumas, drug consumption, addiction, etc.

Both the instincts and the basic needs in each and every person change according to different periods of development and aging – (hence their effect on behavior) and may change through drugs, trauma, diseases and more.

Within the primary self there is the potential for instrumental abilities that are innate, but they can also be promoted, or on the contrary, suppressed through the influence of the reference groups. The primary self also has cognitive abilities that are partly innate and partly dependent on interactions with the environment during the first years of life.

In addition, it includes the temperament and emotional intelligence that are partly innate and partly dependent on interactions with the environment in the first years of life. And finally, it includes an energy charge that is mostly innate but can be suppressed through the influence of the reference groups, as well as through various situational factors.

The primary self also includes the seven channels of personal sensitivity – Individual Sensitivity Channels (ISC) that reflect our individual reactivity in response to stressors (both external and internal).

The status channel – sensitivity to one's status and location, and response to changes in one's social or social status.

The norm channel – sensitivity to changes in social, ethical or cultural norms, and to the person's adaptation to these norms.

The attachment channel – sensitivity to emotional attachment to others and to intimate relationships.

The threat channel – sensitivity to physical or mental threats, and response to a situation of danger or fear.

The routine channel – sensitivity to changes in the routine or the day-to-day structure, and to a feeling of discomfort or confusion when the routine deviates.

The energy channel – sensitivity to changes in personal energy levels and the ability to perform actions.

Proprioceptive channel – sensitivity to the individual's personal proprioceptive reactivity towards internal sensations from his body or hypersensitivity in one of his senses [hearing, sight, smell, touch, etc.] to external stimuli.

The lower the sensitivity in these channels, the better the state of mental health. High sensitivity in a certain channel may indicate mental pathology.

From the primary self, a number of superstructures are developed from innate nuclei that form a basis for development during the interaction of the baby and later the person during his life with the figures around him:

Experience Coordinating Agency

A structure found in the primary self, including three brain networks: the emotional salience network, executive cognition, and the default network.

Overactivity or underactivity in these networks suggests mental pathology.

The role of the mechanism: scanning and evaluation of the internal and external inputs, as well as interpretation of internal and external events.

Board of Internalized Characters:

A collection of internalized influential characters from throughout the individual’s life, arranged in a hierarchy, with continuous dialogue and conflicts.

The figure of the "leader self" (like the "dictator self") affects decision-making and internalization of information.

The internalized figures are representative of important people from life-long experience or imaginary characters.

Enemy group:

A group of negative internalized characters that threaten the person.

The influence of these characters is caused by traumatic events.

If the enemy figures are dominant, this may indicate mental pathology.

Self representations:

Developmental process of self-representations at different stages of life (as a child, teenager, adult).

Self-representations may indicate mental pathology if they are distorted or immature.

Demonstration of the Self-model we are developing

Below is an analysis of dependent personality disorder using the model:

Primary self (biological core to the self) and dependent personality disorder:

Innate elements: the primary self, consisting of biological and instinctual structures, can influence the development of dependent personality disorder. People with increased sensitivity in the attachment channel may exhibit a tendency to depend due to an innate need for connection and security. It is also possible that the threat channel shows sensitivity mainly in situations where there is no character or a supporting character is absent.

Energy regulation and sensitivity: People with a low energy threshold (the energy channel) may feel overwhelmed when there are demands for independence, which reinforces dependence on others for emotional and physical support.

The Experience Coordination Agency:

Potential cognitive dysregulation in Dependent Personality Disorder: The executive state network in individuals with Dependent Personality Disorder may prioritize external evaluations over internal planning and evaluation security, leading to a reliance on need for reinforcement validation and external activation. The default network associated with introspection and thinking about future scenarios may struggle with this.

Interpretation of external events: A poor evaluation mechanism in the experience coordination agency may result in increased perceptions of abandonment and overestimation of threats in relationships.

Internalized characters (directorate of internalized characters):

The role of internalized figures in dependent personality disorder: internalized figures, especially representations of dominant caregiver figures that project control and criticism and convey messages to the child of his inadequacy and inability to cope, usually parental figures in childhood and possibly even dominant figures later in life can shape dependent traits. and helplessness when the need to act independently arises.

In addition, overprotective internalized characters projecting to the child an inability to act independently may discourage autonomous actions and reinforce submissive and dependent behaviors.

Conflict between figures: conflicting messages from internalzied figures – for example, a critical parent versus a loving but weak and dependent nurturing parent – may exacerbate the individual's confusion and reliance on others for decision-making.

Internal enemies’ group:

Impact on Dependent Personality Disorder: Internalized adversarial figures may contribute to fears of failure or abandonment, further reducing the individual's confidence in their abilities. This fear may cause them to overcompensate by seeking excessive reassurance from others.

Self-Representations:

Fragmented self-representation: In dependent personality disorder, representations of the self may be overly influenced by dominant figures in the figure board as shown above and reveal dependencies and a need for external reinforcement and validation. This external reliance leads to difficulty in establishing a stable and autonomous self-concept.

Treatment with the treatment method focused on the reference groups or RGFT:

In the first stage, the figure of the therapist supports, encourages and inspires trust at the beginning of the treatment and in the first stages allows the patient a safe, non-threatening place suitable for his dependent personality. Only later in the second stage does the therapist begin to gradually encourage independence.

The internalization of the figure of the therapist creates an internal figure in the directory of figures of the patient that gradually supports his autonomy.

In the second phase of Reference Group Focused Therapy (RGFT) the exploration of the internalized board and the identification of the characters that contribute to the patient's dependency patterns are applied in order to help people understand and reshape their dependency patterns.

For example:

Identifying harmful figures: Therapists may work with patients to identify and reframe the influence of protective or domineering internalized figures.

Strengthening positive figures: increasing the influence of supportive internal figures can encourage autonomy.

Developing a reflective capacity for introspection and strengthening the experiece coordination agency on its components while balancing internal and external evaluations in order to foster self-efficacy.

Channel-specific interventions: Treating hypersensitivity to attachment and threats through targeted therapeutic exercises to reduce dependency and build resilience.

A clinical case report of dependent personality in the RGFT approach

Case presentation:

A 28-year-old man, known as Mr. Levy, came to treatment with chronic feelings of inadequacy and a pervasive fear of abandonment. He reported a pattern of clinging to relationships despite their dysfunction and his difficulty making decisions independently. His upbringing included a domineering and critical father figure, whose voice Mr. Levy often "heard" in his mind, which discouraged his attempts at independence and reinforced his patterns of dependence on others.

Assessment using RGFT:

After a first phase of encouragement and providing reassurance and support, the therapist helped Mr. Levy identify internalized figures, the contributors to his dependency patterns through RGFT. This is how Mr. Levy's therapist helped identify his father's internalized critical representation in his internalized figures’ directory. This character dominated his internal narrative, preventing him from trusting his judgment. This is done using the hot seat method in which the figure of the father and his influence are raised [see a proper conversation on it].

An enemies’ group: Mr. Levy's mother was seen by him as untrustworthy and harmful to him due to her threatening attitude and her repeated threats to abandon him. Her internalized figure resided in the group of Mr. Levy's enemies, and symbolized his anxiety of abandonment.

The treatment process

Analyzing characters and reference groups:

After the first phase, the therapist worked with Mr. Levy to detach the dominant internalized father figure from his current self-concept and gradually lower it down in the hierarchy of the patient's internalized figures’ directory.

At the same time, the therapist's behavior and impact created an internalized figure high in the hierarchy with a positive attitude, which encourages autonomy and self-esteem. At the same time, other supporting characters such as supportive friends were identified and strengthened within the directorate of internalized characters.

Reframing and empowerment:

Role playing exercises were used to challenge the "dictatorial" inner voice of the father figure and slowly lower him down in the hierarchy in the board of internalized figures.

Guided imagination allowed Mr. Levy to reinterpret past experiences, thus reducing the emotional hold of negative internalized characters.

Building autonomy:

Through behavioral experiments, Mr. Levy practiced making independent decisions, gradually building a renewed confidence in his abilities.

The therapist encouraged Mr. Levy to integrate positive self-representations into his new developing mental makeup.

Regulation of emotional sensitivity:

The therapist initiated specific interventions for Mr. Levy's increased sensitivity to attachment and perceived threats of abandonment and leaving.

Mindfulness exercises helped Mr. Levy’s identify and manage internalized fears without acting on them impulsively.

Results:

Over the course of one year, Mr. Levy showed significant improvement. He reported a reduced influence of his internalized father’s figure and threatening mother’s figure and a greater reliance on his judgment. He began to set limits to the control of others in his relationships and pursued hobbies independently, which reflected a positive change in the hierarchy of his internalized characters’ board and self-representations.

That's it for now,

yours,

Dr. Igor Salganik and Prof. Joseph Levine