Personality Disorders 615
of the two disorders overlap (Chambless, Fydrich, &
Rodebaugh, 2008; Tillfors et al., 2004). However, the
criteria for avoidant personality disorder are broader
than those for social phobia, and the symptoms include
a more pervasive sense of inadequacy or inferiority and a
reluctance to take risks (Skodol, 2005), as was true of
Marcus in Case 13.9.
When making the diagnosis of avoidant personal-ity disorder, clinicians must take cultural factors into
account (American Psychiatric Association, 2000). For
example, recent immigrants may exhibit symptoms of
this disorder, perhaps because of language barriers or
concerns about safety, and so clinicians must be sure
to ask whether the behavior predates immigration.
Similarly, ethnic and religious groups have different
norms about appropriate levels of social contact and
avoidance, and so clinicians should ascertain whether
social norms, and not a true fear of social contact, drive the behaviors. For example,
among deeply observant Muslims, the norm is for women to shun social contact
with men who are not family members, and such behavior by a woman in this group
should not be taken to indicate avoidant personality disorder. Because the three fear-
ful/anxious personality disorders have not been studied in depth, we will discuss the
underlying bases for and treatment of all three disorders after we consider specifi c
features of each of them separately.
Dependent Personality Disorder
Dependent personality disorder is characterized by submissive and clingy behav-
iors, based on fear of separation. The DSM-IV-TR defi nition notes that the clingy
behaviors are intended to elicit attention, reassurance, and decisive behaviors from
other people (American Psychiatric Association, 2000). These behaviors are not a
temporary bid for attention or reassurance (like the behaviors of those with border-
line or histrionic personality disorder), but are part of a chronic pattern of helpless
behavior.
What Is Dependent Personality Disorder?
People with dependent personality disorder are
chronically plagued by self-doubt and consistently
underestimate their abilities (see Table 13.23 for the
list of diagnostic criteria). Thus, they have a hard
time making all kinds of decisions, from life-altering
ones about what career to pursue to mundane deci-
sions about what clothes to wear. They prefer to
have other people make such choices for them. And
because they are so quick to believe they are wrong,
they are likely to see any criticism or disapproval as
proof of their basic negative beliefs about themselves.
People with dependent personality disorder oftendon’t learn the skills needed to function independently
and so are, in fact, dependent on others; they have
reason to be concerned about living on their own.
When a relationship ends, they typically leap into an-
other one in order to ensure that they are not alone.
Even while in an intimate relationship, they are often
preoccupied with the possibility that the relationship
will end and they will have to fend for themselves.
Individuals with dependent personality disorder are
Symptoms of avoidant personality disorder and
social phobia overlap, and people with either
disorder are excessively concerned about being
rejected by others or behaving in a way that leads
them to feel humiliated. However, the social diffi -
culties and feelings of inadequacy of people with
avoidant personality disorder are generally more
pervasive than those of people with the Axis I dis-
order, and can make meetings like this extremely
uncomfortable or even impossible.Patrick Ryan/Getty ImagesTable 13.23 • DSM-IV-TR Diagnostic Criteria for
Dependent Personality DisorderA pervasive and excessive need to be taken care of that leads to submissive and
clinging behavior and fears of separation, beginning by early adulthood and present
in a variety of contexts, as indicated by fi ve (or more) of the following:
(1) has diffi culty making everyday decisions without an excessive amount of advice
and reassurance from others.
(2) needs others to assume responsibility for most major areas of his or her life.
(3) has diffi culty expressing disagreement with others because of fear of loss of
support or approval. Note: Do not include realistic fears of retribution.
(4) has diffi culty initiating projects or doing things on his or her own (because of a
lack of self-confi dence in judgment or abilities rather than a lack of motivation
or energy).
(5) goes to excessive lengths to obtain nurturance and support from others, to the
point of volunteering to do things that are unpleasant.
(6) feels uncomfortable or helpless when alone because of exaggerated fears of
being unable to care for himself or herself.
(7) urgently seeks another relationship as a source of care and support when a close
relationship ends.
(8) is unrealistically preoccupied with fears of being left to take care of himself
or herself
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Text Revision, Fourth Edition, (Copyright 2000) American Psychiatric Association.