A 19-year-old woman comes to the physician because of a 2-day history of difficulty sleeping. She worries that the lack of sleep will ruin her career prospects as a model. She has been coming to the physician multiple times over the past year for minor problems. She is dressed very extravagantly and flirts with the receptionist. When she is asked to sit down in the waiting room, she begins to cry and says that no one listens to her. When she is called to the examination room, she moves close to the physician, repeatedly intends to touch his cheek, and makes inappropriate comments. She does not have a history of self-harm or suicidal ideation. Which of the following is the most likely diagnosis?

Histrionic personality disorder

Schizotypal personality disorder

Borderline personality disorder

Narcissistic personality disorder

A 28-year-old woman is brought to a counselor by her father after he found out that she is being physically abused by her husband. The father reports that she refuses to end the relationship with her husband despite the physical abuse. She says that she feels uneasy when her husband is not around. She adds, “I'm worried that if I leave him, my life will only get worse.” She has never been employed since they got married because she is convinced that nobody would hire her. Her husband takes care of most household errands and pays all of the bills. Physical examination shows several bruises on the thighs and back. Which of the following is the most likely diagnosis?

Borderline personality disorder

A 34-year-old female presents to a counselor at the urging of her parents because they are concerned that she might be depressed. After recently breaking up with her long-term boyfriend, she moved back in with her parents because she could not handle making decisions alone. Soon after their breakup, she started going on 5–7 dates a week. She has been unemployed for 3 years, as her boyfriend took care of all the bills. In the past year, she thought of looking for a job but never felt confident enough to start the process. Her mom arranges her doctor's appointments and handles her car maintenance. She describes feeling uneasy when she is alone. She has hypothyroidism treated with levothyroxine. She does not smoke or drink alcohol. Vital signs are normal. Mental status exam shows a neutral affect. Neurologic examination shows no focal findings. Which of the following is the most likely diagnosis?

Histrionic personality disorder

Borderline personality disorder

A 27-year-old woman is brought to the physician by her parents because they are concerned about her mood. They say that she has “not been herself” since the death of her friend, who was killed 3 weeks ago when the fighter jet he piloted was shot down overseas. She says that since the incident, she feels sad and alone. She reports having repeated nightmares about her friend's death. Her appetite has decreased, but she is still eating regularly and is otherwise able to take care of herself. She does not leave her home for any social activities and avoids visits from friends. She went back to work after taking 1 week off after the incident. Her vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she appears sad, has a full range of affect, and is cooperative. In addition to taking measures to evaluate this patient's anxiety, which of the following is the most appropriate statement by the physician at this time?

I understand that the sudden loss of your friend has affected you deeply. Sometimes in situations like yours, people have thoughts that life is not worth living; have you had such thoughts?

I can see that you have gone through a lot recently, but I think that your reaction is especially severe and has persisted for longer than normal. Would you be open to therapy or medication to help you manage better?

I am worried that you may be having an abnormally severe reaction to what is an understandably stressful event. I recommend attending behavioral therapy sessions to help you deal with this challenge.

Your grief over the loss of your friend appears to have a negative effect on your social and functional capabilities. I recommend starting antidepressants to help you deal with this challenge.

I'm so sorry, but the loss of loved ones is a part of life. Let's try to find better ways for you to deal with this event.

A 13-year-old boy has been suspended 5 times this year for arguing with teachers. He has presented a pattern of negativism and hostility that has lasted for about 8 months. When asked about the suspensions, he admits that he loses his temper easily and often blames the principal for not being fair to him. He usually finds an argument before finishing his homework. At home, he goes out of his way to annoy his siblings. He gets furious if his legal guardian finds out about it and confiscates his smartphone. Which of the following is the primary behavior characteristic of this patient's most likely diagnosis?

Hostile and disobedient behavior towards authority

Destruction of property and theft

Killing and/or harming small animals

A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with "You're not the boss of me." or "You can't make me." He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can "sometimes be difficult," but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?

Antisocial personality disorder

Dependent personality disorder for USMLE Step 2 CK: High-Yield Psychiatry Lessons

Epidemiology & Etiology - The Clingy Vine

Prevalence: ~0.5% in the general population.
More frequently diagnosed in women.
Common in mental health settings due to help-seeking behavior.
Etiology is multifactorial:
- Psychosocial: Childhood experiences like chronic illness, separation anxiety, or overprotective/authoritarian parenting that discourages autonomy.
- Genetic: Higher incidence in families with anxiety disorders, suggesting a heritable component.
- Cultural: Certain cultural norms may inadvertently foster dependency.

⭐ High risk for experiencing abuse (physical or emotional), as they may tolerate it to avoid the ultimate fear of abandonment.

Overprotective parent stunting child's independence

Clinical Features & Diagnosis (DSM-5) - Can't Go It Alone

A pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation. Diagnosis requires meeting ≥ 5 of the following criteria:

📌 Mnemonic: RELIANCE

Reassurance: Needs excessive advice and reassurance to make everyday decisions.
Expression: Has difficulty expressing disagreement for fear of losing support.
Life Responsibilities: Needs others to assume responsibility for most major areas of their life.
Initiating: Lacks self-confidence, leading to difficulty initiating projects.
Alone: Feels uncomfortable or helpless when alone due to exaggerated fears of being unable to care for themself.
Nurturance: Goes to excessive lengths to obtain nurturance and support.
Companionship: Urgently seeks another relationship as a source of care when a close relationship ends.
Exaggerated Fears: Is unrealistically preoccupied with fears of being left to take care of themself.

⭐ High-Yield: Patients with Dependent Personality Disorder are at an ↑ risk of remaining in abusive relationships due to an intense fear of abandonment.

Differential Diagnosis - Distinguishing Dependency

Key Challenge: Distinguishing core personality traits from dependency arising from other conditions.

Disorder	Key Differentiator from DPD
Borderline PD	Reacts to abandonment with rage, emptiness, & impulsivity, not passivity.
Histrionic PD	Seeks attention actively & theatrically; DPD is self-effacing.
Avoidant PD	Fears humiliation & rejection; avoids relationships unless acceptance is certain.
Agoraphobia	Dependency stems from fear of panic attacks, not a pervasive need for care.

Other Psychiatric Disorders: E.g., Major Depressive Disorder, Panic Disorder. Dependency subsides as the primary disorder resolves.

⭐ High-Yield Fact: Dependent and Avoidant personality disorders are highly comorbid. Patients often meet criteria for both, with DPD individuals seeking a relationship to be taken care of, and AvPD individuals avoiding relationships for fear of rejection.

Management & Prognosis - Fostering Independence

Psychotherapy: Mainstay of treatment; insight-oriented therapies are most effective.
- Goal: ↑ assertiveness, autonomy, and self-esteem.
- Modalities: Cognitive-behavioral therapy (CBT) and psychodynamic therapy.
Pharmacotherapy:
- No specific medications for DPD itself.
- Used to treat comorbid anxiety or depression (e.g., SSRIs).
Prognosis:
- Functioning can significantly improve with long-term therapy.

⭐ Therapeutic Challenge: The primary goal is to help the patient without fostering dependence on the therapist, which can be a significant hurdle.

Therapeutic Relationship in Patient Independence

High‑Yield Points - ⚡ Biggest Takeaways

Core feature is a pervasive, excessive need to be cared for, leading to submissive, clinging behavior and intense fears of separation.

Struggle with everyday decisions without constant advice and reassurance, and rarely initiate projects due to low self-confidence.

Avoids conflict and is reluctant to disagree for fear of losing support.

When a close relationship ends, they urgently seek another to provide care.

High risk for abusive relationships and co-occurring anxiety or depressive disorders.

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