Discussion: Scholarly article review guideline

An Examination of Dependent Personality Disorder in the Alternative DSM-5 Model for Personality Disorders

Andrew S. McClintock1,2 & Shannon M. McCarrick1

Published online: 5 August 2017 # Springer Science+Business Media, LLC 2017

Abstract Although the diagnosis of dependent personality disorder (DPD) has demonstrated construct validity and clin- ical utility, little is known about how best to model DPD in the DSM-5’s new, alternative model for diagnosing personality disorders. The current research aimed to represent DPD using the 25 pathological personality traits of the alternative model. Self-report measures of the 25 pathological personality traits, DPD, avoidant personality disorder, borderline personality disorder, and maladaptive interpersonal dependency were ad- ministered to an undergraduate sample (N = 194). Results indicated that— as consistent with extant theory— anxious- ness, submissiveness, and separation insecurity were the three traits most strongly related to DPD symptoms. As a group, anxiousness, submissiveness, and separation inse- curity were more strongly related to DPD symptoms (r = 0.55) than were the remaining 22 personality traits (r = 0.34). This group of three traits was strongly asso- ciated, however, with avoidant personality disorder symptoms (r = 0.55), suggesting that additional scrutiny of DPD and avoidant personality disorder in the alter- native model may be needed. Limitations and directions for future research are presented.

Keywords Dependent personality disorder . Avoidant personality disorder . DSM . Alternative model

In light of frequent criticism of the personality disorder diag- nostic system in the DSM-IV (American Psychiatric Association 2000; for criticisms, see Widiger et al. 2009), the Personality and Personality Disorders Work Group pro- posed a novel approach to the diagnosis of personality disor- ders. This approach, titled the alternative DSM model for per- sonality disorders (AMPD), was not accepted as the official diagnostic system for the DSM-5 (American Psychiatric Association 2013) but rather was published in DSM- 5’s Section III (Bemerging measures and models^ p. 729). If the AMPD holds up to empirical scrutiny, and even outperforms established diagnostic criteria, then the AMPD may become the official system in future edi- tions of the DSM (Few et al. 2013).

In contrast to previous models, the AMPD is a dimensional trait model that represents personality disorders as combina- tions of core personality-related impairments and various con- figurations of 25 pathological personality traits (American Psychiatric Association 2013; Krueger et al. 2012; Morey and Skodol 2013; Skodol 2012). The pathological personality traits are organized into five higher-order domains (i.e., nega- tive affect, detachment, antagonism, disinhibition, and psychoticism) that align with the extensively validated five-factor model of general personality (McCrae and Costa 2003; see Gore and Widiger 2015). That is, the AMPD models personality disorders as extreme, mal- adaptive variants of the same traits that describe normal personality (Samuel et al. 2013).

Four personality disorders were excluded from the AMPD: paranoid personality disorder, schizoid personality disorder, histrionic personality disorder, and— as most relevant to the

* Andrew S. McClintock [email protected]

Shannon M. McCarrick [email protected]

1 Department of Psychology, Ohio University, 264 Porter Hall, Athens, OH 45701, USA

2 Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

J Psychopathol Behav Assess (2017) 39:635–641 DOI 10.1007/s10862-017-9621-y

current research— dependent personality disorder (DPD). According to developers of the AMPD (Skodol 2012), DPD was excluded because of lower prevalence estimates, relative- ly weak associations with functional impairment, and little evidence for discriminant validity. Consequently, individuals who exhibit the signs of DPD would be diagnosed in the AMPD as personality disorder- trait specified and would be described with the three pathological traits of anxiousness, submissiveness, and separation insecurity (American Psychiatric Association 2013; Skodol et al. 2011).

Some scholars, however, have disputed the decision to ex- clude DPD from the AMPD. Bornstein (2011) noted, for in- stance, that DPD prevalence rates are comparable to the prev- alence rates of personality disorders included in the AMPD. There is also evidence that the DPD diagnosis is clinically useful, as DPD symptoms are associated with suicidality, part- ner and child abuse, important elements of treatment process and outcome, and high levels of functional impairment (Bornstein 2012a, b). Indeed, Soeteman et al. (2008) reported that health care costs associated with DPD were higher than the costs associated with obsessive-compulsive, antisocial, and avoidant personality disorders (all included in the AMPD). Furthermore, although DPD overlaps with other per- sonality disorders, particularly avoidant personality disorder and borderline personality disorder (Bastiaansen et al. 2012; Disney 2013; Miller et al. 2015), DPD seems to have comor- bidity rates that are similar to those of personality disorders included in the AMPD (Bornstein 2011, 2012a, b; Disney 2013; Zimmermann et al. 2005).

Because DPD might be at least as valid and clinically useful as personality disorders retained in the AMPD (Bornstein 2011), empirical research is needed to model DPD with AMPD’s pathological personality traits. While theory impli- cates three pathological traits in DPD (i.e., anxiousness, submissiveness, and separation insecurity; Skodol et al. 2011), empirical support for this configuration is mixed. Bornstein (2011) astutely noted that much of the research in this area focuses on personality disorders retained in the AMPD, and thus the evidence base for these personality disorders tends to be larger than the evidence base for excluded personality disor- ders (e.g., DPD). Nevertheless, the data that do exist suggest that anxiousness and separation insecurity are integral to DPD (Anderson et al. 2014; Bornstein 2012b; Hopwood et al. 2012; Morey et al. 2016; Gore and Widiger 2015), whereas submis- siveness may (Bach et al. 2016a, b; Gore and Widiger 2015; Morey et al. 2016; Smith et al. 2009) or may not (Anderson et al. 2014; Bornstein 2012b; Fossati et al. 2013) be integral to DPD. Bornstein (2012b) reported that individuals with DPD can be quite assertive in certain contexts (e.g., when important relationships are threatened), and thus submissiveness should not be regarded as a core trait of DPD.

Even if the Personality and Personality Disorders Work Group is correct in their assertion that DPD is best

characterized by anxiousness, submissiveness, and separation insecurity (Skodol et al. 2011), it remains to be seen if this configuration is distinct from the configurations of other per- sonality disorders. There is evidence that anxiousness, sub- missiveness, and/or separation insecurity are elevated in avoidant personality disorder (APD) and borderline personal- ity disorder (BPD) (Anderson et al. 2014; Disney 2013; Fossati et al. 2013; Gude et al. 2004, 2006; Hopwood et al. 2012; Leising et al. 2006; Morey et al. 2016; Yam and Simms 2014), suggesting that the proposed configuration of DPD may lack discriminant validity.

The present research aimed to model DPD using AMPD’s pathological personality traits and to determine if this config- uration of personality traits is distinct from the configurations of APD and BPD. APD and BPD were selected because, of all 10 personality disorders, these two seem to be most strongly related to DPD (Bastiaansen et al. 2012; Disney 2013; Miller et al. 2015). In addition to the DPD measure, we included a measure of maladaptive interpersonal dependency to compare the DPD configu- ration with the maladaptive dependency configuration.

Method

Participants

Participants in the present study were 200 undergraduates at a large Midwestern university who received course credit for their participation. Six students were excluded for invalid responding, resulting in a final sample of 194 participants. The majority identified as female (66.0%), heterosexual (84.0%), and never married (98.5%). In addition, 84.0% of participants identified as Caucasian, 4.6% identified as African American, 3.6% identified as Asian American, 3.6% identified as Hispanic, 3.6% identified as multiracial, and 0.5% identified as American Indian. Participants had a mean age of 18.7 years (SD = 2.9).

Measures

The Personality Inventory for DSM-5 (PID-5; Krueger et al. 2012) is a 220-item, self-report questionnaire that assesses the 25 pathological personality traits (and five higher-order do- mains) of the AMPD. This measure asks participants to rate statements on a 4-point Likert scale from 0 (very false or often false) to 3 (very true or often true). A sample item is BI usually do things on impulse without thinking about what might hap- pen as a result.^ The PID-5 has demonstrated construct valid- ity, convergent validity, and discriminant validity in past re- search (e.g., Quilty et al. 2013; Wright et al. 2012). In the current research, the PID-5 scales exhibited acceptable to

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good levels of internal consistency (Cronbach αs ranged from 0.75 [PID-5-Grandiosity] to 0.96 [PID-5-Eccentricity]).

The Personality Diagnostic Questionnaire 4+ (PDQ-4+; Hyler 1994) is a 99-item, self-report instrument used to screen for each of the DSM-IV personality disorders. In the present study, only the DPD (8 items), APD (7 items), and BPD (9 items) scales were administered. All items use a true-false response format. Representative items for each scale include BI prefer that other people assume responsibility for me,^ (DPD), BI avoid working with others who may criticize me,^ (APD), and BI’ll go to extremes to prevent those who I love from ever leaving me^ (BPD). In the present study, we chose to measure symptoms dimensionally as opposed to assessing personality disorders categorically, as dimensional scales tend to be more reliable and valid (Hopwood et al. 2012; Markon et al. 2011). Because PDQ-4+ response options are binary (i.e., true/false), we calculated Kuder-Richardson 20 coeffi- cients for the PDQ-4 + −DPD (0.58), PDQ-4 + −APD (0.71), and PDQ-4 + −BPD (0.54).

The Relationship Profile Test (RPT; Bornstein et al. 2003) is a 30-item, self-report measure of three interpersonal styles: healthy dependency, detachment, and overdependence. In the present study, only the Destructive Overdependence (DO) subscale (10 items) was administered. Each item is rated on a 7-point scale, ranging from 1 (not at all true of me) to 7 (very true of me). A representative item from the DO subscale is, BBeing responsible for things makes me nervous.^ The items were constructed based on the dependency literature and aim to assess the cognitive, emotional, motivational, and behav- ioral features of maladaptive dependency (Bornstein et al. 2003). The RPT has exhibited good construct validity in prior research (Bornstein et al. 2003; Haggerty et al. 2010). In the current study, the RPT-DO had acceptable internal consisten- cy (Cronbach α= 0.89).

Procedure

This study was conducted at a large Midwestern university during the 2015–2016 academic year. IRB approval was ob- tained, and all ethical standards were followed. Participants

completed the above measures online in partial fulfillment of research requirements for psychology courses.

Plan of Analysis

Correlational analyses were first employed to assess the rela- tionships between DPD, APD, BPD, and maladaptive inter- personal dependency. Next, correlations were used to deter- mine how DPD, APD, BPD, and maladaptive dependency are related to the 25 pathological personality traits. Given the large number of analyses, coupled with our goal of identifying the core traits of these conditions, we regarded correlations > .40 (and p values < .001) as meaningful (see Hopwood et al. 2012). Finally, we used correlations to examine the relation- ships between personality disorder symptoms, proposed trait configurations, and the remaining non-proposed traits. For these analyses, the following variables were created: DPD Proposed Traits (M of anxiousness, submissiveness, and sep- aration insecurity), DPD Non-Proposed Traits (M of 23 traits; all but anxiousness, submissiveness, and separation insecuri- ty), APD Proposed Traits (M of anhedonia, anxiousness, inti- macy avoidance, and withdrawal), APD Non-Proposed Traits (M of 21 traits; all but anhedonia, anxiousness, intimacy avoidance, and withdrawal),

BPD Proposed Traits (M of anxiousness, depressivity, emotional lability, hostility, impulsivity, risk taking, separa- tion insecurity), BPD Non-Proposed Traits (M of 18 traits; all but anxiousness, depressivity, emotional lability, hostility, impulsivity, risk taking, separation insecurity). For each per- sonality disorder (DPD, APD, BPD), we evaluated whether the correlation of the personality disorder and the proposed configuration is significantly larger than the correlation of the personality disorder and the non-proposed traits.

Results

Correlations between PDQ-4 + −DPD, PDQ-4 + −APD, PDQ-4 + −BPD, and RPT-DO are presented in Table 1. Of note, PDQ-4 + −DPD was highly correlated with PDQ-4 + −APD (r = 0.56) and PDQ-4 + −BPD (r = 0.50). Surprisingly,

Table 1 Correlations between measures of DPD, APD, BPD, and maladaptive dependency (N = 194)

M (SD) PDQ-4 + − DPD PDQ-4 + − APD PDQ-4 + − BPD RPT- DO

PDQ-4 + −DPD 1.55 (1.56) − .56* .50* .56* PDQ-4 + −APD 2.61 (2.00) − .47* .63* PDQ-4 + −BPD 2.73 (1.80) − .32* RPT-DO 26.77 (8.14) −

PDQ-4+ Personality Diagnostic Questionnaire 4+, DPD Dependent Personality Disorder, APD Avoidant Personality Disorder, BPD Borderline Personality Disorder, RPT-DO Relationship Profile Test-Destructive Overdependence

*p < .001

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RPT-DO was at least as strongly related to the PDQ-4 + −APD (r = 0.63) as it was to PDQ-4 + −DPD (r = 0.56).

Correlations of PDQ-4 + −DPD, PDQ-4 + −APD, PDQ- 4 + −BPD, and RPT-DO with PID-5 traits/domains are pre- sented in Table 2. The three PID-5 scales most strongly cor- related with PDQ-4 + −DPD were PID-5-Anxiousness, (r = 0.41), PID-5-Submissiveness (r = 0.42), and PID-5- Separation Insecurity (r = 0.52). This configuration was gen- erally replicated with RPT-DO, as PID-5-Anxiousness and PID-5-Submissiveness were the two scales most strongly

correlated with RPT-DO, and PID-5-Separation Insecurity was the fifth scale most strongly correlated with RPT-DO. Importantly, PID-5-Anxiousness, PID-5-Submissiveness, and PID-5-Separation Insecurity were also strongly correlated with PDQ-4 + −APD (all rs > 0.40).

Next, correlations were conducted to examine the relation- ships between personality disorder symptoms, proposed trait configurations, and the remaining non-proposed traits (see Table 3). The proposed configuration of DPD (i.e., PID-5- Anxiousness, PID-5-Submissiveness, and PID-5-Separation

Table 2 Correlations between PID-5 traits/domains and measures of DPD, APD, BPD, and maladaptive dependency (N = 194)

M (SD) PDQ-4 + − DPD

PDQ-4 + − APD

PDQ-4 + − BPD

RPT- DO

PID-5 Traits

Emotional Lability 0.98 (0.70) .39 .44 .58 .44

Anxiousness 1.45 (0.72) .41 .49 .46 .54

Separation Insecurity 0.84 (0.65) .52 .41 .36 .42

Submissiveness 1.03 (0.70) .42 .46 .32 .57

Hostility 0.91 (0.52) .26 .24 .55 .12

Perseveration 0.86 (0.59) .36 .32 .46 .36

Depressivity 0.59 (0.61) .36 .48 .56 .38

Suspiciousness 1.03 (0.45) .29 .34 .47 .18

Restricted Affectivity 0.89 (0.66) .07 .07 .10 −.06 Withdrawal 0.79 (0.59) .21 .42 .40 .26

Intimacy Avoidance 0.68 (0.64) .09 .15 .23 .10

Anhedonia 0.85 (0.61) .29 .41 .50 .27

Manipulativeness 0.85 (0.66) .11 −.02 .22 −.10 Deceitfulness 0.67 (0.56) .23 .14 .33 .08

Grandiosity 0.63 (0.54) .16 −.07 .15 −.05 Attention Seeking 0.93 (0.64) .23 .06 .23 .11

Callousness 0.50 (0.49) .12 −.04 .29 .16 Irresponsibility 0.53 (0.51) .35 .24 .43 .22

Impulsivity 0.83 (0.62) .18 .07 .34 .08

Distractibility 1.03 (0.66) .38 .39 .47 .44

Risk Taking 1.43 (0.50) −.14 −.23 .01 −.29 Rigid Perfectionism 1.01 (0.66) .19 .15 .22 .11

Unusual Beliefs & Experiences

0.68 (0.59) .18 .13 .32 .12

Eccentricity 0.93 (0.76) .22 .15 .37 .23

Perceptual Dysregulation 0.64 (0.53) .33 .28 .47 .28

PID-5 Domains

Negative Affect 1.09 (0.58) .52 .53 .56 .56

Detachment 0.77 (0.50) .24 .40 .47 .26

Antagonism 0.72 (0.51) .19 .02 .27 −.03 Disinhibition 0.80 (0.49) .37 .29 .50 .31

Psychoticism 0.75 (0.56) .26 .20 .42 .24

Traits that are used to describe each personality disorder in the alternative model are bolded. Correlations >0.4 were regarded as meaningful

PID-5 Personality Inventory for DSM-5, PDQ-4+ Personality Diagnostic Questionnaire 4+, DPD Dependent Personality Disorder, APD Avoidant Personality Disorder, BPD Borderline Personality Disorder, RPT-DO Relationship Profile Test-Destructive Overdependence

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Insecurity) accounted for 30% of the variability in PDQ-4 + −DPD scores (r = 0.55). The non-proposed traits (i.e., all but PID-5-Anxiousness, PID-5-Submissiveness, and PID-5- Separation Insecurity) collectively accounted for 12% of the variability in PDQ-4 + −DPD scores (r = 0.34). These corre- lation coefficients were significantly different (p < 0.05). Of note, the proposed configuration of DPD was as strongly re- lated to PDQ-4 + −APD (r = 0.55) as it was to PDQ-4 + −DPD (r = 0.55).

The proposed configuration of APD (i.e., PID-5-Anhedonia, PID-5-Anxiousness, PID-5-Intimacy Avoidance, and PID-5- Withdrawal) accounted for 25% of the variability in PDQ- 4 + −APD scores (r = 0.50). The non-proposed traits (i.e., all but PID-5-Anhedonia, PID-5-Anxiousness, PID-5-Intimacy Avoidance, and PID-5-Withdrawal) collectively accounted for 9% of the variability in PDQ-4 + −APD scores (r = 0.30). These correlation coefficients were significantly different (p < 0.05).

The proposed configuration of BPD (i.e., PID-5- Anxiousness, PID-5-Depressivity, PID-5-Emotional Lability, PID-5-Hostility, PID-5-Impulsivity, PID-5-Risk Taking, and PID-5-Separation Insecurity) accounted for 40% of the variability in PDQ-4 + −BPD scores (r = 0.63). The non-proposed traits (i.e., all but PID-5- Anxiousness, PID-5-Depressivity, PID-5-Emotional Lability, PID-5-Hostility, PID-5-Impulsivity, PID-5-Risk Taking, and PID-5-Separation Insecurity) collectively accounted for 27% of the variability in in PDQ-4 + −BPD scores (r = 0.52). These correlation coefficients were not significantly different.

Discussion

We found that— of all personality traits included in the AMPD— anxiousness, submissiveness, and separation inse- curity were most strongly associated with DPD symptoms. These are the same traits used to describe DPD symptomatol- ogy in the current edition of the AMPD (e.g., see Skodol et al. 2011). Past research has consistently linked anxiousness and separation insecurity to DPD symptoms (Anderson et al. 2014; Hopwood et al. 2012; Morey et al. 2016; Gore and Widiger 2015), though the link between submissiveness and DPD symptoms has received somewhat mixed results (Anderson et al. 2014; Bornstein 2012b; Fossati et al. 2013; Gore and Widiger 2015; Leising et al. 2006; Morey et al. 2016; Smith et al. 2009).

Correlation analyses revealed that anxiousness, submis- siveness, and separation insecurity collectively accounted for 30% of the variability in DPD symptoms, which is compara- ble to figs. (28–36%) reported in prior research (Anderson et al. 2014; Few et al. 2013). We also found that DPD symp- toms were more strongly related to anxiousness, submissive- ness, and separation insecurity as a group (r = 0.55) than to the remaining 22 personality traits (r = 0.34). Taken together, these results suggest that DPD can be well-modeled with anx- iousness, submissiveness, and separation insecurity (see Skodol et al. 2011).

Substantial overlap was observed, however, between DPD and APD. Specifically, APD was strongly associated with both DPD (r = 0.56) and maladaptive interpersonal dependen- cy (r = 0.63). Furthermore, and as consistent with extant

Table 3 Correlations (N = 194) between DPD, APD, BPD, proposed traits, and non-proposed traits (N = 194)

1 2 3 4 5 6 7 8 9

PDQ-4 + −DPD (1) – 0.55 0.34 0.56 0.35 0.39 0.50 0.45 0.31 DPD Proposed Traits (2) – 0.56 0.55 0.64 0.64 0.47 0.78 0.52

DPD Non-Proposed Traits (3) – 0.29 0.76 0.99 0.53 0.84 0.89

PDQ-4 + −APD (4) – 0.50 0.30 0.47 0.44 0.40 APD Proposed Traits (5) – 0.69 0.55 0.71 0.92

APD Non-Proposed Traits (6) – 0.53 0.88 0.83

PDQ-4 + −BPD (7) – 0.63 0.52 APD Proposed Traits (8) – 0.70

APD Non-Proposed Traits (9) –

DPD Proposed Traits (anxiousness, submissiveness, and separation insecurity), DPD Non-Proposed Traits (23 traits; all but anxiousness, submissiveness, and separation insecurity). APD Proposed Traits (anhedonia, anxious- ness, intimacy avoidance, and withdrawal), APD Non-Proposed Traits (21 traits; all but anhedonia, anxiousness, intimacy avoidance, and withdrawal). BPD Proposed Traits (anxiousness, depressivity, emotional lability, hostil- ity, impulsivity, risk taking, separation insecurity), BPD Non-Proposed Traits (18 traits; all but anxiousness, depressivity, emotional lability, hostility, impulsivity, risk taking, separation insecurity). All correlations coeffi- cients were significant at p < 0.001. Bold values indicate a significant difference between correlation coefficients for the proposed and non-proposed traits for that personality disorder

PDQ-4+ Personality Diagnostic Questionnaire 4+, DPD Dependent Personality Disorder, APD Avoidant Personality Disorder, BPD Borderline Personality Disorder

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literature (e.g., Anderson et al. 2014; Hopwood et al. 2012; Morey et al. 2016), APD symptoms were strongly correlated (all rs > 0.40) with the traits representing DPD (i.e., anxious- ness, submissiveness, and separation insecurity), and these correlations were as strong or stronger than the correlations between APD symptoms and the APD’s proposed traits (i.e., anhedonia, anxiousness, intimacy avoidance, and withdraw- al). It stands to reason, from these results, that anxiousness, submissiveness, and separation insecurity may be integral to both DPD and APD.

For decades, scholars have expressed doubt about whether DPD and APD are truly distinct (Grant et al. 2005; Trull et al. 1987). Large correlations (e.g., r = 0.66) have been documented between DPD and APD symptoms, regardless of whether symptoms are assessed via self-report (Bachrach et al. 2012) or struc- tured interview (Leising et al. 2006). In a large, nationally representative survey of the U.S. population, Grant et al. (2005) found that the comorbidity of DPD and APD was exceedingly high (odds ratio = 118.6). The high degree of overlap between DPD and APD raises concerns about their validity as independent disorders (Disney 2013). On the other hand, we found that detachment was corre- lated with APD symptoms at 0.40 and DPD symptoms at 0.24, which may suggest that while DPD and APD are highly similar in the negative affect domain (i.e., anxious- ness, submissiveness, and separation insecurity), APD may include additional features belonging to the detach- ment domain (e.g., withdrawal and anhedonia). This in- terpretation should be regarded as speculative; future re- search is needed to examine how and to what degree DPD and APD are distinct.

This research has several shortcomings. The use of a non- clinical (undergraduate) sample, comprised mostly of young, White females, limits the generalizability of our results to clinical populations, males, people of color, and members of other age groups. Additionally, our reliance on self-report data may have led to shared method variance, potentially inflating the size of the associations. This concern is somewhat miti- gated by our focus on correlations >0.40. Nevertheless, given that some participants may have been unaware of their own behavior and symptoms, future research should attempt to replicate these findings with structured interviews and informant-based assessments (e.g., see Bach et al. 2016b).

In sum, the present research corroborates the idea that DPD can be well-modeled with anxiousness, submissiveness, and separation insecurity in the AMPD. At the same time, each of these traits was robustly associated with APD symptoms, sug- gesting that additional work is needed to understand the dis- tinction between DPD and APD in the AMPD. We are hopeful that the current study will spur efforts to verify DPD and APD and to determine how these diagnoses best fit into our ever- evolving diagnostic systems.

Compliance with Ethical Standards

Funding This study was not funded.

Ethical Approval All procedures performed in studies involving hu- man participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained from all individual participants included in the study.

Conflict of Interest Andrew S. McClintock and Shannon M. McCarrick declare that they have no conflict of interest.

Experiment Participants This study received approval by the university's Institutional Review Board.

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