When illness becomes a bond: dependent personality disorder comorbid with functional neurological disorder and psychotic features

Background and Aims

Dependent Personality Disorder (DPD) is characterised by a persistent and excessive need for care, resulting in submissive, clingy behaviour and fears of separation. Individuals often struggle with everyday decisions without reassurance, rely heavily on others for responsibility, and quickly seek new relationships when support is lost. When co-occurring with Functional Neurological Disorder (FND), obsessive-compulsive disorder (OCD), or psychotic features, the clinical picture becomes more complex and potentially treatment-resistant. Illness behaviour may be maintained through dependency patterns and reinforcement of the sick role within close relationships, as described in the literature [1]. This case aims to illustrate how psychiatric symptoms can be perpetuated within a dependent attachment framework and to highlight the therapeutic implications of recognising this dynamic.

Methods

A detailed longitudinal case review was conducted drawing on inpatient records, outpatient follow-up notes, neurological and internal medicine consultations, and collateral information obtained from the primary caregiver. Psychopathology was assessed through structured clinical interviews, mental state examinations, and review of prior diagnostic evaluations spanning over two decades.

Results

Ü.M.G. is a 42-year-old single woman who first presented to psychiatry at age 17 with contamination obsessions, compulsive handwashing, social withdrawal, and command auditory hallucinations. Over more than two decades she accumulated diagnoses of OCD, FND, non-organic psychosis, and DPD, alongside ten inpatient admissions, two series of electroconvulsive therapy, nasogastric and percutaneous endoscopic gastrostomy tube feeding, and an extensive pharmacological history including antipsychotics, antidepressants, and benzodiazepines. Prior to her most recent admission she had been bedridden for approximately two years, unable to walk, dress, or feed herself orally. A key clinical observation was that motor initiation was markedly better when the patient was alone than when her mother was present, revealing the reinforcing role of the caregiver relationship [2]. Her mother, who had left employment to become a full-time carer, inadvertently perpetuated dependency through overinvolvement — consistent with secondary gain mechanisms described in the DPD literature [3]. The patient–mother dyad reflected the absence of earlier parental warmth and a conflictual family environment in which illness had become the primary vehicle for attachment. During the index admission, pharmacological treatment was optimised: venlafaxine (serotonin and noradrenaline reuptake inhibitor) was titrated to 300 mg/day and mirtazapine (noradrenergic and specific serotonergic antidepressant) to 45 mg/day, alongside structured psychotherapeutic intervention including behavioural activation, graded motor exercises, and caregiver boundary-setting work. Nasogastric feeding was successfully discontinued. In outpatient follow-up visits continued to the present, the patient is able to walk independently, dress herself, manage her own personal care, and feed herself orally. Conflict with her mother persists, consistent with the chronic interpersonal dependency and fear of separation that characterise DPD [1].

Conclusions

This case demonstrates that in DPD, illness behaviour may extend and amplify functional impairment well beyond what comorbid Axis I diagnoses account for. Caregiver psychoeducation and boundary restructuring are essential yet frequently overlooked components of treatment. Comorbid DPD increases treatment chronicity and pharmacological burden, underscoring the importance of early personality disorder assessment in complex, treatment-resistant psychiatric presentations [4].

References

1. StatPearls Publishing, 2024. Dependent Personality Disorder. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK606086/
2. Stone, J., LaFrance, W.C., Brown, R., Spiegel, D., Levenson, J.L., Sharpe, M., 2011. Conversion disorder: current problems and potential solutions for DSM-5. J. Psychosom. Res. 71 (6), 369–376.
3. Malik, M.F.A., Najeeb, B., Ishaque, A., 2022. A case study of psychogenic non-epileptic seizures in a patient with dependent personality disorder. Eur. Psychiatry 65 (S1). http://dx.doi.org/10.1192/j.eurpsy.2022.1180.
4. Tyrer, P., Reed, G.M., Crawford, M.J., 2015. Classification, assessment, prevalence, and effect of personality disorder. Lancet 385 (9969), 717–726.