Internet Mental Health

DEPENDENT PERSONALITY DISORDER






Internet Mental Health Quality of Life Scale (Client Version)

Internet Mental Health Quality of Life Scale (Therapist Version)

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • Individuals with Dependent Personality Disorder are highly dependent and fearful of being alone, tend to show insufficient concern for their own well-being to the point of jeopardizing their welfare or safety, and have difficulty expressing anger directly.

  • Since childhood or adolescence, was dependent, unassertive, and feared conflict.

  • Is not due to a medical or substance use disorder.

Prediction

    Can last for years or be lifelong

Problems

Occupational-Economic Problems:

  • Avoids positions of responsibility and becomes anxious when faced with decisions

Negative Emotions (Negative Emotion):

    Dependency:

  • Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

  • Needs others to assume responsibility for most major areas of her life

  • Has difficulty expressing disagreement with others because of her fear of loss of support or approval

  • Has difficulty initiating projects or doing things on her own

  • Goes to excessive lengths to obtain nurturance and support from others

  • Separation Anxiety:

  • Feels uncomfortable or helpless when alone because of her exaggerated fears of being unable to cope

  • Urgently seeks another relationship as a source of care and support when a close relationship ends

  • Is unrealistically preoccupied with fears of being left to take care of herself


SAPAS Personality Screening Test

Individuals with this disorder would answer "Yes" to the red questions:

      In general, do you have difficulty making and keeping friends?
      Would you normally describe yourself as a loner?
      In general, do you trust other people?
      Do you normally lose your temper easily?
      Are you normally an impulsive sort of person?
      Are you normally a worrier?
      In general, do you depend on others a lot?
      In general, are you a perfectionist?

Back to top


Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Dependent Personality Disorder 301.6

This diagnosis is based on the following findings:

  • Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others (still present)

  • Needs others to assume responsibility for most major areas of his or her life (still present)

  • Has difficulty expressing disagreement with others because of fear of loss of support or approval (still present)

  • Has difficulty initiating projects or doing things on his or her own (still present)

  • Goes to excessive lengths to obtain nurturance and support from others (still present)

  • Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to cope (still present)

  • Urgently seeks another relationship as a source of care and support when a close relationship ends (still present)

  • Is unrealistically preoccupied with fears of being left to take care of himself or herself (still present)

Treatment Goals:

  • Goal: be more independent in making decisions.
    If this problem persists: She will continue to have great difficulty making everyday decisions without an excessive amount of advice and reassurance from others. She will be overly reliant on family help. She will depend on a parent or spouse to decide where to live, what kind of job to have, and which people to befriend.

  • Goal: don't rely on others to make all the important decisions.
    If this problem persists: She will continue to be passive and allow other people to take the initiative and to assume responsibility for most major areas of her life. She will avoid personal responsibility by being passive and allowing other people to assume responsibility. Her need for others to assume responsibility will go beyond appropriate requests for assistance from others.

  • Goal: be able to express disagreement.
    If this problem persists: Because she fears losing support or approval, she will continue to have difficulty expressing disagreement with others. She will submit to what others want, even if the demands are unreasonable.

  • Goal: have enough confidence to start projects or do things alone.
    If this problem persists: She will continue to have difficulty initiating projects or doing things independently. She will present as being inept and requiring constant assistance.

  • Goal: do not go to excessive lengths to obtain support from others.
    If this problem persists: She will continue to be devastated by separation and loss and will go to great lengths, even suffering abuse, to stay in a relationship. Thus she will make extraordinary self-sacrifices or tolerate verbal, physical, or sexual abuse.

  • Goal: do not fear being alone.
    If this problem persists: She will continue to feel helpless when alone, because of an exaggerated fear of being unable to cope. She will "tag along" with important others just to avoid being alone.

  • Goal: do not urgently and indiscriminately seek another supportive relationship when a close relationship ends.
    If this problem persists: If a relationship does end, she will continue to urgently seek another relationship to provide care and support. This search may become so urgent that she quickly and indiscriminately attaches to another person.

  • Goal: overcome excessive fear of abandonment.
    If this problem persists: She will continue to be so dependent on the advice and help of another person that she will worry about being abandoned by that person when there are no grounds to justify such fears.


Back to top


Dependent Personality Disorder F60.7 - ICD10 Description, World Health Organization

Dependent personality disorder is characterized by pervasive passive reliance on other people to make one's major and minor life decisions, great fear of abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others, and a weak response to the demands of daily life. Lack of vigour may show itself in the intellectual or emotional spheres; there is often a tendency to transfer responsibility to others.

ICD-10 International Personality Disorder Examination Screening Questions

  • I let others make my big decisions for me.

  • I find it hard to disagree with people if I depend on them a lot.

  • I usually feel uncomfortable or helpless when I am alone.

  • I worry about being left alone and having to take care for myself.

  • I don't ask favors from people I depend on a lot.

  • I often seek advice or reassurance about everyday decisions.

ICD-10 Diagnostic Criteria (For Research)

    A. The general criteria of personality disorder must be met:

    • Evidence that the individual's characteristic and enduring patterns of inner experience and behavior deviate markedly as a whole from the culturally expected and accepted range (or 'norm').

    • The deviation must manifest itself pervasively as behavior that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (i.e. not being limited to one specific 'triggering' stimulus or situation).

    • There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behavior.

    • There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence.

    • The deviation cannot be explained as a manifestation or consequence of other adult mental disorders.

    • Organic brain disease, injury, or dysfunction must be excluded as possible cause of the deviation.

    B. At least four of the following must be present:

    • Encouraging or allowing others to make most of one's important life decisions.
        (E.g., "I let others make my big decisions for me.")

    • Subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes.
        (E.g., "I find it hard to disagree with people if I depend on them a lot.")

    • Unwillingness to make even reasonable demands on the people one depends on.
        (E.g., "I don't ask favors from people that I depend on a lot.")

    • Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself.
        (E.g., "I usually feel uncomfortable or helpless when I'm alone.")

    • Preoccupation with fears of being left to take care of oneself.
        (E.g., "I worry about being left alone and having to care for myself.")

    • Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.
        (E.g., "I often seek advice or reassurance about everyday decisions.")

Dependent Personality Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with Dependent Personality Disorder needs to show at least 5 of the following criteria:

  • Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.

  • Needs others to assume responsibility for most major areas of his or her life.

  • Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)

  • Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).

  • Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.

  • Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.

  • Urgently seeks another relationship as a source of care and support when a close relationship ends.

  • Is unrealistically preoccupied with fears of being left to take care of himself or herself.

  • This enduring pattern of inner experience and behavior must deviate markedly from the expectations of the individual's culture.

  • This enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

  • This enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Dependency and separation anxiety are developmentally appropriate in children and adolescents. Most adolescents grow out of their dependency and separation anxiety; however, for some it increases. By early adulthood, if this dependency and separation anxiety becomes very pervasive and persistent; it is diagnosed as being Dependent Personality Disorder.

    Separation Anxiety Disorder - Diagnostic Criteria, American Psychiatric Association

    An individual diagnosed with separation anxiety disorder needs to meet all of the following criteria:

    • Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

      • Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.

      • Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.

      • Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.

      • Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.

      • Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.

      • Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.

      • Repeated nightmares involving the theme of separation.

      • Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.

    • The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

    • The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

    • The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

    Empirically Derived Taxonomy for Personality Diagnosis: Dependent Personality Disorder

    (This section uses an alternative classification system to that of the American Psychiatric Association)

    These individuals:
    • Are needy and dependent, fear being alone, and fear rejection or abandonment.

    • Are ingratiating or submissive, often consenting to things they find objectionable in an effort to maintain support or approval.

    • Are passive and unassertive and feel helpless and powerless.

    • Are indecisive, suggestible or easily influenced, and naive or innocent, seeming to know less about the ways of the world than would be expected.

    • Become attached to people who are emotionally unavailable, and create relationships in which they are in the role of caring for or rescuing the other person.

    • Get drawn into or remain in relationships in which they are emotionally or physically abused, or needlessly put themselves in dangerous situations (e.g., walking alone or agreeing to meet strangers in unsafe places).

    • Are insufficiently concerned with meeting their own needs and tend to feel unworthy or undeserving.

    • Have trouble acknowledging or expressing anger and instead become depressed, self-critical, or self-punitive.

    • Express anger in passive and indirect ways (e.g., making mistakes, procrastinating, forgetting) that may provoke or trigger anger or mistreatment from others.


    Back to top


    Diagnostic Features

    Dependent Personality Disorder is a condition characterized by an over-reliance on others that leads to submissive and clinging behavior and fears of separation. The dependent and submissive behaviors arise from feeling unable to cope without the help of others. This disorder is only diagnosed when these behaviors become persistent and very disabling/distressing. This diagnosis should be used with great caution, if at all, in children and adolescents, for whom dependent behavior may be developmentally appropriate.

    Individuals with this disorder grow up having excessive separation anxiety. They have an excessive need to be taken care of that leads to submissiveness, clinging behavior and fears of separation. The core feature of this disorder is negative emotion (separation insecurity, anxiousness, submissiveness). This disorder is only diagnosed if: (1) it begins no later than early adulthood, (2) these behaviors occur at home, work, and in the community, and (3) these behaviors lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning. Dependent Personality Disorder should not be diagnosed if its symptoms can be better explained as due to another mental disorder, Substance Use Disorder, or another medical condition.

    Dependency and separation anxiety are developmentally appropriate in children and adolescents. However, in some, the dependency and separation anxiety becomes excessive. Most adolescents grow out of their dependency and separation anxiety; however, for some it increases. By early adulthood, if this dependency and separation anxiety becomes very pervasive and persistent; it is diagnosed as being Dependent Personality Disorder. Individuals with this disorder fear rejection/separation, are submissive, and are unable to handle conflict. These individuals do not trust their own ability to make decisions. They go to great lengths, even suffering abuse, to stay in a relationship. They usually have feelings of inadequacy, hypersensitivity to criticism, and an excessive need for reassurance.

    Like all personality disorders, Dependent Personality Disorder is a deeply ingrained and enduring behavior pattern, manifesting as an inflexible response to a broad range of personal and social situations. This behavior represents an extreme or significant deviation from the way in which the average individual in a given culture relates to others. This behavior pattern tends to be stable. It causes subjective distress and problems in social performance.

    Course

    Dependent Personality Disorder usually begins by early adulthood, and has a chronic course. Dependent behavior is very common in childhood, but most adolescents grow out of this behavior. Unfortunately, for some, this dependent behavior persists and intensifies into adulthood; thus they become diagnosed with this disorder. Chronic physical illness or Separation Anxiety Disorder in childhood or adolescence may predispose the individual to develop this disorder.

    Complications

    Dependent personality disorder has an increased risk of: depression; alcohol or drug abuse; physical, emotional, or sexual abuse. Occupational functioning is impaired if independent initiative is required. The individual avoids positions of responsibility and becomes anxious when faced with decisions. Social relations tend to be limited to those few people on whom the individual is dependent.

    Comorbidity

    Some other disorders frequently occur with this disorder:

      Non-Personality Disorders

              Depressive Disorders:
        • Persistent Depressive Disorder (Dysthymia)
              Anxiety Disorders:
        • Separation Anxiety Disorder, Panic Disorder, Agoraphobia

      Personality Disorders

              Avoidant Personality Disorder

              Borderline Personality Disorder
          Note: Avoidant, Dependent and Borderline Personality Disorders are closely related since they all share the same core feature of anxiety. If an individual has one of these personality disorders, they are very likely to have one of the others.

    Associated Laboratory Findings

    No laboratory test has been found to be diagnostic of this disorder.

    Prevalence

    Dependent personality disorder is more frequent in females, and is present in about 0.6% of the general population.

    Controlled Clinical Trials Of Therapy

    Click here for a list of all the controlled clinical trials of therapy for this disorder.

    Psychotherapy

    Dependent Personality Disorder is a very common disorder; yet there are no randomized controlled trials on psychotherapy for this disorder. However, amongst clinicians, there is a consensus that improvements are usually seen only with long-term therapy. Cognitive behavior therapy and interpersonal therapy are believed to be partially effective. The goal of therapy is to assist the client in becoming more independent - and to not become dependent upon the therapist. Some long-term therapies require years of multiple therapy visits per week. Financially, this greatly benefits the therapist, but there is no research that shows that this over-treatment is effective.

    Pharmacotherapy

    There are currently no medications approved by the FDA to treat this disorder. Vitamins and dietary supplements are ineffective for all Personality Disorders.

    A Dangerous Cult: Videos


    Back to top


    Videos


    Stories

    Rating Scales

    SWAP-200 DPD - measures the severity of Dependent Personality Disorder

    Lack Of Social Skills In Personality Disorders

    There are social skills that are essential for healthy social functioning. Individuals with Dependent Personality Disorder lack the essential social skills of independence, Extraversion, and peacemaking.

    Social Skills That Are Lacking In Dependent Personality Disorder

    SOCIAL SKILL DEPENDENT PERSONALITY NORMAL
    Independence Dependence on others Freedom from the control, influence, or support of others; not fearing separation from others
    Assertiveness Submissiveness Being confident and direct in claiming one's rights or putting forward one's views
    Peacemaking Inability to handle conflict Skillfully preventing (or handling) conflict within a group or family


    Avoidant, borderline, and dependent personality disorders are closely related and can be thought of as forming an "low emotional stability cluster" of personality disorders. On personality testing, these three disorders all have low Emotional Stability scores.

    Social Skills That Are Lacking In The "Low Emotional Stability Cluster" Of Personality Disorders

    PERSONALITY DISORDER LACKING LACKING LACKING
    Avoidant Personality Self-Confidence (instead has feeling inferior or shy) Optimism (instead has pessimism or expecting the worst) Belonging (instead has fearing rejection by others)
    Dependent Personality Independence (instead has dependence on others) Assertiveness (instead has submissiveness) Peacemaking (instead has inability to handle conflict)
    Borderline Personality Emotional Stability (instead has emotional instability) Stable Self-Image (instead has unstable self-image) Stable Relationships (instead has intense, chaotic relationships)

    A Emotionally Stable Life (Emotional Stability)

    How does one live a Emotionally Stable life?

    One approach to answering this question is to study the behavior of individuals who live anxious, emotionally unstable lives. Could the opposite of their maladaptive behavior define how to live a Emotionally Stable life?

    Research has shown that anxiety and emotional instability highly correlates with low scores on the emotional stability personality dimension. The personality disorders that have the lowest scores on the emotional stability personality dimension are the Avoidant, Dependent, and Borderline Personality Disorders.

    Could the opposite of the personality traits seen in the Avoidant, Dependent, and Borderline Personality Disorders be a clue as to how to live a Emotionally Stable life? If so, the right side of the following table would define a calm, emotionally stable life. (This table uses DSM-5 diagnostic criteria.)


      Avoidant Personality Disorder The Opposite Of Avoidant Personality Disorder
      Avoidance: Sociability:
      Avoids occupational activities that involve significant interpersonal contact, because of her fear of criticism, disapproval, or rejection Doesn't avoid occupational activities that involve significant interpersonal contact, because of any fear of criticism, disapproval, or rejection
      Is unwilling to get involved with people unless she is certain of being liked Is willing to get involved with people even if she is uncertain of being liked
      Shows restraint within intimate relationships because of her fear of being shamed or ridiculed Is not reluctant in intimate relationships because of any fear of being shamed or ridiculed
      Is preoccupied with being criticized or rejected in social situations Doesn't worry excessively about being criticized or rejected in social situations
      Social Anxiety: Self-Confidence:
      Is inhibited in new interpersonal situations because of her feelings of inadequacy Is not inhibited in new interpersonal situations because of any feelings of inadequacy
      Views herself as socially inept, personally unappealing, or inferior to others Does not view herself as socially inept, personally unappealing, or inferior to others
      Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing Is not reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
      Dependent Personality Disorder The Opposite Of Dependent Personality Disorder
      Dependency: Independence:
      Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others Can make everyday decisions without an excessive amount of advice and reassurance from others
      Needs others to assume responsibility for most major areas of her life Assumes responsibility for most major areas of her life
      Has difficulty expressing disagreement with others because of her fear of loss of support or approval Can express disagreement with others
      Has difficulty initiating projects or doing things on her own No difficulty initiating projects or doing things on her own
      Goes to excessive lengths to obtain nurturance and support from others Does not go to excessive lengths to obtain nurturance and support from others
      Feels uncomfortable or helpless when alone because of her exaggerated fears of being unable to cope Feels comfortable when alone
      Urgently seeks another relationship as a source of care and support when a close relationship ends Does not urgently seek another relationship as a source of care and support when a close relationship ends
      Is unrealistically preoccupied with fears of being left to take care of herself Is not preoccupied with fears of being left to take care of herself
      Borderline (Emotionally Unstable) Personality Disorder The Opposite Of Borderline (Emotionally Unstable) Personality Disorder
      Emotional Instability: Emotional Stability:
      Rapidly shifting emotions Stable emotions
      Inappropriate, intense anger or difficulty controlling anger Good anger control
      Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior No suicidal behavior, gestures, or threats, or self-mutilating behavior
      Chronic feelings of emptiness Has meaning and purpose to her life
      Impulsivity: Caution:
      Potentially self-damaging impulsivity (e.g., spending, sex, substance abuse, reckless driving, binge eating) No potentially self-damaging impulsivity
      Unstable, Intense, Chaotic Relationships: Stable Relationships:
      Unstable and intense 'love-hate' relationships Stable, close, long-lasting interpersonal relationships
      Frantic efforts to avoid real or imagined abandonment Can calmly cope with real or imagined abandonment
      Markedly and persistently unstable self-image or sense of self Stable self-image; positive sense of herself

    An Anxious, Emotionally Unstable Life (Negative Emotion)

    How does one live an anxious, emotionally unstable life?

    The following table summarizes the personality traits of individuals with Avoidant, Dependent and Borderline Personality Disorder. Individuals with these low emotional stability personality disorders have marked anxiety or emotional instability. (This table uses ICD-10 diagnostic criteria.)

      The Most Anxious and Emotionally Unstable Personality Traits Examples
      Avoidant Personality Traits:
      Persistent and pervasive feelings of tension and apprehension. "I usually feel tense or nervous."
      Belief that oneself is socially inept, personally unappealing, or inferior to others. "I feel awkward or out of place in social situations."
      Excessive preoccupation about being criticized or rejected in social situations. "I worry a lot that people may not like me."
      Unwillingness to get involved with people unless certain of being liked. "I won't get involved with people until I'm certain they like me."
      Restrictions in lifestyle because of need of security. "A lot of things seem dangerous to me that don't bother most people."
      Avoidance of social or occupational activities that involve significant interpersonal contact, because of fear of criticism, disapproval or rejection. "I keep to myself even when there are other people around."
      Dependent Personality Traits:
      Encouraging or allowing others to make most of one's important life decisions. "I let others make my big decisions for me."
      Subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes. "I find it hard to disagree with people if I depend on them a lot."
      Unwillingness to make even reasonable demands on the people one depends on. "I don't ask favors from people that I depend on a lot."
      Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself. "I usually feel uncomfortable or helpless when I'm alone."
      Preoccupation with fears of being left to take care of oneself. "I worry about being left alone and having to care for myself."
      Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others. "I often seek advice or reassurance about everyday decisions."
      Borderline Personality Traits:
      A marked tendency to quarrelsome behavior and to conflicts with others, especially when impulsive acts are thwarted or criticized "I argue or fight when people try to stop me from doing what I want."
      A marked tendency to act unexpectedly and without consideration of the consequences "I take chances and do reckless things."
      Liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions "Sometimes I get so angry I break or smash things."
      Difficulty in maintaining any course of action that offers no immediate reward "I don't stick with a plan if I don't get results right away."
      Unstable and capricious mood "I'm very moody."
      Disturbances in and uncertainty about self-image, aims and internal preferences (including sexual) "I can't decide what kind of person I want to be."
      Liability to become involved in intense and unstable relationships, often leading to emotional crises "I get into very intense relationships that don't last."
      Excessive efforts to avoid abandonment "I go to extremes to try to keep people from leaving me."
      Recurrent threats or acts of self-harm "A number of times, I've threatened suicide or injured myself on purpose."
      Chronic feelings of emptiness "I often feel empty inside."

    Parental Behaviors Which Increase The Risk Of Developing A Personality Disorder

    Research has shown that genetic, environmental, and prenatal factors all play important roles in the development of personality disorder. Research has also shown that low parental affection and harsh parenting increase the risk of a child later developing a personality disorder.

    "Low affection" was defined as: low parental affection, low parental time spent with the child, poor parental communication with the child, poor home maintenance, low educational aspirations for the child, poor parental supervision, low paternal assistance to the child's mother, and poor paternal role fulfillment. "Harsh parenting" was defined as: harsh punishment, inconsistent maternal enforcement of rules, frequent loud arguments between the parents, difficulty controlling anger toward the child, possessiveness, use of guilt to control the child, and verbal abuse.


    Back to top



    Treatment Guidelines

    Setting Goals In Therapy

      Questions To Ask When Setting Goals

      In The Past Week:
      • WHO: was your problem?

      • EVENT: what did he/she do?

      • RESPONSE: how did you respond to that event?

      • OUTCOME: did your response help?

      • TRIGGER: what did you do that could have triggered this problem?

      • GOAL: what life skill(s) do you have to work on? (from checklist)

      Example Of Setting Goals In Interviewing A Person With Dependent Personality Disorder

      In The Past Week:
      • WHO: was your problem?
        "My boyfriend."

      • EVENT: what did he/she do?
        "I just found out he's sleeping with my best girlfriend."

      • RESPONSE: how did you respond to that event?
        "I felt so angry at both of them. I couldn't stand for this, but I couldn't walk out on my boyfriend. So I don't know what to do."

      • OUTCOME: did your response help?
        "No, I'm paralyzed - I don't want to lose either my girlfriend or my boyfriend. But my doing nothing about this is making me sick."

      • TRIGGER: what did you do that could have triggered this problem?
        "This isn't the first time that my boyfriend has cheated on me, but I never do anything about it."

      • GOAL: what life skill(s) do you have to work on? (from checklist)
        "I want to work on: (1) Independence ("not fearing rejection, being alone, or being temporarily separated from loved ones"), and (2) Extraversion ("being confident and direct in claiming one's rights or putting forward one's views")."

    Back to top



    Self-Help Resources

    Improving Positive Behavior

    Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

    This habit of planning your day in the morning, and reviewing your day in the evening, is a time-proven technique for more successful living.

    Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.



    Morning Meditation (5-Minute Video)



    Afternoon Meditation (Learn How To Have Healthy Relationships)



    Evening Meditation (5-Minute Video)



    Life Satisfaction Scale (Video)



    Healthy Social Behavior Scale (Video)



    Mental Health Scale (Video)




    Click Here For More Self-Help



    Back to top


      "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

      Lord Kelvin (1824 – 1907)


    • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

    • Canadian researchers who commit scientific fraud are protected by privacy laws: There are criminals in every community - even in the scientific research community (especially if a lot of money is at stake). Criminal researchers can hide their fraud behind outdated privacy laws.

    • The power of asking "what if?"

    • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

    • Criteria For High Quality Research Studies

    • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

      • Randomized Controlled Trial:
        Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

      • Representative Sample:
        Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

      • Single Blind Trial:
        Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

      • Double Blind Trial (Better Than Single Blind Trial):
        Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

      • Baseline Comparability:
        Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

      • Confounding Factors:
        Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

      • Intervention Integrity:
        Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

      • Statistical analysis:
        Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

        Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

          Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

          Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

          Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

        Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

      • Completeness of follow-up data:
        Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

      • Handling of missing data:
        Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

      • Replication of Findings:
        Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

      • Fraud:
        Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

        • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

        • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

        • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

        • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

        • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

        • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

        • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

        • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

    • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

    • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

    • Not All Scientific Studies Are Created Equal - video

    • The efficacy of psychological, educational, and behavioral treatment

    • Estimating the reproducibility of psychological science

    • Psychologists grapple with validity of research

    • Industry sponsorship and research outcome (Review) - Cochrane Library

    • 'We've been deceived': Many clinical trial results are never published - (text and video)

    • Junk science misleading doctors and researchers

    • Junk science under spotlight after controversial firm buys Canadian journals

    • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

    • When Evidence Says No, But Doctors Say Yes


    • Cochrane Reviews (the best evidence-based, standardized reviews available)

    Research Topics

    Dependent Personality Disorder - Latest Research (2016-2017)


    Back to top



    Which Behavioral Dimensions Are Involved?

    Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

    This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

    These 5 major dimensions of human behavior seem to represent 5 major dimensions whereby our early ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, and calm.

    Which Dimensions of Human Behavior are Impaired in Dependent Personality Disorder?

    THE POSITIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THE NEGATIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THIS DISORDER
    Agreeableness Antagonism       Agreeableness
    Conscientiousness Disinhibition       Conscientiousness
    Intellect Decreased Intellect       Intellect
    Sociability (Extraversion) Detachment       Sociability (Extraversion)
    Emotional Stability Negative Emotion       Negative Emotion



    The 5 Major Dimensions of Mental Illness

    The Big 5 Factors or dimensions of mental illness each has a healthy side and an unhealthy side. Thus the Big 5 Factors are: (1) Agreeableness vs. Antagonism, (2) Conscientiousness vs. Disinhibition, (3) Intellect vs. Decreased Intellect, (4) Sociability (Extraversion) vs. Detachment (Introversion), and (5) Emotional Stability vs. Negative Emotion.

    The Following Will Only Discuss The Dimension of Mental Illness That Is Abnormal In This Disorder

    The problems that are diagnostic of this disorder are highlighted in   Pink  . Other problems that are often seen in this disorder are highlighted in   Yellow  .



    Treatment Goals for Negative Emotion In Dependent Personality Disorder

    EMOTIONAL STABILITY VS. NEGATIVE EMOTION
    .
    EMOTIONAL STABILITY
    .
    Description: Emotional Stability is synonymous with being calm and emotionally stable. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. High emotional stability is associated with better: longevity, leadership, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate safety from danger.)
    Descriptors: Calm, even-tempered, peaceful, confident
    Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
    "I am relaxed, and I handle stress well."
    "I am emotionally stable, and not easily upset."
    "I remain calm in tense situations."
    "I rarely get irritated."
    "I keep my emotions under control."
    "I rarely lose my composure."
    "I am not easily annoyed."
    "I seldom feel blue."
    "I feel comfortable with myself."
    "I rarely feel depressed."
    "I am not embarrassed easily."
    .
    NEGATIVE EMOTION
    .
    Description: Degree to which people experience persistent anxiety or depression and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
    Descriptors: Emotionally unstable, anxious, separation-insecure, depressed, self-conscious, oversensitive, vulnerable.
    Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
    Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Negative Emotion or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
    .
    * Emotional Instability:
    "I get emotional easily, often for very little reason."
    "I get emotional over every little thing."
    "My emotions are unpredictable."
    "I never know where my emotions will go from moment to moment."
    "I am a highly emotional person."
    "I have much stronger emotional reactions than almost everyone else."
    "My emotions sometimes change for no good reason."
    "I get angry easily."
    "I get upset easily."
    "I change my mood a lot."
    "I am a person whose moods go up and down easily."
    "I get easily agitated."
    "I can be stirred up easily."
    .
    * Anxiety:
    "I worry about almost everything."
    "I'm always fearful or on edge about bad things that might happen."
    "I always expect the worst to happen."
    "I am a very anxious person."
    "I get very nervous when I think about the future."
    "I often worry that something bad will happen due to mistakes I made in the past."
    "I am filled with doubts about things."
    "I feel threatened easily."
    "I am afraid of many things."
    .
    * Separation Insecurity:
    "I fear being alone in life more than anything else."
    "I can't stand being left alone, even for a few hours."
    "I’d rather be in a bad relationship than be alone."
    "I'll do just about anything to keep someone from abandoning me."
    "I dread being without someone to love me."
    .
    * Submissiveness:
    "I usually do what others think I should do."
    "I do what other people tell me to do."
    "I change what I do depending on what others want."
    .
    * Perseveration:
    "I get stuck on one way of doing things, even when it's clear it won't work."
    "I get stuck on things a lot."
    "It is hard for me to shift from one activity to another."
    "I get fixated on certain things and can’t stop."
    "I feel compelled to go on with things even when it makes little sense to do so."
    "I keep approaching things the same way, even when it isn’t working."
    .
    * Depressed Mood:
    "I have no worth as a person."
    "Everything seems pointless to me."
    "I often feel like a failure."
    "The world would be better off if I were dead."
    "The future looks really hopeless to me."
    "I often feel just miserable."
    "I'm very dissatisfied with myself."
    "I often feel like nothing I do really matters."
    "I know I'll commit suicide sooner or later."
    "I talk about suicide a lot."
    "I feel guilty much of the time."
    "I'm so ashamed by how I've let people down in lots of little ways."
    "I am easily discouraged."
    "I become overwhelmed by events."
    .
    ("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
    *MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.



    The "Big 5" Dimensions of Personality and Personality Disorders

    There are two free online personality tests that assess your personality in terms of the "Big 5" dimensions of personality. The following diagram shows the relationship between the "Big 5" dimensions of personality and personality disorders. This diagram is based on the research of Sam Gosling, Jason Rentfrow, and Bill Swann, Gerard Saucier, Colin G. DeYoung, and Douglas Samuel and Thomas Widiger.


    Enlarge Image


    Enlarge Image

    Personality Disorders Scoring Low On Emotional Stability

    In personality testing, individuals with Dependent, Avoidant or Borderline Personality Disorders often have a low emotional stability test score.



    Low emotional stability test scores are associated with negative emotion (i.e., anxiety, depression and anger). The following scale lists the emotions and behaviors most associated with emotional stability.

    EMOTIONAL STABILITY NEGATIVE EMOTION
    Emotional Stability Emotional Instability
    Having a stable and predictable mood Over-reacting to events with rapidly changing, intense, unpredictable emotions
    Sense of Purpose No Sense of Purpose
    Feeling that one’s life has a sense of purpose, direction or meaning; knowing one’s passion Wandering aimlessly through life without purpose, direction, meaning or a passion
    Social Stability Social Instability
    Having a stable and peaceful social life Unstable and stormy social life; frequently going from one social crisis to another
    Self-Appreciation Self-Depreciation
    Having a good opinion of oneself; feeling capable and of worth; good self-esteem Having a poor opinion of oneself; feeling worthless or useless; low self-esteem
    Optimism Pessimism
    Having a positive outlook on life; expecting a good outcome; hopeful; not giving up too easily Having a negative outlook on life; expecting the worst outcome; giving up too easily
    Social Support Lack of Social Support
    Having friends to turn to in times of need or crisis; having supportive companionship Feeling there is nobody to talk to, or to turn to in times of need or crisis; lacking companionship
    Independence Separation Anxiety
    Not fearing rejection, being alone, or being temporarily separated from loved ones Fear of abandonment; fear of rejection by, or separation from, significant others
    Assertiveness Submissiveness
    Being confident to think or express your own ideas or opinions Humble obedience and unassertiveness; frequently seeks advice and reassurance
    Peacemaking Difficulty Handling Conflict
    Skillfully preventing (or handling) conflict within a group or family Difficulty handling conflict with others

    Internet Mental Health: Emotional Stability Scale


    The "Big 5 Factors" of Personality as Shown In Dogs

    The same "Big 5 Factors" of personality found in humans can be found in dogs. This makes sense because dogs, like humans, are a social species.



    AGREEABLENESS VS. ANTAGONISM
    .
    Agreeableness ("Friend")
    .
    Dog is friendly towards unfamiliar people.
    Dog is friendly towards other dogs.
    When off leash, dog comes immediately when called.
    Dog willingly shares toys with other dogs.
    Dog leaves food or objects alone when told to do so.
    .
    Antagonism ("Foe")
    .
    Dog is dominant over other dogs.
    Dog is assertive with other dogs (e.g., if in a home with other dogs, when greeting).
    Dog behaves aggressively towards unfamiliar people.
    Dog shows aggression when nervous or fearful.
    Dog aggressively guards coveted items (e.g., stolen item, treats, food bowl).
    Dog is quick to sneak out through open doors, gates.

    CONSCIENTIOUSNESS VS. DISINHIBITION
    .
    Conscientiousness ("Self-Controlled")
    .
    Dog works at tasks (e.g., getting treats out of a dispenser, shredding toys) until entirely finished.
    Dog works hard all day herding or pulling a sleigh (if a "working dog" on the farm or in the snow). *
    Dog is curious.
    .
    Disinhibition ("Disinhibited")
    .
    Dog is boisterous.
    Dog seeks constant activity.
    Dog is very excitable around other dogs.

    INTELLECT VS. DECREASED INTELLECT
    .
    Open To Experience ("Open-Minded")
    .
    Dog is able to focus on a task in a distracting situation (e.g., loud or busy places, around other dogs).
    .
    Closed To Experience ("Closed-Minded")
    .
    Dog is slow to respond to corrections.
    Dog ignores commands.
    Dog is slow to learn new tricks or tasks.

    SOCIABILITY (EXTRAVERSION) VS. DETACHMENT
    .
    Sociability ("Approach")
    .
    Dog is attention seeking (e.g., nuzzling, pawing or jumping up on family members looking for attention and physical contact).*
    Dog seeks companionship from people.
    Dog is affectionate.
    .
    Detachment ("Avoidance")
    .
    Dog is aloof.
    Dog gets bored in play quickly.
    Dog is lethargic.

    EMOTIONAL STABILITY VS. NEGATIVE EMOTION
    .
    Emotional Stability ("Safety")
    .
    Dog tends to be calm.
    Dog is relaxed when greeting people.
    Dog is confident.
    Dog adapts easily to new situations and environments.
    .
    Negative Emotion ("Danger")
    .
    Dog is anxious.
    Dog is shy.
    Dog behaves fearfully towards unfamiliar people.
    Dog exhibits fearful behaviors when restrained.
    Dog avoids other dogs.
    Dog behaves fearfully towards other dogs.
    Dog behaves submissively (e.g., rolls over, avoids eye contact, licks lips) when greeting other dogs.
    .
    Modified from Jones, A. C. (2009). Development and validation of a dog personality questionnaire. Ph.D. Thesis. University of Texas, Austin.

    * New items added by Phillip W. Long MD


    Personality Difference Between Dogs and Humans

    Dogs and humans are strikingly similar on 4 of the "Big 5 Factors" of personality. However, dogs and humans are quite different on the "Conscientiousness" factor - because the canine brain is designed for hunting, not building. That's why dogs don't build dog houses.

    The Brain and the "Big-5 Factors" of Personality In A Social Species

    The "Big-5 Factors" of personality represent basic brain functions in social species. For example, when a male approaches a female, the female must: (1) decide whether the male is friend or foe ["Agreeableness"], (2) decide if this represents safety or danger ["Emotional Stability"], (3) decide whether to approach or avoid him ["Sociability"], (4) decide whether to be self-controlled or disinhibited ["Conscientiousness"], and (5) learn from this experience ["Openness to Experience"].

    The "Big-5 Factors" of Human and Cat Personality

    Cats are a social species, but less social than dogs. Nevertheless, cats also show the "Big 5 Factors" of personality.





    Primate Evolution

    There appears to be three different ways in which primates have evolved socially:
    • The chimpanzees have evolved to be socially antagonistic, competitive, callous, and manipulative. Chimpanzees are the only primates (apart from humans) that wage organized war. Thus chimpanzee social behavior most closely mirrors the antagonistic behavior of the antisocial-narcissistic-borderline-histrionic cluster of personality disorders.

    • In contrast, the bonobos have evolved to be socially anxious, peaceful, cooperative, and loving. Thus bonobo social behavior most closely mirrors the negative emotion (anxious) behavior of the avoidant-dependent cluster of personality disorders.

    • Another separate evolutionary path was followed by the orangutans. They evolved to become solitary hermits. Thus orangutan social behavior most closely mirrors the detached behavior of the paranoid-schizoid-schizotypal cluster of personality disorders.


    Back to top

    Internet Mental Health © 1995-2018 Phillip W. Long, M.D.