Ah, Hell, I'm a Walking DSM

I was going to make this into 3 posts, but when I Copy/Paste it doesn’t keep all the formatting changes I made!! There is a section for Avoidant Personality Disorder, Dependent Personality Disorder, and Depressive Personality Disorder (in that order). All the red or black text is from Wikipedia. All the red text are descriptions or feelings I identify with and the blue words are my comments. Each section heading is purple and bolded. To be clear I have none of these diagnoses, but they fit me too well. My real diagnoses are: Major Depressive Disorder, Generalized Anxiety Disorder, Social Phobia, Anorexia Nervosa (Then EDNOS, then Bulimia, now EDNOS again) and Bi-polar type 2. (Only one psychiatrist gave the bipolar diagnosis and no one before or after him agrees, nonetheless, it is written in some file, somewhere.)

Avoidant personality disorder (AvPD) THIS IS LIKE MY ENTIRE FUCKING PERSONALITY AS A MENTAL ILLNESS O.o

also known as anxious personality disorder,^[1] is a Cluster C personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook as afflicting persons when they display a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction.^[2] Individuals afflicted with the disorder tend to describe themselves as ill at ease, anxious, lonely, and generally feel unwanted and isolated from others.^[3]

People with avoidant personality disorder often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. Avoidant personality disorder is usually first noticed in early adulthood. Childhood emotional neglect and peer group rejection (e.g., bullying) are both associated with an increased risk for the development of AvPD.^[4]

There is controversy as to whether avoidant personality disorder is a distinct disorder from generalized social phobia (I have a Social Phobia diagnosis *Shrug*) are merely different conceptualisations of the same disorder, where avoidant personality disorder may represent the more severe form.^[5][6] This is argued because generalized social phobia and avoidant personality disorder have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment, and identical underlying personality features, such as shyness.^[7][8][9]

Signs and symptoms

People with avoidant personality disorder are preoccupied with their own shortcomings (Ahahahaha, Have you read this blog?!?!?) and form relationships with others only if they believe they will not be rejected. Loss and rejection are so painful that these individuals will choose to be lonely rather than risk trying to connect with others. They often view themselves with contempt,^[3] while showing an increased inability to identify traits within themselves which are generally considered as positive within their societies.^[10] Childhood emotional neglect—in particular, the rejection of a child by one or both parents—has been associated with an increased risk for the development of AvPD, as well as rejection by peers.^[4]

• Hypersensitivity to rejection/criticism
• Self-imposed social isolation
• Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships^[11]
• Avoids physical contact because it has been associated with an unpleasant or painful stimulus…Except when I want pain.
• Feelings of inadequacy
• Severe low self-esteem
• Self-loathing
• Mistrust of others
• Emotional distancing related to intimacy
• Highly self-conscious
• Self-critical about their problems relating to others
• Problems in occupational functioning
• Lonely self-perception, although others may find the relationship with them meaningful
• Feeling inferior to others
• In some extreme cases, agoraphobia
• Uses fantasy as a form of escapism and to interrupt painful thoughts^[12][13] …Well, that is just awkward! Many of the psychodynamic theorists think masochism is a form of self-escapism. I despise psycho dynamic theory, but who knows…

Causes

Causes of avoidant personality disorder are not clearly defined and may be influenced by a combination of social, genetic, and psychological factors. The disorder may be related to temperamental factors that are inherited.^[14][15] Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful, and withdrawn in new situations.^[16] These inherited characteristics may give an individual a genetic predisposition towards AvPD.^[17] Childhood emotional neglect^{[18][19][20][21]} and peer group rejection^[12] are both associated with an increased risk for the development of AvPD.^[14]

Millon’s subtypes

Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or more secondary personality disorder types.^[22] He identified four adult subtypes of avoidant personality disorder.^[23]

Subtype	Features
Phobic (including dependent features)	General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by repugnant and specific dreadful object or circumstances.
Conflicted (including negativistic features)	Internal discord and dissension; fears dependence (ironically, yes); unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; unresolvable angst.
Hypersensitive (including paranoid features)	Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Self-deserting (including depressive features)	Blocks or fragments self awareness; discards painful images and memories *cough* “memories” *cough*; casts away untenable thoughts and impulses OMFG, it is like this man has been inside my head!; ultimately jettisons self (suicidal) I like the name of this one it; I used to wish I could literally run away from my mind.[22]

Diagnosis

World Health Organization

The World Health Organization’s ICD-10 lists avoidant personality disorder as (F60.6) anxious (avoidant) personality disorder.^[1] It is characterized by at least four of the following:

1. persistent and pervasive feelings of tension and apprehension;
2. belief that one is socially inept, personally unappealing, or inferior to others;
3. excessive preoccupation with being criticized or rejected in social situations;
4. unwillingness to become involved with people unless certain of being liked;
5. restrictions in lifestyle because of need to have physical security;
6. avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

Associated features may include hypersensitivity to rejection and criticism.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfy a set of general personality disorder criteria.

American Psychiatric Association

The DSM-IV-TR also has an Avoidant Personality Disorder diagnosis. It refers in general to a widespread pattern of inhibition around people, feeling inadequate and being very sensitive to being evaluated negatively, since early adulthood and occurring in a range of situations. In addition, four of seven specific criteria should be met, which are: AW, that is adorable APA! 4/7!! 😉 Although, I don’t know what the hell these people are talking about “early adulthood”. Everyone around me describes me in these terms, even people that like me…but it had always been this way!

1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
2. Is unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
4. Is preoccupied with being criticized or rejected in social situations
5. Is inhibited in new interpersonal situations because of feelings of inadequacy
6. Views self as socially inept, personally unappealing, or inferior to others
7. Is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing Personal risk if it means self-harm, a lack of concern for my own safety, etc., is certainly not me! However, mentally I hate new situations because of awkwardness/ embarrassing-ness.

Other

Earlier theorists proposed a personality disorder with a combination of features from borderline personality disorder and avoidant personality disorder, called “avoidant-borderline mixed personality” (AvPD/BPD).*shudders in disgust* No one has yet to diagnose me with BPD, but it seems like all ED people who don’t “grow out of it:” end up with this diagnosis and it terrifies me!

Differential diagnosis

Research suggests that people with avoidant personality disorder, in common with sufferers of chronic social anxiety disorder (also called social phobia), <- See, most of the time I think the diagnostic differences are silly! I believe everything, my thoughts (Self-loathing), my actions (ED, SI), and feelings (depression, nerves, fear) result from the same core anxiety. excessively monitor their own internal reactions when they are involved in social interaction. However, unlike social phobics they also excessively monitor the reactions of the people with whom they are interacting. The extreme tension created by this monitoring may account for the hesitant speech and taciturnity of many people with avoidant personality disorder; they are so preoccupied with monitoring themselves and others that producing fluent speech is difficult.

According to the Diagnostic and Statistical Manual of Mental Disorders, avoidant personality disorder must be differentiated from dependent, paranoid, schizoid and schizotypal personality disorders.^[26]

Comorbidity

Avoidant personality disorder is reported to be especially prevalent in people with anxiety disorders, (SEE?! Clinicians of the world: I’m telling you it is all the same freaking thing! Believe me I was practically born this way, I’ve heard about psychological theories all my life because my mom is a psychologist, and really I should have an honorary PhD in psychology because I’ve spent almost half my life (it will be exactly half my life once I turn 24) in therapy 1 – 4 times/week!) although estimates of comorbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10–50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20–40% of people who have social phobia (social anxiety disorder).

Some studies report prevalence rates of up to 45% among people with generalized anxiety disorder (Yep, this is in my thick medical chart to) and up to 56% of those with obsessive-compulsive disorder.^[27]

Treatment

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, cognitive therapy, exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.^[28] A key issue in treatment is gaining and keeping the patient’s trust, since people with avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection. LOLZ, does that sound familiar? …Ahem…The day I wrote this I skipped therapy (oops) The primary purpose of both individual therapy and social skills group training is for individuals with avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.^[29]

People with AvPD can improve social awareness and skills, but with deep-seated feelings of inferiority and significant social fear, these patterns usually do not change dramatically. MAOIs such as Phenelzine can be very helpful by increasing confidence and the feeling of wanting to become more socially active.

Dependent personality disorder (DPD),

formerly known as asthenic personality disorder, is a personality disorder that is characterized by a pervasive psychological dependence on other people. This personality disorder is a long-term (chronic) condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. 😦 I’m actually terrified of this possibility because I know (numerous therapists and my parents have all said) I’m slightly behind in terms of emotional development and independence because eating disorders stunt emotional growth. 

The difference between a ‘dependent personality’ and a ‘dependent personality disorder’ is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations.

Characteristics

View of others

Individuals with DPD see other people as much more capable to shoulder life’s responsibilities, to navigate a complex world, and to deal with the competitions of life.^[1] Other people appear powerful, competent, and capable of providing a sense of security and support to individuals with DPD. Dependent individuals avoid situations that require them to accept responsibility for themselves; they look to others to take the lead and provide continuous support. O.O Submissiveness?!?!?

DPD judgment of others is distorted by their inclination to see others as they wish they were, rather than as they are.^[3] These individuals are fixated in the past. They maintain youthful impressions; they retain unsophisticated ideas and childlike views of the people toward whom they remain totally submissive.^[4] Individuals with DPD view strong caretakers, in particular, in an idealized manner; they believe they will be all right as long as the strong figure upon whom they depend is accessible. Dear God, that family therapist was right. We’re enmeshed! 😦

Self-image

Individuals with DPD see themselves as inadequate and/or helpless; they believe they are in a cold and dangerous world and are unable to cope on their own. Actually, I believe everyone is in a cold and dangerous world…They define themselves as inept and abdicate self-responsibility (using mental illness as an excuse?); they turn their fate over to others (submission and/or masochism??). These individuals will decline to be ambitious and believe that they lack abilities, virtues and attractiveness.^[6][7]

The solution to being helpless in a frightening world is to find capable people who will be nurturing and supportive toward those with DPD…Except people scare me (See avoidant Personality Disorder *laughs bitterly* Within protective relationships, individuals with DPD will be self-effacing, obsequious, agreeable, docile, and ingratiating. People like me because I am all those adjectives. They will deny their individuality and subordinate their desires to significant others. STOP describing my romantic relationships in the context of mental illness, please! They internalize the beliefs and values of significant others. They imagine themselves to be one with or a part of something more powerful and they imagine themselves to be supporting others. This diagnosis is making me angry! By seeing themselves as protected by the power of others, they do not have to feel the anxiety attached to their own helplessness and impotence. A-freaking-men.

However, to be comfortable with themselves and their inordinate helplessness, (not helpless, just hopelessly pathetic) individuals with DPD must deny the feelings they experience and the deceptive strategies they employ. (Bwahahaha maybe that is why this one is pissing me off but the other 3 didn’t) They limit their awareness of both themselves and others. Their limited perceptiveness allows them to be naive and uncritical.^[9] Their limited tolerance for negative feelings, perceptions, or interaction results in the interpersonal and logistical ineptness that they already believe to be true about themselves. Their defensive structure reinforces and actually results in verification of the self-image they already hold.

Relationships

Individuals with DPD see relationships with significant others as necessary for survival. They do not define themselves as able to function independently (I’m afraid and I’ve verbally expressed that fear numerous times to numerous people…all of whom say I’m being an idiot because I’m perfectly capable of independence…but…but…IDK…); they have to be in supportive relationships to be able to manage their lives. (Like how I thrive in D/s relationships?) In order to establish and maintain these life-sustaining relationships, people with DPD will avoid even covert expressions of anger. They will be more than meek and docile; they will be admiring, loving, and willing to give their all. They will be loyal, unquestioning, and affectionate. They will be tender and considerate toward those upon whom they depend.…But…these qualities are the only things (other than raw intelligence) that I like about myself! I have trouble expressing anger because I don’t like conflict. I want to please people. I want to make people happy. So, I rarely display anger. I admire sacrifice and all encompassing love. I’m definitely loyal, but affectionate only with people I love (which are few, otherwise people should keep to their own personal bubbles) So, apparently, I’m not really a nice person; I’m self-serving and traits people have praised me for my entire life are disordered? The first thing people say about it me is that accommodating, easy-going, loyal, kind, sweet, gentle, slow to anger…I always pride myself on these attributes because I thought that made me a better person (that is, better than the nameless evil I usually see in the mirror – not literal psychosis fyi). 😦

Dependent individuals play the inferior role to the superior other very well; they communicate to the dominant people in their lives that those people are useful, sympathetic, strong, and competent (but what if they truly are useful, sympathetic, strong, and competent?…Err, complimenting people is bad?!?!) With these methods, individuals with DPD are often able to get along with unpredictable or isolated people. (Not really! I’m geeky (Oh, I like that about me to!) and geeky people are sometimes isolated) To further make this possible, individuals with DPD will approach both their own (LOL, NOPE, NOT MY OWN!!) and others’ failures and shortcomings with a saccharine attitude and indulgent tolerance.^[11] They will engage in a mawkish minimization, denial, or distortion of both their own and others’ negative, self-defeating, or destructive behaviors to sustain an idealized, and sometimes fictional, story of the relationships upon which they depend. (but…I love the people I love! STOP telling me it is abnormal to ignore people’s faults! >.< How could you have a relationship without minimizing the other person’s faults? I’m not saying I think everyone else is perfect, but if I looked at others the way I looked at myself, I would probably try to destroy the universe) They will deny their individuality, their differences, and ask for little other than acceptance and support.^[12]

Not only will individuals with DPD subordinate their needs to those of others, they will meet unreasonable demands and submit to abuse and intimidation to avoid isolation and abandonment. (This is just getting awkward…I like submission and masochism damn it! And it isn’t abuse if it occurs between 2 consenting adults! Also, all relationships involve compromise of some kind) Dependent individuals so fear being unable to function alone that they will agree with things they believe are wrong rather than risk losing the help of people upon whom they depend. (Yay! A trait that isn’t true for me!  I might do something minor like idk, drugs, but I wouldn’t do something that is undeniably immoral, such as abusing puppies) They will volunteer for unpleasant tasks if that will bring them the care and support they need. (Ummm….Isn’t that what we’re supposed to do for people we care about?! Help them?!?!) They will make extraordinary self-sacrifices to maintain important bonds. (But self-sacrifice makes you a better person…It shows you care! Also, it makes people like you.)

It is important to note that individuals with DPD, in spite of the intensity of their need for others, do not necessarily attach strongly to specific individuals, i.e., they will become quickly and indiscriminately attached to others when they have lost a significant relationship. *crickets chirping in the background* It is the strength of the dependency needs that is being addressed; attachment figures are basically interchangeable. (SO, NOT TRUE!!!! NOPE! NADA! My “strong” people are irreplaceable! Also, it takes me a looong time to attach and trust people because people are scary (see avoidant personality disorder)) Attachment to others is a self-referenced and, at times, haphazard process of securing the protection of the most readily available powerful other willing to provide nurturance and care. (Oh shut up! Everyone cares about their partner’s ability to meet their needs! If that happens to involve dominance…so what?)

Comparison with other PDs

Both DPD and HPD are distinguished from other personality disorders by their need for social approval and affection and by their willingness to live in accord with the desires of others. (Said everyone EVER! Everyone makes concessions for people they care about! And everyone (most everyone) cares about social approval) They both feel paralyzed when they are alone and need constant assurance that they will not be abandoned. (ah, my poor family.. I am continuously extracting promises that no matter what I do, they’ll love me, I’m not a burden, once my grandparents die my uncles and parents and my generation will get together on holidays, once my parents die my brother and sister-in-law will invite me to see them and stuff like that because everyone leaves eventually) Individuals with DPD are passive individuals who lean on others to guide their lives. (UGH, passiveness makes me agreeable and likable and fun to be around. I don’t argue. I might be saying awful things in my head, but they’ll never know) People with HPD are active individuals who take the initiative to arrange and modify the circumstances of their lives. They have the will and ability to take charge of their lives and to make active demands on others.^[17]

Causes

No studies of genetics or of biological traits for dependents have been conducted. Central to their psychodynamic constellation is an insecure form of attachment to others, which may be the result of clinging parental behavior.^[18]

Epidemiology

Dependent personality disorder occurs in about 0.5% of the general population. It is more frequent in females.^[19]

Diagnosis

The following questions when assessing individuals for DPD:^[20]

• Some people enjoy making decisions. Others prefer to have someone they trust guide them. Which do you prefer?
• Do you seek advice for everyday decisions? (Are the decisions you make understood by the practitioner?) NO…maybe….IDK…
• Do you find yourself in situations where other people have made decisions about important areas in your life, e.g. what job to take? No!
• Is it hard for you to express a different opinion with someone you are close to? What do you think might happen if you did? Yes because then they’ll see me for the monster I am and they’ll despise me as much as I despise myself.
• Do you often pretend to agree with others even if you do not? Why? Do you think it could get you into trouble if you disagree? Yes (see above). Also, why sow discord in general? If it is something I really care about, I’ll disagree, but if it is about what movie we should watch or most political beliefs…
• Do you often need help to get started on a project? What does that mean? Like I need help because I’m incapable of starting it (no) or I need help because I procrastinate? No one helps me start projects, well, the professors do with their due dates…
• Do you ever volunteer to do unpleasant things for others so they will take care of you when you need it? Duh.
• Are you uncomfortable when you are alone? Are you afraid you will not be able to take care of yourself? Not really. The problem is I’m afraid I’ll be alone FOREVER.  In the moment, I usually prefer being alone because then there is no chance of embarrassing myself or hurting someone, etc. I just don’t want to be totally alone forever…
• Have you found that you are desperate to get into another relationship right away when a close relationship ends? Even if the new relationship might not be the best person for you? NOPE. It has been 3 years. :p Screw you, test! (Ha, that would not be received well if this was a real diagnostic interview!)
• Do you worry about important people in your life leaving you? Yes, because they’re all going to die eventually. More likely, they’ll move on with their lives, find better friends/lovers/people and forget me because at the core, I suck.

American Psychiatric Association

The DSM-IV-TR contains a Dependent Personality Disorder diagnosis. It refers to a pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of separation. (I am not clingy because clinginess annoys people! Also, I fear separation because it might turn into abandonment, but I don’t fear separation itself like toddlers who cry when their mom drops them off at daycare) This begins by early adulthood and can present in a variety of contexts.:^[21]

World Health Organization

The World Health Organization’s ICD-10 lists dependent personality disorder as F60.7 Dependent personality disorder:^[22]

It is characterized by at least 3 of the following:

1. encouraging or allowing others to make most of one’s important life decisions;
2. subordination of one’s own needs to those of others on whom one is dependent, and undue compliance with their wishes; (and what do you, World Health Organization, expect someone who is dependant on another person, for whatever reason, to do? NOT comply with their wishes and risk getting kicked out?)
3. unwillingness to make even reasonable demands on the people one depends on;
4. feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself;
5. preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;
6. limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others. Maybe…but I refuse to acknowledge this! I need reassurance, of course! is that so bad? 😦 How do you know what is excessive?

Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina.

Includes:

• asthenic (physical or emotional? Physical: No; Emotional: Yes), inadequate, passive, and self-defeating personality (disorder) (AKA Masochistic Personality Disorder)

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Millon’s subtypes

Psychologist Theodore Millon identified five adult subtypes of dependent personality disorder.^[23][24] Any individual dependent may exhibit none or one of the following:

Subtype	Description	Personality Traits
Disquieted	Including avoidant features	Restlessly perturbed; disconcerted and fretful; feels dread and foreboding; apprehensively vulnerable to abandonment; lonely unless near supportive figures.
Selfless	Including depressive features	Merges with and immersed into another; is engulfed, enshrouded, absorbed, incorporated, willingly giving up own identity; becomes one with or an extension of another.
Immature	Variant of “pure” pattern	Unsophisticated, half-grown, unversed, childlike; undeveloped, inexperienced, gullible, and unformed; incapable of assuming adult responsibilities.
Accommodating	Including masochistic features	Gracious, neighborly, eager, benevolent, compliant, obliging, agreeable; denies disturbing feelings; adopts submissive and inferior role well.
Ineffectual	Including schizoid features	Unproductive, gainless, incompetent, useless, meritless; seeks untroubled life; refuses to deal with difficulties; untroubled by shortcomings.

LOLOLOLOLOLOLOLOL, I fit all the personality traits of masochistic and depressive subtypes of Dependant Personality Disorder! And 1/2 of the Avoidant subtype. …WHY does no one acknowledge that all of this is the SAME problem?!?!?! THINK ABOUT IT! ED, SI, suicide, they’re all a result of dysregulation, often involving anxiety!

Differential diagnosis

The following conditions commonly coexist (comorbid) with dependent personality disorder:^[19]

• mood disorders Wouldn’t you be depressed or anxious with all these fears and beliefs abut yourself running rampant in your head?!?!? YES YOU WOULD 😛 Ha, I tried explaining my depressive episode from last semester to my mom by articulating a bunch of my daily thoughts and her exact words were, “Wow, no wonder you’re depressed”
• anxiety disorders (SAME THING; Also, I think EDs are anxiety disorders)
• adjustment disorder
• borderline personality disorder (REALLY FREAKING SIMILAR…but not identical)
• avoidant personality disorder (SAME THING)
• histrionic personality disorder

Treatment

Adler suggests that treatment goals for all personality disorders include: preventing further deterioration, regaining an adaptive equilibrium, (I have no adaptive equilibrium) alleviating symptoms, restoring lost skills, and fostering improved adaptive capacity. Goals may not necessarily include characterological restructuring. The focus of treatment is adaptation, i.e., how individuals respond to the environment. Treatment interventions teach more adaptive methods of managing distress, improving interpersonal effectiveness, and building skills for affective regulation.^[25]

For individuals with DPD, the goal of treatment is not independence but autonomy. Autonomy has been defined as the capacity for independence and the ability to develop intimate relationships (Great, I already have the capacity for independence – or so they keep telling me- and I’m definitely capable of long-term intimate relationships. In fact, my longest, albeit tepid, relationship was with a vanilla person! So if I seriously have this disorder, there is nothing more you can do to help?) Sperry suggests that the basic goal for DPD treatment is self-efficacy.^[27] Individuals with DPD must recognize their dependent patterns and the high price they pay to maintain those patterns. This allows them to explore alternatives. (You fools, no one will like me and then I’ll have, well…no one!) The long-range goal is to increase DPD individuals’ sense of independence and ability to function. Clients with DPD must build strength rather than foster neediness.^[28]

As with other personality disorders, treatment goals should not be in contradiction to the basic personality and temperament of these individuals. (But all these things (from all the personality disorders here) are my basic personality and temperament! For as long as I can remember all these characteristics fit me. My parents say I was really confident and outgoing when I was little, but I don’t remember that. They say it changed around age 4 or 5. We are presently going to ignore the connection that just invaded my thoughts…) They can work toward a more functional version of those characteristics that are intrinsic to their style. Oldham suggests seven traits and behaviors of the “devoted personality style“, i.e., the non-personality-disordered version of DPD. Finally something I like about this article.

• ability to make commitments;
• enjoyment of intimacy;
• skills as a team player—without need to compete with the leader;
• willingness to seek the opinions and advice of others;
• ability to promote interpersonal harmony;
• thoughtfulness and consideration for others; and,
• willingness to self-correct in response to criticism.
• See?! This ^^^ is what I kept saying! Except without self-defense and anger….

Medication

There is little evidence to suggest that the use of medication will result in long-term benefits in the personality functioning of individuals with DPD.^[30] DPD is not amenable to pharmacological measures; treatment relies upon verbal therapies.^[31] It is recommended that target symptoms rather than specific personality disorders be medicated. One of these target symptoms of particular importance is dysphoria—marked by low energy, leaden fatigue, and depression. Dysphoria can also be associated with a craving for chocolate and for stimulants, e.g. cocaine. DPD is one of the most vulnerable personality disorders to dysphoria and some individuals with DPD respond well to antidepressant medications. In other words binging?! I’m surprised there is not a huge correlation with BED or Bulimia or EDNOS.

People with DPD are prone to both depressive and anxiety disorders. (Again, live in my brain and see how you feel after 24 hours 🙂 ) Stone suggests that these individuals may respond well to benzodiazepines in a crisis.^[31] However, clients with DPD are likely to abuse anxiolytics and their use should be limited and monitored with caution.^[33]

Unfortunately, individuals with DPD tend to be appealing clients. They are not inclined to be demanding and provocative. This can be precisely why they are given benzodiazepines by psychiatrists who may feel both benevolent and protective. Their inclination to use denial and escape to manage their lives makes the use of sedative-hypnotics familiar and pleasant. Iatrogenic addiction is a serious concern. Meh, not so much, I used my anxiety meds to attempt suicide. Nonetheless, I was later put back on the same medication because I’m appealing and amiable. :p

Depressive personality disorder (also known as melancholic personality disorder)

is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features.

Originally included in the American Psychiatric Association’s DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R.^[1] Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study. Although no longer listed in the manual’s personality disorder category, the diagnosis is included under the section “personality disorder not otherwise specified”.

While depressive personality disorder shares some similarities with mood disorders such as dysthymic disorder, it also shares many similarities with personality disorders including avoidant personality disorder. Some researchers argue that depressive personality disorder is sufficiently distinct from these other conditions so as to warrant a separate diagnosis.

Characteristics

The DSM-IV defines depressive personality disorder as “a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and occurring in a variety of contexts.”^[1] Depressive personality disorder occurs before, during, and after major depressive episodes, making it a distinct diagnosis not included in the definition of either major depressive episodes or dysthymic disorder. Specifically, five or more of the following must be present most days for at least two years in order for a diagnosis of depressive personality disorder to be made:

• Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness and unhappiness
• Self-concept centers on beliefs of inadequacy, worthlessness and low self-esteem
• Is critical, blaming and derogatory towards the self
• Is brooding and given to worry
• Is negativistic, critical and judgmental toward others
• Is pessimistic
• Is prone to feeling guilty or remorseful

People with depressive personality disorder have a generally gloomy outlook on life, themselves, the past and the future. They are plagued by issues developing and maintaining relationships. In addition, studies have found that people with depressive personality disorder are more likely to seek psychotherapy than people with Axis I depression spectrums diagnoses.

Recent studies have concluded that people with depressive personality disorder are at a greater risk of developing dysthymic disorder than a comparable group of people without depressive personality disorder.^[2] These findings lead to the fact that depressive personality disorder is a potential precursor to dysthymia or other depression spectrum diagnoses. If included in the DSM-V, depressive personality disorder would be included as a warning sign for potential development of more severe depressive episodes.

Researchers at McLean Hospital in Massachusetts looked at the comorbidity of depressive personality disorder and a variety of other disorders. It was found that subjects with depressive personality disorder were more likely than the subjects without depressive personality disorder to currently have major depression and an eating disorder. Subjects with and without depressive personality disorder were statistically equally likely to have any of the other disorders examined.^{[citation needed]}

Axis I Disorders in Subjects With and Without Depressive Personality Disorder^{[citation needed]}

	Present (N=30)		Absent (N=24)
Disorder	N	%	N	%	pa[clarification needed]
Major Depression
Current	12	40	7	29	0.57
Lifetime	25	83	17	71	0.33
Bipolar Disorder
Current	2	7	2	8	1.00
Lifetime	2	7	4	17	0.39
Dysthymia
All Types	11	37	8	33	1.00
Primary early onset	5	17	5	21	0.74
Any mood disorder
Current	20	67	14	58	0.58
Lifetime	28	93	22	92	1.00
Substance use disorders (lifetime)	11	37	7	29	0.77
Anxiety disorders (lifetime)	15	50	11	46	0.79
Somatoform disorders (lifetime)	2	7	1	4	1.00
Eating disorders (lifetime)	7	23	1	4	0.06

Millon’s subtypes

Theodore Millon identified five subtypes of depression.^[1][3] Any individual depressive may exhibit none, or one or more of the following:

• Ill-humored depressive, including negativistic (passive-aggressive) features. Patients in this subtype are often hypochondriacal, cantankerous and irritable, and guilt-ridden and self-condemning. In general, ill-humored depressives are down on themselves and think the worst of everything.
• Voguish depressive, including histrionic, narcissistic features. Voguish depressives see unhappiness as a popular and stylish mode of social disenchantment, personal depression as self-glorifying, and suffering as ennobling. The attention from friends, family, and doctors is seen as a positive aspect of the voguish depressive’s condition.
• Self-derogating depressive, including dependent features. Patients who fall under this subtype are self-deriding, discrediting, odious, dishonorable, and disparage themselves for weaknesses and shortcomings. These patients blame themselves for not being good enough.
• Morbid depressive, including masochistic features. Morbid depressives experience profound dejection and gloom, are highly lugubrious, and often feel drained and oppressed.
• Restive depressive, including avoidant features. Patients who fall under this subtype are consistently unsettled, agitated, wrought in despair, and perturbed. This is the subtype most likely to commit suicide in order to avoid all the despair in life.^[1]

Not all patients with a depressive disorder fall into a subtype. These subtypes are multidimensional in that patients usually experience multiple subtypes, instead of being limited to fitting into one subtype category. Currently, this set of subtypes is associated with melancholic personality disorders. All depression spectrum personality disorders are melancholic and can be looked at in terms of these subtypes.

DSM-V

Similarities to dysthymic disorder

Much of the controversy surrounding the potential inclusion of depressive personality disorder in the DSM-V stems from its apparent similarities to dysthymic disorder, a diagnosis already included in the DSM-IV. Dysthymic disorder is characterized by a variety of depressive symptoms, such as hypersomnia or fatigue, low self-esteem, poor appetite, or difficulty making decisions, for over two years, with symptoms never numerous or severe enough to qualify as major depressive disorder. Patients with dysthymic disorder may experience social withdrawal, pessimism, and feelings of inadequacy at higher rates than other depression spectrum patients. Early-onset dysthymia is the diagnosis most closely related to depressive personality disorder.^[4]

The key difference between dysthymic disorder and depressive personality disorder is the focus of the symptoms used to diagnose. Dysthymic disorder is diagnosed by looking at the somatic senses, the more tangible senses. Depressive personality disorder is diagnosed by looking at the cognitive and intrapsychic symptoms. The symptoms of dysthymic disorder and depressive personality disorder may look similar at first glance, but the way these symptoms are considered distinguish the two diagnoses.

Comorbidity with Other Disorders

Many researchers believe that depressive personality disorder is so highly comorbid with other depressive disorders, manic-depressive episodes and dysthymic disorder, that it is redundant to include it as a distinct diagnosis. Recent studies however, have found that dysthymic disorder and depressive personality disorder are not as comorbid as previously thought. It was found that almost two thirds of the test subjects with depressive personality disorder did not have dysthymic disorder, and 83% did not have early-onset dysthymia.^[1]

The comorbidity with Axis I depressive disorders is not as high as had been assumed. An experiment conducted by American psychologists showed that depressive personality disorder shows a high comorbidity rate with major depression experienced at some point in a lifetime and with any mood disorders experienced at any point in a lifetime. A high comorbidity rate with these disorders is expected of many diagnoses. As for the extremely high comorbidity rate with mood disorders, it has been found that essentially all mood disorders are comorbid with at least one other, especially when looking at a lifetime sample size.^[5]

Changes to Cluster C

If depressive personality disorder were added to the DSM-V, it would be included in the Cluster C personality disorders, anxious and fearful personality disorders. At this time, those include avoidant, obsessive-compulsive, and dependent personality disorders. The make-up of Cluster C would have to be rethought, as the figure shown below could no longer represent all of the disorders if depressive personality disorder were to be included. The relation shown in the Venn diagram has been accepted for years and would have to be rethought and redesigned if depressive personality disorder were to be added. Further studies are in progress looking into the comorbidity of Cluster C disorders and depressive personality disorder, as well as how these disorders interact with each other in patients diagnosed with multiple Cluster C disorders.