Dependent Personality Disorder (DPD) is a Cluster C personality disorder defined in DSM-5-TR by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation, beginning by early adulthood and present across contexts.^[1] Clinically, patients defer routine decisions to others, struggle to initiate projects independently, and tolerate mistreatment to preserve attachments, which drives presentation for comorbid depression, anxiety, and adjustment crises rather than for the personality pathology itself.^[1-2] Population prevalence is low (roughly 0.5-0.6% in U.S. community surveys), but rates rise substantially in clinical samples and in patients with mood and anxiety disorders.^[3] No medication is FDA-approved for DPD; evidence-based care is structured psychotherapy aimed at autonomy, assertiveness, and tolerance of being alone, with pharmacotherapy reserved for comorbid conditions.^[2,4] The bottom line: diagnose DPD only when dependency is pervasive, longstanding, and impairing beyond what any comorbid mood or anxiety disorder explains, and treat with psychotherapy first.

DPD is one of the less prevalent personality disorders in community samples but is overrepresented in psychiatric clinics, where it commonly co-travels with depressive and anxiety disorders.^[3,5]

Prevalence and demographics

• 12-month and lifetime prevalence in U.S. adults is approximately 0.5-0.6% based on NESARC and NESARC-III data.^[3]
• Prevalence in psychiatric outpatient samples is several-fold higher, with reported rates of 2-4% depending on instrument and setting.^[2,5]
• More frequently diagnosed in women than men in clinical samples, though epidemiologic surveys show smaller sex differences and the gap may partly reflect referral and diagnostic bias.^[1,3]
• Typical age of onset of recognizable traits is adolescence to early adulthood, with clinical presentation most often in the 20s-40s.^[1-2]

Comorbidity

• High comorbidity with major depressive disorder, persistent depressive disorder, and anxiety disorders, particularly social anxiety disorder and generalized anxiety disorder.^[2,5]
• Frequent overlap with other Cluster C disorders (avoidant, obsessive-compulsive) and with borderline personality disorder.^[1-2]
• Elevated risk of intimate partner violence victimization and tolerance of abusive relationships.^[2]

Risk factors

• Childhood chronic illness or separation anxiety disorder is associated with later dependent traits.^[2]
• Overprotective or authoritarian parenting styles are linked in retrospective studies, though causal inference is limited.^[2]
• Heritability estimates for dependent traits from twin studies are moderate (roughly 0.3-0.5), shared with broader Cluster C neuroticism dimensions.^[6]

No single neurobiological substrate explains DPD. Current models integrate temperamental, developmental, and cognitive contributions, with the strongest evidence for early attachment and learning factors.^[2,6]

Developmental and psychosocial

• Insecure (anxious-preoccupied) attachment in childhood is the most consistently described developmental correlate.^[2,5]
• Parental overprotection and authoritarianism may reinforce help-seeking and discourage autonomous problem-solving.^[2]
• Chronic childhood illness, by enforcing dependence on caregivers, is a recognized risk factor.^[2]

Cognitive model

• Core schemas center on perceived incompetence ("I cannot manage on my own") and need for a stronger other to function.^[7]
• Behavioral submission and help-seeking are negatively reinforced by anxiety relief, perpetuating the pattern.^[7]

Biological

• Twin studies place heritability of dependent traits in the moderate range, shared with general neuroticism and internalizing dimensions.^[2]
• No neuroimaging or neurotransmitter findings unique to DPD have been established; the biological literature is sparse and largely shared with anxiety and depressive disorders.^[2,4]

DSM-5-TR places DPD in the personality disorders chapter as a Cluster C condition characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts.^[1] Five or more of eight criteria are required.^[1]

DSM-5-TR criteria (paraphrased)

• Difficulty making everyday decisions without excessive advice and reassurance from others.^[1]
• Need for others to assume responsibility for most major areas of life.^[1]
• Difficulty expressing disagreement with others because of fear of loss of support or approval (excluding realistic fears of retribution).^[1]
• Difficulty initiating projects or doing things independently, reflecting a lack of self-confidence in judgment or abilities rather than lack of motivation or energy.^[1]
• Goes to excessive lengths to obtain nurturance and support, to the point of volunteering for unpleasant tasks.^[1]
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for oneself.^[1]
• Urgently seeks another relationship as a source of care and support when a close relationship ends.^[1]
• Unrealistically preoccupied with fears of being left to take care of oneself.^[1]

General personality disorder requirements also apply: the pattern is enduring, inflexible, pervasive across personal and social situations, causes clinically significant distress or impairment, traces to adolescence or early adulthood, and is not better explained by another mental disorder, a substance, or another medical condition.^[1]

ICD-11 considerations

• ICD-11 abandoned categorical personality disorder subtypes in favor of a single Personality Disorder diagnosis graded by severity (mild, moderate, severe) with optional trait-domain specifiers (negative affectivity, detachment, dissociality, disinhibition, anankastia) and an optional borderline pattern specifier.^[6]
• DPD-like presentations are captured under negative affectivity (dependency, separation insecurity) and personality difficulty rather than as a discrete diagnosis.^[6]

Patients with DPD rarely present asking for help with "dependency." The pattern surfaces as depression after a relationship loss, anxiety about an upcoming decision, or repeated tolerance of an exploitative partner.^[2]

Core presentation

• Pervasive submissiveness: agreeing with others to avoid conflict, deferring choices about job, residence, and social activities to a partner or parent.^[1-2]
• Marked help-seeking: repeated reassurance from clinicians, family, and friends; difficulty terminating sessions or making independent treatment decisions.^[2]
• Separation anxiety in adults: distress, panic, or depression triggered by anticipated or actual separation from an attachment figure.^[1-2]

Behavioral and interpersonal patterns

• Tolerating mistreatment, including emotional, physical, or financial abuse, to preserve attachments.^[2]
• Rapid replacement of lost relationships, sometimes with poorly chosen partners, to restore a caretaker.^[1]
• Difficulty disagreeing even on small matters; pseudo-agreement with the most recent authority figure.^[2]

Classic exam vignette: an adult who, after the end of a relationship, urgently seeks a new one specifically to obtain care and support, and who cannot initiate everyday projects without reassurance.^[1]

The differential is dominated by other Cluster C disorders, mood and anxiety disorders that produce state-dependent dependency, and cultural variation in deference norms.^[1-2] The diagnostic question is whether dependency is a longstanding personality trait or a feature of an episodic disorder.

Personality disorders

• Avoidant Personality Disorder: shares fear of rejection, but avoidant patients withdraw from relationships, whereas DPD patients cling to them.^[1]
• Borderline Personality Disorder: fear of abandonment is also central, but borderline features include identity disturbance, affective instability, and reactive anger; DPD patients respond to loss with submissive help-seeking rather than rage.^[1-2]
• Histrionic Personality Disorder: also seeks attention and reassurance, but histrionic presentation is flamboyant and attention-demanding rather than submissive.^[1]

Mood and anxiety disorders

• Major depressive disorder and persistent depressive disorder can produce state-dependent helplessness and indecisiveness that resolve with treatment; DPD criteria require the pattern to predate and persist beyond mood episodes.^[1-2]
• Generalized anxiety disorder and social anxiety disorder share reassurance-seeking and avoidance of independent action; the differential rests on pervasiveness across domains and on personality-disorder general criteria.^[1]
• Panic disorder with agoraphobia involves needing a companion outside the home; DPD dependence is broader and not limited to phobic situations.^[1]

Other conditions

• Separation anxiety disorder (now permitted in adults in DSM-5-TR) overlaps clinically; DPD is broader, with submissiveness extending beyond fear of separation from specific attachment figures.^[1]
• Medical and neurologic conditions causing dependency (dementia, late-stage Parkinson disease, severe chronic illness) must be excluded; the personality-disorder pattern requires longstanding traits dating to early adulthood.^[1]
• Cultural and developmental context: filial piety, prescribed female deference, or arranged-marriage norms can mimic DPD criteria; diagnose only when behavior is excessive for that context and produces distress or impairment.^[1]

Assessment requires longitudinal history, collateral information when feasible, and explicit screening for the comorbidities that usually drive the visit.^[2]

Interview approach

• Take a careful relationship and decision-making history: who decides where the patient lives, works, banks, parents; how are routine decisions made; what happens when an attachment figure is unavailable.^[1-2]
• Ask about responses to past relationship endings, tolerance of mistreatment, and patterns of urgent rebound relationships.^[1-2]
• Distinguish trait from state: clarify whether dependency predates the current mood or anxiety episode and persisted across prior euthymic periods.^[1-2]

Mandatory history elements

• Childhood attachment, separations, chronic illness, parenting style.^[2]
• Trauma history, including intimate-partner and family violence; explicit safety screening.^[2]
• Suicide risk, particularly around real or threatened separations.^[2]
• Comorbid mood, anxiety, eating, and substance use disorders.^[2]

Validated rating scales

• Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) for categorical diagnosis.^[2]
• International Personality Disorder Examination (IPDE) for ICD and DSM personality disorder assessment.^[2]
• Personality Inventory for DSM-5 (PID-5) for dimensional trait assessment, including submissiveness and separation insecurity facets.^[8]
• Millon Clinical Multiaxial Inventory-IV (MCMI-IV) includes a dependent scale, used clinically though less validated against ICD-11 dimensions.^[2]

Labs and imaging

• No labs or imaging diagnose DPD.^[1]
• Order targeted workup only to exclude medical or neurologic causes of acute dependency (e.g., TSH, B12, MMSE/MoCA in older adults with new cognitive complaints).^[2]

Psychotherapy is the cornerstone; no medication has demonstrated efficacy for the core DPD pattern, and pharmacotherapy targets comorbid mood, anxiety, or sleep disorders.^[2,4] The therapeutic challenge is that dependency replays inside the therapy itself: the patient may seek to be told what to do, miss appointments when the therapist is unavailable, or terminate prematurely when pushed toward autonomy.^[2,7]

Pharmacotherapy

• No medication is FDA-approved for DPD and no agent has shown specific efficacy for the personality pattern in controlled trials.^[2,4]
• Treat comorbid major depressive disorder, generalized anxiety disorder, social anxiety disorder, or panic disorder with first-line agents per the relevant indication, typically sertraline 50 mg PO QD titrated to effect or escitalopram 10 mg PO QD.^[2]
• Use benzodiazepines cautiously and time-limited; chronic use can reinforce help-seeking and risks dependence, particularly relevant in this population.^[2]
• Avoid polypharmacy aimed at "treating dependency"; high-quality evidence is lacking.^[2,4]

Psychotherapy

• Evidence specific to DPD is limited; most data come from mixed Cluster C samples and from clinical experience.^[4,9]
• Cognitive behavioral therapy (CBT) targets schemas of incompetence, builds problem-solving and assertiveness skills, and uses behavioral experiments to test the belief that the patient cannot manage alone; limited evidence suggests benefit in mixed Cluster C samples.^[7,9]
• Psychodynamic psychotherapy addresses transference-driven dependency, separation anxiety, and developmental antecedents; some experts recommend it as a primary modality, though high-quality comparative evidence is lacking.^[2,4]
• Group therapy can reduce isolation, expose the patient to peer feedback, and dilute dependency on a single therapist.^[2]
• Assertiveness training and skills-based modules are commonly used adjuncts; evidence is largely from analogue and case-series data.^[2,7]

Neuromodulation

• No role for ECT, rTMS, or other neuromodulation in DPD itself; consider only when a comorbid mood or psychotic disorder has an independent indication.^[2]

Adjunctive

• Couples or family therapy when dependency is enacted within a specific relationship and that system is willing to engage; useful particularly when intimate partner violence is identified.^[2]
• Case management and graded exposure to independent tasks (banking, transportation, scheduling) reinforce autonomy in patients with longstanding functional deficits.^[2]
• Routine screening and safety planning for intimate partner violence, given elevated victimization risk.^[2]

Most harms in DPD arise from the relational and therapeutic context rather than from medications. The evidence base is small and dominated by mixed Cluster C samples, limiting certainty about DPD-specific outcomes.^[4,9]

Adverse effects of treatment

• SSRIs used for comorbidity carry standard adverse effects (gastrointestinal upset, sexual dysfunction, transient activation, hyponatremia in older adults).^[2]
• Benzodiazepines risk dependence, falls, and cognitive impairment, and may reinforce help-seeking behavior in DPD.^[2]
• Open-ended supportive therapy without autonomy goals can entrench dependency and prolong impairment.^[2,7]

Relational and safety harms

• Tolerance of intimate partner violence and exploitation is a recognized harm of untreated DPD; screening and safety planning are essential.^[2]
• Premature termination, missed sessions when the therapist is unavailable, and excessive between-session contact are common boundary challenges.^[2]

Evidence limitations

• Few RCTs target DPD specifically; most personality-disorder psychotherapy trials pool Cluster C diagnoses.^[4,9]
• Studies are typically small, short, and from specialist centers, limiting generalizability.^[4,9]
• ICD-11's shift to a dimensional model complicates synthesis of categorical-diagnosis-era literature.^[6]

Cultural, developmental, and gender norms heavily shape what looks like dependency. Diagnosis requires that dependent behavior exceed cultural expectations and produce distress or impairment.^[1]

Pediatric and adolescent

• Personality disorder diagnosis under age 18 requires features present for at least one year, and DPD specifically should not be diagnosed before adulthood except in unusual cases.^[1]
• Persistent dependency in adolescents more often reflects separation anxiety disorder, autism spectrum disorder, or attachment-related presentations than emerging DPD.^[1-2]

Geriatric

• New-onset dependency in older adults should prompt evaluation for neurocognitive disorder, depression, medical frailty, or elder abuse before considering personality pathology.^[2]
• Age-appropriate need for assistance with instrumental activities does not constitute DPD; the diagnosis requires the longstanding pattern documented before functional decline.^[1]

Perinatal and women's health

• DPD is diagnosed more frequently in women in clinical samples, though community prevalence differences are smaller; clinicians should guard against gender bias in applying criteria.^[3,5]
• Pregnancy and the postpartum period can intensify dependency features; comorbid perinatal depression and anxiety should be treated concurrently.^[2]

Cultural considerations

• Sociocentric cultures value interdependence and deference to family or elders; these behaviors are not pathological absent personal distress or impairment.^[1]
• Diagnosis should be calibrated to the patient's reference group, with collateral history from family or community informants where appropriate.^[1-2]

Comorbid medical illness

• Chronic medical illness can produce realistic dependency; the DPD diagnosis requires the pattern to predate or extend beyond what the illness accounts for.^[1]
• Comorbid substance use disorders are common and worsen prognosis; integrated treatment is preferred.^[2,5]

DPD tends to be chronic but is among the more treatment-responsive personality disorders, particularly when comorbid mood or anxiety disorders are addressed concurrently.^[2,4]

Natural history

• Onset is by early adulthood by definition; features often emerge from childhood temperament and attachment patterns.^[1]
• Longitudinal data on Cluster C disorders suggest meaningful symptomatic improvement over years, though core interpersonal patterns are more persistent.^[2,4]

Response to treatment

• Limited RCT evidence and broader Cluster C data suggest that structured psychotherapy produces clinically meaningful improvement in dependency, assertiveness, and global functioning.^[4,9]
• Concurrent treatment of comorbid major depressive disorder, generalized anxiety disorder, or panic disorder is associated with better personality-disorder outcomes.^[2]

Functional outcome

• Untreated DPD is associated with relationship dysfunction, tolerance of partner violence and exploitation, occupational underachievement, and recurrent depressive episodes.^[2-3,5]
• Suicide risk is elevated relative to the general population, mediated largely by comorbid mood disorders, substance use, and relationship loss.^[2,5]

DPD itself rarely drives emergency presentations, but the interpersonal pattern shapes how mood, anxiety, and relationship crises present in the emergency department.^[2]

Suicide risk markers

• Acute risk rises sharply around real or threatened loss of a primary attachment figure: breakup, separation, death of a caregiver.^[2,5]
• Comorbid major depression, alcohol use, and recent self-harm carry the same weight as in any patient and should drive disposition.^[2]

Intimate partner violence

• Screen routinely; patients with DPD are at elevated risk of tolerating ongoing abuse to preserve the relationship.^[2,5]
• Safety planning should be concrete and involve community resources; avoid pressuring the patient to leave a relationship before they are ready, which often backfires.^[2]

Hospitalization criteria

• Inpatient admission is reserved for acute suicidality, severe comorbid depression, or inability to maintain basic self-care, not for chronic dependency itself.^[2]
• WARNING: Prolonged hospitalization can reinforce dependent behaviors and undermine outpatient treatment; admissions should be brief, goal-directed, and linked to a clear outpatient plan.^[2]

Agitation and crisis behavior

• Crises typically present as distress and clinging rather than aggression; standard de-escalation and brief problem-focused intervention usually suffice.^[2]
• Avoid creating new dependency on the emergency clinician or service; explicitly hand off to the longitudinal treatment team.^[2]

DPD sits at the center of several long-running debates about whether the category captures a coherent disorder or culturally and developmentally normative variation.

Validity of the category

• Some authors argue DPD lacks discriminant validity from avoidant personality disorder and from chronic anxiety and depressive disorders, given high comorbidity and overlapping features.^[3,5]
• Others counter that the dependency dimension (helplessness, submissiveness, attachment to a specific other) is empirically separable from avoidance (fear of negative evaluation, social inhibition).^[2,5]

Gender bias

• Higher diagnosis rates in women raise concern that gender-stereotyped behavior is being pathologized; structured interviews reduce but do not eliminate the gap.^[3,5]
• Clinicians should apply the impairment threshold rigorously and seek collateral information before assigning the diagnosis.^[1]

Categorical versus dimensional models

• DSM-5-TR Section II retains the categorical diagnosis; the Alternative Model for Personality Disorders (Section III) and ICD-11 frame personality pathology dimensionally.^[1,6]
• The dimensional shift complicates literature synthesis and may eventually replace DPD as a stand-alone category in routine practice.^[1,6]

Treatment evidence gaps

• No medication is FDA-approved for DPD; pharmacotherapy targets comorbid conditions only.^[2,4]
• Psychotherapy recommendations rest largely on Cluster C and personality-disorder-general trials rather than DPD-specific RCTs; high-quality DPD-specific evidence is limited.^[4,9]

• DPD is a Cluster C (anxious-fearful) personality disorder defined by a pervasive need to be taken care of, with onset by early adulthood and presence across contexts.^[1]
• DSM-5-TR requires at least five of eight criteria, including difficulty making everyday decisions without reassurance and urgent seeking of a new relationship when one ends.^[1]
• Community prevalence is approximately 0.5-0.6% in U.S. surveys; rates are higher in clinical samples and in patients with mood and anxiety disorders.^[3]
• DPD is diagnosed more often in women in clinical samples, though community sex differences are smaller and gender bias likely contributes.^[3,5]
• Avoidant personality disorder shares Cluster C anxiety but is driven by fear of negative evaluation, not by need for caretaking; the two frequently co-occur.^[1-2]
• Separation anxiety disorder focuses on attachment to specific figures and can have adult onset; DPD is a broader dependency pattern across relationships.^[1]
• Borderline personality disorder also fears abandonment but features identity disturbance, affective instability, and impulsivity absent in DPD.^[1]
• First-line treatment is structured psychotherapy targeting autonomy and assertiveness; no medication is FDA-approved for DPD.^[2,4]
• Pharmacotherapy is reserved for comorbid major depressive disorder, generalized anxiety disorder, or panic disorder; benzodiazepines should be avoided long-term given reinforcement of dependency.^[2,4]
• Patients with DPD are at elevated risk of tolerating intimate partner violence; routine screening and concrete safety planning are required.^[2,5]
• Acute suicide risk rises around loss of a primary attachment figure; comorbid depression and substance use carry the main risk weight.^[2,5]
• The Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) is the reference standard for research-grade diagnosis.^[2]
• Cultural and developmental norms must be considered before diagnosis; sociocentric cultures normatively value interdependence.^[1]
• Prolonged inpatient hospitalization can reinforce dependent behavior and should be avoided absent acute safety indications.^[2]

No external funding. No conflicts of interest declared. Peer-review status: pending.