Dependent personality disorder — criteria, risk and stepped care (MEQ)

(i) Working diagnosis. Dependent personality disorder (DSM-5-TR): general PD criteria plus ≥5 of 8 features — needs others to assume major life responsibilities, difficulty disagreeing for fear of losing support, difficulty initiating projects from lack of self-confidence, feels helpless when alone, urgently seeks another relationship as a source of care when a close relationship ends, and (from history) difficulty making everyday decisions without excessive advice/reassurance — pattern from adolescence, pervasive, impairing. Concurrent major depressive episode is justified by current depressive symptoms and passive suicidal ideation after separation (dual diagnosis). Screen for anxiety disorders and other PD traits. Note active care-enlisting and compliance with controlling partner behaviour is consistent with Bornstein's interactionist view of dependency (active as well as passive strategies), not "mere passivity."^[1][2]

(ii) Differentials with discriminators. Avoidant PD (fear of evaluation/rejection with social inhibition rather than primarily caretaking need — she urgently re-partners rather than avoiding intimacy). Borderline PD (affective instability, identity disturbance, impulsivity, self-harm repertoire — not described as dominant lifelong pattern here, though reassess). Separation anxiety disorder (anxiety-disorder frame; can co-occur). Pure major depression without PD (episode course vs lifelong dependence pattern — both can be true). Cultural/family interdependence without impairment (not fitting her incompetence schema and exploitation). Late-onset organic change (age and history argue against).^[1]

(iii) Risk and safeguarding. Current intent, plan, means, protective factors; hopelessness; depression severity; alcohol/substances; ability to care for self alone; support network quality (new acquaintance may be unsafe); IPV/exploitation given bank-card control history — safety planning, local family-violence pathways, capacity for financial decisions under coercion; means restriction of medications if prescribed; collaborative safety plan with rapid follow-up; least-restrictive disposition matching risk. Do not dismiss as "personality drama."^[1][4]

(iv) Psychological plan. Alliance that validates fear of abandonment without becoming permanent decision-maker. CBT: shared formulation of helplessness beliefs → reassurance-seeking/submissive care-enlisting → skill atrophy → confirmation. Graded hierarchy of independent decisions (appointments, small finances, expressing disagreement safely); behavioural experiments; assertiveness skills; brief graded exposure to aloneness with coping plans; reduce excessive reassurance. If global dependence/abandonment modes dominate, schema therapy — cite Bamelis multicentre RCT effectiveness for PD including Cluster C-relevant samples. Address safety before autonomy goals that increase risk in unsafe relationships. Measurement (depression scale + functional autonomy goals).^[1][2][3]

(v) Pharmacotherapy principles. No drug treats DPD as a whole. For comorbid major depression, first-line SSRI is appropriate alongside psychotherapy. Example: sertraline 50 mg orally once daily, early review (1–2 weeks) for activation and suicidality, titrate toward 50–150 mg daily as tolerated with response review at 6–12 weeks; counsel sexual side effects and discontinuation; limited dispensing given suicidal ideation. Avoid chronic benzodiazepines as the only separation-anxiety solution. Stop/review dates and measurement-based care. Network meta-analysis supports multiple antidepressants as options in adult MDD — choose one, monitor, do not stack polypharmacy for "personality."^[5]