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Dedicated devotees...or "dependent personality disorder"?
Concerned former cult members are often frustrated and puzzled at the continuing irrational and unspiritual attitudes of those remaining behind in the cult. Written as an aid to psychiatrists, this clinical description of the "dependent personality disorder" is a strikingly accurate picture of the often bizarre attitudes of those choosing to remain in cults.
The following is from:
"DISORDERS OF PERSONALITY, DSM 3: AXIS 2"
by Theodore Millon
(Areas of particular interest appear in bold)
Dependent Personality: The Submissive Pattern
Dependent personalities are distinguished from other pathological patterns by their marked need for social approval and affection, and by their willingness to live in accord with the desires of others. Dependent persons' "centers of gravity" lie in others, not in themselves. They adapt their behavior to please those upon whom they depend, and their search for love leads them to deny thoughts and feelings that may arouse the displeasure of others. They avoid asserting themselves lest their actions be seen as aggressive. Dependents may feel paralyzed when alone and need repeated assurances that they will not be abandoned. Exceedingly sensitive to disapproval, they may experience criticism as devastating.
Dependent personalities tend to denigrate themselves and their accomplishments. What self-esteem they possess is determined largely by the support and encouragement of others. Unable to draw upon themselves as a major source of comfort and gratification, they must arrange their lives to ensure a constant supply of nurturance and reinforcement from their environment. However, by turning exclusively to external sources for sustenance, dependents leave themselves open to the whims and moods of others. Losing the affection and protection of those upon whom they depend leads them to feel exposed to the void of self-determination. To protect themselves, dependents quickly submit and comply with what others wish, or make themselves so pleasing that no one could possibly want to abandon them.
Dependents are notably self-effacing, obsequious, ever-agreeable, docile, and ingratiating. A clinging helplessness and a search for support and reassurance characterize them. They tend to be self-depreciating, feel inferior to others, and avoid displaying initiative and self-determination. Except for needing signs of belonging and acceptance, they refrain from making demands on others. They deny their individuality, subordinate their desires, and hide what vestiges they possess as identities apart from others. They often submit to abuse and intimidation in the hope of avoiding isolation,
loneliness, and the dread of abandonment. Paralyzed and empty if left on their own, they feel the need for guidance in fulfilling even simple tasks or making routine decisions.
Many dependent individuals search for a single, all-powerful "magic helper," a partner in whom they can place their trust and depend on to protect them from having to assume responsibilities or face the competitive struggles of life alone. Supplied with a nurturant partner, they may function with ease, be sociable, and display warmth, affection, and generosity. Deprived of this support, they withdraw into themselves and become tense, despondent, and forlorn.
Despite the well-known prevalence of this personality pattern, there was only passing reference to it in the DSM-I and no provision at all in the DSM-IL The closest approximation in the DSM-II, though far from sufficient in either scope or clarity, was the "inadequate personality." Fortunately, the DSM-III has taken cognizance of this important syndrome and has given it the status of a separate and major personality disorder. The following quote is taken from this official manual, and it highlights the essential features and diagnostic criteria selected to represent the syndrome:
The individual passively allows others to assume responsibility for major areas of his or her life because of a lack of self-confidence and an inability to function independently; the individual subordinates his or her own needs to those of others on whom he or she is dependent in order to avoid any possibility of having to be self-reliant.
Such individuals leave major decisions to others. For example, an adult with this disorder will typically assume a passive role and allow his or her spouse to decide where they should live, what kind of job he or she should have, and with which neighbors they should be friendly. Generally individuals with this disorder are unwilling to make demands on supporting people for fear of jeopardizing these relationships and being forced to rely on themselves.
Individuals with this disorder invariably lack self-confidence. They tend to belittle their abilities and assets. (p. 324)
HISTORICAL AND THEORETICAL ANTECEDENTS
Before elaborating the clinical picture of the DSM-III dependent personality it will be useful and illuminating to briefly review formulations of a parallel nature that have been published by early as well as contemporary clinical theorists.
The features of passively allowing others to assume responsibility and the characteristic receptivity to external influence were first described under the labels of the "shiftless" type by Kraepelin (1913) and the "weak-willed" personality by Schneider (1923). Both theorists made little reference to the need for and the seeking of external support that typify dependent patients,
Historical and Theoretical Antecedents
stressing instead "their irresoluteness of will" and the ease with which they can be "seduced" by others. Schneider noted, "as far as their pliable natures will allow they are responsive to good influences, show regret for their lapses and display good intentions" (p. 133). Kraepelin considered these types to be a product of delayed maturation. Viewing them as readily "exploited to no good end," both Kraepelin and Schneider conceived these personalities as not merely minimally competent to handle their affairs and susceptible to influence, but as easy prey to "bad notions" and ready targets for social forms of misconduct such as addiction and thievery.
A distinct shift from the notion that these personalities were potentially immoral characters was taken by psychoanalytic theorists who were also writing in the first two decades of this century. Evolving their formulations in line with libidinal or psychosexual stage theory, both Freud and Abraham gradually constructed the "oral character" type and, more specifically, what has been termed either the "oral-sucking" or "oral-receptive" character. Most clearly presented by Karl Abraham in 1924, he writes of this major precursor of the DSM-III dependent personality as follows:
According to my experience we are here concerned with persons in whom the sucking was undisturbed and highly pleasurable. They have brought with them from this happy period a deeply rooted conviction that everything will always be well with them. They face life with an imperturbable optimism which often does in fact help them to achieve their aims. But we also meet with less favorable types of development. Some people are dominated by the belief that there will always be some kind person--a representative of the mother, of course--to care for them and to give them everything they need. This optimistic belief condemns them to inactivity...they make no kind of effort, and in some cases they even disdain to undertake a bread-winning occupation. (1924a, pp. 599-400)
Elaborating on this early statement, Fenichel highlighted other prime traits of the oral character, particularly those individuals who have experienced deprivation at this stage:
If a person remains fixated to the world of oral wishes, he will, in his general behavior, present a disinclination to take care of himself, and require others to look after him. . . . The behavior of persons with oral characters frequently shows signs of identification with the object by whom they want to be fed. Certain persons act as nursing mothers in all their object relationships. They are always generous and shower everybody with presents and help. (1945, p. 489)
Sullivan, although drawing from a different theoretical framework than libidinal theory, described in his "inadequate" personality a series of characteristics that correspond in many respects to the current DSM-III criteria:
Some of these people have been obedient children of a dominating parent. They go through life needing a strong person to make decisions for them. Some
of them learned their helplessness and clinging vine adaptation from parental example. (1947, p. 84)
Perhaps the closest parallel to the DSM-III dependent personality is found in the descriptive features of the "compliant" type as formulated by Karen Horney:
He shows a marked need for affection and approval and an especial need for a "partner"--that is, a friend, lover, husband or wife who is to fulfill all expectations of life and take responsibility for good and evil....
This type has certain characteristic attitudes toward himself. One is the pervasive feeling that he is weak and helpless--a "poor little me" feeling....A second characteristic grows out of his tendency to subordinate himself. He takes for granted that everyone is superior to him....The third feature...is his unconscious tendency to rate himself by what others think of him. His self- esteem rises and falls with their approval or disapproval, their affection or lack of it. (1945, pp. 49-54)
A similar set of traits was provided by Erich Fromm in his characterization of the "receptive orientation."
In the receptive orientation a person feels "the source of all good" to be outside, and he believes that the only way to get what he wants--be it something material, be it affection, love, knowledge, pleasure--is to receive it from that outside source.... They are dependent not only on authorities for knowledge and help but on people in general for any kind of support. They feel lost when alone because they feel that they cannot do anything without help. This helplessness is especially important with regard to those acts by which their very nature can only be done alone--making decisions and taking responsibility. (1947, pp. 67-63)
As noted earlier--and quite surprisingly given its extensive reference in the literature--the dependent personality syndrome was accorded only brief mention in the DSM-I, noted as a subvariant of the passive-aggressive disorder, and it was totally overlooked in the DSM-IL Features of dependency were most closely represented in the inadequate personality disorder, but these failed to provide either a comprehensive or coherent picture of the clinical type. For reference purposes, the salient aspects of the inadequate personality were noted as follows:
This behavior pattern is characterized by ineffectual responses to emotional, social, intellectual and physical demands. While the patient seems neither physically nor mentally deficient, he does manifest inadaptability, ineptness, poor judgment, social instability and lack of physical and emotional stamina.
Of potential interest are factor analytic studies of "oral character" traits. For example, in a series of cross-validated projects designed to assess the factorial
unity of certain presumed psychoanalytic types, Lazare, Klerman, and Armor (1966, 1970) identified the following characteristics as covarying to a high degree in what they termed the "oral factor": dependence, pessimism, passivity, self-doubt, fear of sexuality, and suggestibility. Along similar lines, Walton and Presley (1973a, 1978b) rated a population of patients on an inventory of personality traits and extracted a major component that they labeled "submissiveness"; it was composed of the following items: timidity, meekness, submissiveness, intropunitiveness, indecisiveness, and avoidance of competition. In noting possible parallels to this component in the clinical literature, Walton and Presley referred to the "obviously related" dependent personality, a classification well known to practicing professionals but one that did not appear in either the DSM-II or the ICD system.
Millon drew upon his theoretically derived passive-dependent personality pattern (1969), and in 1975 he provided the following descriptive features and criteria as the initial working draft for the personality subcommittee of the DSM-III Task Force.
This pattern is typified by a passive-dependency, general social naivete and a friendly and obliging temperament. There is a striking lack of initiative and competitiveness, self-effacement of aptitudes and a general avoidance of autonomy. Appeasing and conciliatory submission to others is notable, as is a conspicuous seeking and clinging to supporting persons. Except where dependency is at stake, social difficulties are cognitively denied or neutralized by an uncritical and charitable outlook. Since adolescence or early adulthood at least S of the following have been present to a notably greater degree than in most people and were not limited to discrete periods nor necessarily prompted by stressful life events.
1. Pacific temperament (e.g., is characteristically docile and noncompetitive; avoids social tension and interpersonal conflicts).
2. Interpersonal submissiveness (e.g., needs a stronger, nurturing figure, and without one feels anxiously helpless; is often conciliatory, placating, and self-sacrificing).
3. Inadequate self-image (e.g., perceives self as weak, fragile and ineffectual; exhibits lack of confidence by belittling own aptitudes and competencies).
4. Pollyana cognitive style (e.g., reveals a naive or benign attitude toward interpersonal difficulties; smooths over troubling events).
5. Initiative deficit (e.g., prefers a subdued, uneventful and passive life style; avoids self-assertion and refuses autonomous responsibilities).
In a second draft revision of the criteria, the following list was written by the author in 1977 for review by his DSM-III Task Force associates.
Excessive dependency (e.g., displays a chronic and conspicuous need for supporting or nurturant persons).
Isolation anxiety (e.g., cannot tolerate being alone for more than brief periods).
Lack of confidence and initiative (e.g., perceives self as weak, belittles aptitudes and is non-competitive). Submissive and socially conciliatory (e.g., avoids self-assertion, is self- sacrificing and pollyanna-like). E. Abdication of responsibilities (e.g., seeks others to assume leadership and direction for one's affairs).
With the foregoing as a precis, there is a reasonable foundation for detailing the major clinical characteristics of the dependent personality. Although the analysis is separated into four sections, the traits described should be seen as forming a coherent picture. Congruity among the four descriptive realms of behavior, self-report, intrapsychic processes, and interpersonal coping style should be expected since a distinguishing characteristic of a personality trait is its pervasiveness--that is, its tendency to operate in all spheres of psychological functioning. It should not be surprising, therefore, that each section provides a clinical impression similar to the others.
Among the most notable features of dependents is their lack of self-confidence, a characteristic apparent in their posture, voice, and mannerisms. They tend to be overly cooperative and acquiescent, preferring to yield and placate rather than be assertive. Large social groups and noisy events are abhorrent, and they go to great pains to avoid attention by underplaying both their attractiveness and their achievements. They are often viewed by friends as generous and thoughtful, and at times as unduly apologetic and obsequious. Neighbors may be impressed by their humility, cordiality, and graciousness, and by the "softness" and gentility of their behavior. Beneath their warmth and affability may lie a plaintive and solemn quality a searching for assurances of acceptance and approval. These needs may be especially manifest under conditions of stress. At these times, dependents are likely to exhibit overt signs of helplessness and clinging behaviors. They may actively solicit and plead for attention and encouragement. A depressive tone will often color their mood, and they may become overtly wistful or mournful. Maudlin and sentimental by disposition, they may also become excessively conciliatory and self-sacrificing in their relationships.
Self-Descriptions and Complaints
It is characteristic of dependents to limit awareness of self and others to a narrow sphere, well within comfortable boundaries.They constrict their world and are minimally introspective and pollyanna like with regard to difficulties that surround them. From an introspective view dependent personalities tend
to be naive, unperceptive, and uncritical. They are inclined to see only the "good" in things, the pleasant side of troubling events. Underneath their pollyanna veneer, dependent personalities often feel little of the joy of living. Once their "hair is let down" they may report feeling pessimistic, discouraged, and dejected. Their "suffering" is done in silence, however, away from those for whom they must appear pleased and content with life.
Dependents see themselves, at least superficially, as considerate, thoughtful, and cooperative, disinclined to be ambitious and modest in their aspirations. Closer probing, however, is likely to evoke marked feelings of personal inadequacy and insecurity. Dependents tend to downgrade themselves, claiming to lack abilities, virtues, and attractiveness. They are disposed to magnify their failures and defects. When comparing themselves to others they minimize their attainments, underplay their attributes, note their inferiorities, and assume personal blame for problems they feel they have brought upon others. Of course, much of this self-belittling has little basis in reality. Clinically, this pattern of self-deprecation may best be conceived as a strategy by which dependents elicit assurances that they are not unworthy and unloved. Hence, it serves as an instrument for evoking praise and commendation.
Inferred Intrapsychic Dynamics
By claiming weakness and inferiority, dependents effectively absolve themselves of the responsibilities they know they should assume but would rather not. In a similar manner, self-depreciation evokes sympathy and attention from others, for which dependents are bound to feel guilt. Maneuvers and conflicts such as these are difficult for dependents to tolerate consciously. To experience comfort with themselves, dependents are likely to deny the feelings they experience and the deceptive strategies they employ. Likewise, they may cover up their obvious need to be dependent by rationalizing their inadequacies--that is, by attributing them to some physical illness, unfortunate circumstance, and the like. And to prevent social condemnation, they are careful to restrain assertive impulses and to deny feelings that might provoke criticism and rejection.
Dependents' social affability and good-naturedness not only forestall social deprecation but reflect a gentility toward the self, a tender indulgence that protects them from being overly harsh with their own shortcomings. To maintain equilibrium, they must take care not to overplay their expressions of guilt, shame, and self-condemnation. They are able to maintain a balance between moderate and severe self-deprecation by a pollyanna tolerance of the self, "sweetening" their own failures with the same saccharine attitude that they use to dilute the shortcomings of others.
The inadequacies that dependents see within themselves may provoke feelings of emptiness and the dread of being alone. These terrifying thoughts are often controlled by identification, a process by which they imagine
themselves to be an integral part of a more powerful and supporting figure. By allying themselves with the competencies of their partners, they can avoid the anxieties evoked by the thought of their own impotence. Not only are they uplifted by illusions of shared competence, but through identification they may find solace in the belief that the bonds they have constructed are firm and inseparable.
Denial mechanisms also characterize the dependent's defensive style. This is seen most clearly in the pollyanna quality of dependents' thoughts. Dependents are ever-alert to soften the edges of interpersonal strain and discomfort. A syrupy sweetness may typify their speech, and they may persistently cover up or smooth over troublesome events. Especially threatening are their own hostile impulses; any inner feeling or thought that might endanger their security and acceptance is quickly staved off. A torrent of contrition and self- debasement may burst forth to expiate momentary transgressions.
Interpersonal Coping Style
What interpersonal behaviors do dependents use to manipulate their environment, and how do they arrange their relationships to achieve their aims.
A major problem for dependent individuals is that they not only find little reinforcement within themselves but feel that they are inept and stumbling, and thus lacking in the skills necessary to secure their needs elsewhere. As they see it, only others possess the requisite talents and experience to attain the rewards of life. Given these attitudes, they conclude that it is best to abdicate self-responsibility, to leave matters to others, and to place their fate in others' hands. Others are so much better equipped to shoulder responsibilities, to navigate the intricacies of a complex world, and to discover and achieve the pleasures to be found in the competitions of life.
To achieve their goals, dependent personalities learn to attach themselves to others, to submerge their individuality, to deny points of difference, to avoid expressions of power, and to ask for little other than acceptance and support-- in other words, to assume an attitude of helplessness, submission, and compliance. Moreover, by acting weak, expressing self-doubt, communicating a need for assurance, and displaying a willingness to comply and submit, dependents are likely to elicit the nurture and protection they seek.
Dependents must be more than meek and docile if they are to secure and retain their "hold" on others. They must be admiring, loving, and willing to give their "all." Only by total submission and loyalty can they be assured of consistent care and affection. Fortunately, most dependents have learned through parental models how to behave affectionately and admiringly. Most possess an ingrained capacity for expressing tenderness and consideration, essential elements in holding their protectors. Also important is that most have learned the "inferior" role well. They are able, thereby, to provide their "superior" partners with the feeling of being useful, sympathetic, stronger, and competent--precisely those behaviors that dependents seek in their mates.
From many sources, then, dependent personalities have learned interpersonal strategies that succeed well in achieving the goals they seek.
Before detailing the disorders that frequently accompany the dependent personality, it may be useful to reiterate an earlier discussion in Chapter 1 concerning distinctions between personality and symptom disorders. Essentially, the behaviors that typify personality persist as permanent features of the individual's way of life and seem to have an inner autonomy; that is, they exhibit themselves with or without external precipitants. In contrast, the behaviors that characterize Axis I symptom disorders arise as a reaction to stressful situations and tend to be transient; that is, they are of brief duration, subsiding or disappearing shortly after these conditions are removed. The clinical features of personality are highly complex and widely generalized, with many attitudes and habits exhibited only in subtle and indirect ways. In contrast, symptom disorders tend to be characterized by isolated and dramatic behaviors that often simplify, accentuate, and caricature the more prosaic features of the patient's personality. That is, they stand out in sharp relief against the background of more enduring and typical modes of functioning. Furthermore, personality traits feel "right" to the patients. They seem to be part and parcel of their makeup. In contrast, symptom disorders often are experienced as discrepant, irrational, and uncomfortable. The behaviors, thoughts, and feelings of disorders seem strange and alien not only to others but to the patients themselves. They often feel as if they were driven by forces beyond their control.
It is the contention of this book that a full understanding of Axis I symptom disorders requires the study of Axis II personalities. Symptom disorders are but an outgrowth of deeply rooted sensitivities and coping strategies. What events a person perceives as threatening or rewarding, and what behaviors and mechanisms he or she employs in response to them reflects a long history of interwoven biogenic and psychogenic factors that have formed the person's basic personality pattern.
Several qualifications should be noted lest the discussion imply an overly simplified relation between Axis I and Axis II syndromes. First, symptom disorders do not arise in one personality pattern only. Second, in many cases several Axis I symptom disorders may be simultaneously present since they reflect the operation of similar coping processes. Third, symptoms are likely to be transient since their underlying functions wax and wane as the need for them changes. And last, Axis I symptoms should, in large measure, be interchangeable, with one symptom appearing dominant at one time and a different one at another.
Despite the fact that Axis I symptom disorders often covary and are frequently interchangeable, we would expect some measure of symptom
dominance and durability among different Axis II personalities. No one-to- one correspondence should be expected, of course, but differences in lifelong coping habits should lead us to anticipate that certain personalities would be more inclined to exhibit certain symptoms than others. In the compulsive personality, for example, where ingrained mechanisms such as reaction formation and undoing have been present for years, we would expect the patient to display symptoms that reflect these mechanisms. Similarly, histrionic personalities should exhibit the more dramatic and attention- getting symptoms since exhibitionistic histrionics have characterized their coping behaviors.
There are other reasons not to overstate the correspondence between personality and symptom disorders. Thus, symptoms that are often indistinguishable from those exhibited by pathological personalities arise also in normal persons. More importantly, there are endless variations in the particular experiences to which different members of the same personality syndrome have been exposed. To illustrate, compare two individuals who have been "trained" to become dependent personalities. One was exposed to a mother who was chronically ill, a pattern of behavior that brought her considerable sympathy and freedom from many daily burdens. With this as the background, the patient in question followed the model observed in the mother when faced with undue anxiety and threat, and thereby displayed hypochondriacal symptoms. A second dependent personality learned to imitate a mother who expressed endless fears about every kind of event and situation. In this case, phobic symptoms arose in response to stressful and anxiety-laden circumstances. In short, the specific symptom "choice" is not a function solely of the patient's personality but may reflect particular and entirely incidental events of prior experience and learning.
Concomitant Axis I Symptoms
This section (also provided in each of the following chapters) briefly discusses the prime Axis I disorders that often covary with the personality syndrome under review. In addition to identifying the most frequent of these accompanying difficulties, there is also a description of the more common sensitivities and vulnerabilities that dispose this personality to react in a "disordered" fashion. Further, note is made of several of the hypothesized dynamics and secondary gains that characteristically occur among these personalities when they exhibit the Axis I disorder under discussion. As noted earlier, objective precipitants in symptom disorders play a secondary role to those which exist internally. It is the patients' anticipatory sensitivities that dispose them to transform innocuous elements of reality so that they are duplicates of the past. As in a vicious circle, this distorted perception stirs up a wide range of associated past reactions. To specify the source of an Axis I disorder, then, we must look not so much to the objective conditions of reality, though these may in fact exist, as to the deeply rooted personality vulnerabilities of the patient.
Identifying these sensitivities is a highly speculative task since no one can specify exactly what goes on intrapsychically. The best we can do is to make theoretically and clinically informed guesses as to which attitudes in each of the major personality types are likely to give rise to the vulnerability. There is, of course, no single "cause" for Axis I symptom disorders, even in patients with similar personalities. Moreover, not only do triggering precipitants differ from patient to patient, but different sensitivities may take precedence from one time to another within a single patient. The discussion proceeds with these cautions in mind.
Dependent personalities are extremely vulnerable to anxiety disorders, especially those referred to as separation anxieties. Having placed their welfare entirely in the hands of others, they expose themselves to conditions that are ripe for generalized anxieties. There may be an ever-present worry of being abandoned by their sole benefactor and left alone to struggle with their meager competencies. Another factor that may give rise to panic anxiety attacks is the anticipation and dread of new responsibilities. Their sense of personal inadequacy and the fear that new burdens may tax their limited competencies (thereby bringing disapproval from others) may precipitate a dramatic change from calmness to marked anxiety. It should be noted, of course, that anxious displays often serve to evoke nurtural and supporting responses from others. Thus, an anxiety disorder may come to be used as a tool that enables the dependent to avoid the discomforting responsibilities of autonomy and independence.
Dependent personalities develop phobic disorders when their security is threatened or when demands are made which exceed their feelings of competence. They avoid responsibility, especially actions which require self-assertion and independence. To ensure the safety of their dependency, they will quickly displace or transform any thought or impulse that may provoke rebuke. Social phobias are not uncommon among these personalities. Not only do phobic symptoms externalize anxiety and avoid threats to security, but by anchoring inner tensions to tangible outside sources dependents prompt others to come to their assistance. For these reasons, dependents are especially vulnerable to agoraphobic attacks. These anticipatory fears of leaving familiar and secure settings, most frequently one's home, serve well as a means of soliciting care and protection. Thus, the phobic maneuver achieves secondary gains that are fully consonant with the patient's basic dependent orientation.
Often preoccupied with self-doubts, dependent personalities may be subject to a variety of obsessive-compulsive disorders. These symptoms usually stem from reactivated feelings of inadequacy and are precipitated by situations calling for independence and responsibility. At these times, they are likely to weigh interminably the pros
and cons of the situation and thereby endlessly postpone any change in their dependent status. Obsessional thoughts and compulsive acts may also arise in response to feelings of separation anxiety or repressed anger. Here, coping is an aid (through reaction formation or undoing) in countering tensions that stem from the isolation or discharge of security-jeopardizing impulses. These symptoms often take the form of "sweet" thoughts and approval-gaining acts.
Dependent personalities may develop somatoform disorders as a means of controlling the upsurge of forbidden impulses. More commonly, these symptoms promote the avoidance of onerous responsibilities and help recruit secondary gains such as sympathy and nurture. By displaying physical helplessness, dependents often succeed in eliciting the attention and care they need. Conversion symptoms may be a form of self- punishment for feelings of guilt and worthlessness. Dependents tend, however, not to be too harsh with themselves. Their conversion symptoms are likely to take the form of relatively mild sensory anesthesias such as a generalized numbness in the hands and feet. It is notable that their symptoms often are located in their limbs, a way perhaps of demonstrating to others that they are "disabled" and, therefore, incapable of performing even routine chores.
Among the principal goals of hypochondriacal and somatization disorders are dependents' desires to solicit attention and nurture from others and to evoke assurances that they will be loved and cared for, despite weaknesses and inadequacy. By their "illness," dependents divert attention from the true source of their dismay, the feeling that others are showing little interest and paying little attention to them. Without complaining directly about their dissappointment and resentment, dependents still manage through their physical ailments to attract and rekindle the flagging devotions of others. Not to be overlooked also is that illness complaints may be employed to control others, make them feel guilty, and thereby retaliate for the disinterest and mistreatment dependents may feel they have suffered. In some cases, pain and nagging symptoms represent a form of self-punishment, an attack upon oneself that is disguised in bodily ailments and physical exhaustion.
Since dependent personalities have been well trained to view themselves as weak and inadequate, it would not be unlike them to readily assume the role of "the patient" and, hence, be disposed to factitious disorders. Overdependency and excessive parental solicitousness may have taught them as children to protect themselves, not to exert their frail capacities or assume responsibilities that may strain their delicate bodies. Any source of tension, be it externally precipitated or based on the control of forbidden impulses, may lead to an anxious conservation of energy. Having learned that frailty and weakness elicit protective and nurtural reactions from others, dependents may "allow" themselves to succumb to physical exhaustion or illness as a device to ensure these desired responses. It is not unlikely
that genuinely felt guilt may be stirred up when dependents recognize how thoughtless and ineffectual they have been in carrying out their responsibilities. But here again, physical weariness and bodily illness come to the rescue as a rationalization to exempt them from assuming their share of chores.
Although infrequent, dependent personalities may develop dissociative disorders. These dreamlike trance states may occur when they are faced with responsibilities that surpass their feelings of competence. Through this process the dependent effectively fades out of contact with threatening realities. Amnesic episodes, however, are likely to be rare since they would prompt to intensify existent separation anxieties. Repetitive somnambulistic states may not be as uncommon. Here dependents may vent minor forbidden impulses or seek to secure affect and nurture. Brief, frenzied actions may arise if the patient is in a decompensated state. Here dependents may feel an upsurge of intense hostile impulses that can threaten their dependency security. By these means, contrary feelings are discharged without the patient knowing it and therefore without having to assume blame. Irrational acts such as these are so uncharacteristic of this personality that these behaviors are seen by others as a sure sign of "sickness," thereby eliciting support (rather than rejecting) responses.
Since dependent personalities are especially susceptible to separation anxiety, feelings of helplessness readily come to the fore when they anticipate abandonment. The actual loss of a significant person is very likely to prompt any number of affective disorders, including a major depression. Actual abandonment may prompt the dependent to plead for reassurance and support. Expressions of guilt and self condemnation are not uncommon since these verbalizations often deflect criticisms and transform threats into sympathy. Guilt may be employed as a defense against outbursts of resentment and hostility. Dependents usually contain their anger since they dread provoking retribution. To prevent this, dependents typically turn their aggressive impulses inward, discharging them through self-derisive comments, guilt, and contrition. These statements not only temper the exasperation of others but often prompt them to respond in ways which make the patient feel redeemed and loved.
On occasion, dependent personalities exhibit a marked, although usually temporary, reversal of their more subdued and acquiescent style. In these cases of bipolar disorder, with their unusual manic episodes, the happy-go-lucky air, boundless energy, and buoyant optimism are merely a front, an act in which they try to convince themselves as well as others that "all will be well." What we see at these times is a desperate effort to counter the beginning signs of hopelessness and depression, a last-ditch attempt to deny what they really feel and to recapture the attention and security they fear they have lost.
Schizoaffective and catatonic disorders.
Dependent personalities succumb on rare occasion to schizoaffective disorders. Here we often see a coloring of sadness that draws others to, rather than away, from the patient. The tone of inner softness reflects an inclination to acquiesce to the wishes of others in the hope of maintaining some measure of affection and support from them. It is in dependent patients that we often see the cataleptic waxy flexibility of the catatonic disorder. This willingness to be molded according to the desires of others signifies the personality's complete abandonment of self-initiative and its total dependence and submission to external directives. At the heart of these patients' passive acquiescence is the deep need that dependents have to counter their separation anxieties and to avoid actions that might result in disapproval and rejection.
Concurrent Axis II Personalities
Although all combinations are possible theoretically, experience and research show that only certain personality types tend to overlap or coexist (Millon, 1977). This discussion draws upon the evidence of several statistical cluster studies employing the Millon Clinical Multiaxial Inventory (MCMI) to supplement what theoretical deduction and observation suggests as the most prevalent personality mixtures. To furnish a picture of the more prominent characteristics of these clusters, sections are included from clinical reports generated by an MCMI computer program devised and written specifically to provide assessments of personality profile combinations.
Dependent-avoidant mixed personality.
Perhaps the most common personality disorder found concurrently with the dependent is the new DSM- III avoidant personality, which is described in detail in Chapter 11. This combination has been identified as highly prevalent in centers such as V.A. outpatient clinics and other settings that minister to ambulatory chronic patients who are sustained in a dependent and largely parasitic state by virtue of institutional rewards and requirements. The MCMI computer report of a 57-year-old married and unemployed World War II veteran follows. He has remained in outpatient treatment at a mental hygiene clinic for varying periods since the early 1950's and has continued to receive a 75 percent psychiatric disability. The report was "blind" concerning background data and history.
The patient's behavior may be characterized as submissively dependent, self- effacing, and noncompetitive. Others are leaned upon for guidance and security, and a passive role is assumed in relationships. There is a striking lack of initiative and a general avoidance of autonomy. The patient is exceedingly dependent, not only in needing attention and support from others to maintain equanimity but in being especially vulnerable to separation from those who provide support. However, intense resentment is felt toward those upon whom
there is dependence since he has been subjected to frequent rebuff and disapproval. Outbursts of anger have been directed toward others for having failed to appreciate the patient's needs for affection and nurturance. The very security that he needs is threatened, however, when such resentments are expressed. The patient has become apprehensive and has acquired a pattern of withdrawing from social encounters. Further, he has built a tight armor to damp-down and deaden excessive sensitivity to rejection. Loneliness and isolation are commonly experienced. Although efforts are made to be pleasant and agreeable, there is an underlying tension and emotional dysphoria, expressed in disturbing mixtures of anxious, sad, and guilt-ridden feelings. Insecurity and fears of abandonment underlie what may appear on the surface to be a quiet, submissive, and benign attitude toward difficulties. Despite past rebuff and fears of isolation, he continues to evidence a clinging helplessness and a persistent search for support and reassurance. Complaints of weakness and easy fatigueability may reflect an underlying mood of depression. Having experienced continuing rebuff from others, the patient may succumb to physical exhaustion and illness. Under these circumstances, simple responsibilities demand more energy than the patient can muster. He expresses the feeling that life is empty but heavy, experiencing a pervasive sense of fatigue and apathy.
Dependent-histrionic mixed personality.
Another frequent combination is found between the dependent and histrionic personalities. Cluster research suggests chat this mixture is particularly prevalent among women as they approach mid-life, and it appears to be commonly diagnosed in private practice settings as well as at marital and family agencies. The following MCMI report was computer generated on the basis of replies given by a 57- year-old woman with three adolescent children who was facing the imminent possibility of an undesired divorce.
The patient's behavior is best characterized by a submissive dependency and a leaning upon others for affection, nurturance, and security. The fear of being abandoned leads the patient to be overly compliant and obliging. At times, she handles this fear by being socially gregarious and superficially charming, often evident in the seeking of attention and in self-dramatizing behaviors. The patient typically reveals a naive attitude toward interpersonal problems. Critical thinking rarely is evident and most cognitive knowledge appears to be unreflected and scattered. In an effort to maintain an air of buoyancy, she tends to deny all disturbing emotions, covering inner disharmonies by short-lived enthusiasms. In part, this may stem from a tendency to be genuinely docile, soft- hearted, and sensitive to the desires of others. The patient is more than merely accommodating and docile in efforts to secure dependency needs. She is admiring and loving, giving all to those upon whom there is dependence. The patient has also learned to play the inferior role well, providing partners with the rewards of feeling useful, sympathetic, stronger, and more competent. There is often an active solicitousness of praise, a marketing of appeal, and a tendency to be seductive and entertaining.
The patient persistently seeks harmony with others, if necessary at the expense of internal values and beliefs, and is likely to actively avoid all situations that may involve personal conflict. To minimize distressing relationships, she avoids self-assertion and abdicates autonomous responsibilities, preferring to leave matters in the hands of others. The preoccupation with external rewards and approval has left her bereft of an identity apart from others. The patient values herself not in terms of intrinsic traits but in terms of relationships. By submerging or allying herself with the competencies and virtues of others, the patient not only is bolstered by the illusion of shared competence but finds solace in the belief that bonds so constructed are firm and inseparable.
The patient feels helpless when faced with responsibilities that demand autonomy or initiative. The loss of a significant source of support or identification often prompts severe dejection. Under such conditions of potential rejection or loss, she will openly solicit signs of reassurance and approval. Guilt, illness, anxiety, and depression are frankly displayed since these tend to deflect criticism and transform threats of disapproval into those of support and sympathy. When dependency security is genuinely threatened, the patient will manifest an anxious depressiveness covarying with other, more extreme reactions such as brief manic periods of either euphoria or disorganized hostility.
The picture portrayed clearly reflects both dependent and histrionic personality features. Not included in the report are sections that dealt with her current symptom state, notably a moderate level of separation anxiety and considerable situational depression.
Differential Diagnostic Signs
Since multiple diagnoses among mental disorders are not only possible but encouraged by the DSM-III multiaxial schema, the importance of differential diagnosis, so central to conventional medical assessment, has clearly diminished. Despite its lessened role, there are justifications for insisting on clear differentiations among disorders. The main reason is to reduce diagnostic confusion, not to separate syndromes that naturally overlap. Diagnostic clarity is important because it bears on the nature and goals of treatment. For example, if a dependent personality style accounts for a particular set of symptoms more accurately than a transient or situationally specific agoraphobia, the therapist will likely decide that cognitive or intrapsychic, rather than behavioral, methods are most suitable to the case. Turning to diagnostic discriminations involving the dependent personality, we find that confusions are made most often with the two personality patterns with which they frequently overlap--the histrionic and the avoidant. The key features differentiating the dependent from the histrionic are the passivity, submissiveness, self-effacement, and docility of the former--in contrast to the actively manipulative, gregarious, charming, and frequently seductive attention-getting behaviors of the latter. As far as differentiating avoidant from dependent personalities, the primary distinction relates to
matters of trust; both have strong needs for affection and nurturance, but the avoidant fears and strongly doubts the good faith of others, anticipating instead both rejection and humiliation, whereas the dependent is not only receptive to others and willing to rely on their goodwill but has learned to anticipate gratifying consequences when turning to them.
Occasional difficulties may arise in drawing the line between decompensated dependent personalities and personalities diagnosed in accord with DSM-III criteria as borderline types. The degree of overlap may be substantial, and further, if viewed longitudinally, borderline patients may be understood best as progressively impaired or deteriorated variants of other personality types, such as the dependent. Not only do the severe features of the borderline overlap and shade into personality types that are characteristically less impaired, but these features often reflect the insidious and progressive disintegration of formerly adaptive functions. For purposes of differential diagnosis it would appear most apt, where the collapse of coping and self- control has advanced significantly, to apply the label of borderline. However, it is the author's view that a double entry, including both borderline and dependen t diagnoses, would be more suitable and informative in that it would convey simultaneously the long-term and characteristic dependent style, and the more recent and decompensated level to which this style has regressed.
Few problems should be encountered when separating personality syndromes from disorders listed under Axis I. Given the fact that multiaxial diagnosis requires a listing of impairments from both Axis I and Axis II, the task should not be primarily that of differentiating between these two spheres but of finding which categories in the first axis covary with which categories in the second. Nevertheless, if the behaviors under scrutiny give evidence of having been lifelong, then they should be identified as representing a personality, rather than a symptom, disorder. Similarly, if the clinical features manifest themselves across a wide variety of settings and circumstances, rather than being limited to specific situations, then a personality diagnosis is again the likely correct one.
There are two Axis I syndromes that present more than the usual level of differential diagnostic difficulty with the dependent personality. The first of these potentially confusing classifications is "chronic depressive disorder"; the second is "agoraphobia." In the first of these syndromes, the problem centers on the so-called stability, or long-standing nature, of the Axis I category; chronic means enduring, that is, for an extended period of time. However, the descriptive criteria for this diagnosis focuses almost exclusively on the patient's depressed mood and fails to include the diverse clinical traits that comprise the dependent personality complex. Of course, the Axis I chronic depression disorder may be diagnosed as concurrent with the Axis II dependent personality.
As far as agoraphobia is concerned, the issue is essentially one of duration and pervasiveness of symptomatology. Quite typically, the symptoms of agoraphobics are situationally specific and arise episodically. Moreover, the
dependent's hesitations in assuming responsibility and autonomy take a passive form, whereas agoraphobics are insistent and demanding of the support of others. Additionally, the dependents' interpersonal submissiveness and feelings of inadequacy are characteristics that are not found in most patients who have an agoraphobic fear of being alone or in "unprotected" situations. Again, where appropriate, the simultaneous diagnosis of an agoraphobic Axis I disorder and a dependent Axis II personality is available to the clinician.