Treatment complications: Co-occurring Disorders

We have previously reviewed that personality disorders frequently co-occur with other disorders. Robert Cloninger, points out in his introductory chapter to the book Personality Disorders- Towards the DSM V, that nearly every personality disorder can be reliably paired with at least one other disorder (Cloninger, 2007, p. xi).  Therefore, we conclude our section on the treatment of personality disorders by revisiting this important topic. We will specifically focus on how the co-occurrence of disorders impacts the treatment process.

It is important for the clinician to keep in mind that some disorders frequently co-occur.  In addition, many disorders are very similar, yet distinct.  Therefore, a thorough evaluation is necessary. The co-occurrence of different disorders may affect what type of treatment is recommended. It may further determine the priority of treatment goals.  The clinician may decide to recommend a specific type of therapy, or to prescribe certain medications that will address the co-occurring conditions.

People with co-occurring disorders will often seek treatment because of their most obvious and distressing symptoms.  As we have previously noted, some people with personality disorders seem less bothered by their personality disorder than the people with whom they must interact.  Alternatively, they may be unaware of the impact of their disorder on their lives. When someone is seeking relief from distressing symptoms, such as depression or anxiety, the presence of a personality disorder will likely complicate the treatment process. Sometimes the causal relationship between the symptoms of the two disorders can complicate treatment.  For instance, suppose someone comes to treatment for alcohol abuse following a DUI.  The presence of an underlying Borderline Personality Disorder would suggest that the abuse of alcohol may be occurring as a result of impulsivity. It may also result from an effort to regulate intense emotions.  Both of these causal "reasons" are rooted in the symptoms of the Borderline Personality Disorder.  Therefore, the treatment of an alcohol use disorder is complicated by a Borderline Personality Disorder because of these problems with emotional dys-regulation and impulsivity.

Another factor that complicates the treatment process is that people with personality disorders tend to have great difficulties in interpersonal relationships. Regardless of the reason for seeking therapy, the therapy relationship is itself an interpersonal one.  Personality disorders can interfere with the formation of this healing, therapeutic relationship.  Some people with certain personality disorders (such as Paranoid Personality Disorder) are extremely distrustful. They may find it very difficult to trust their treatment providers. Other personality disorders, such as Borderline Personality Disorder are characterized by a pattern of first idealizing their treatment provider, and then becoming quickly disillusioned by them. As a result, they may leave therapy prematurely.

Therapists must often address unpleasant topics such as a client's negative behavior, in an honest and forthright manner. This can certainly cause people to experience some discomfort, frustration, or annoyance.  Therefore, in order to benefit from therapy, a person must be able to tolerate small amounts of discomfort, even momentary anger.. As you may recall, some people with personality disorders become easily frustrated and anger quickly.  Many people with personality disorders lack the necessary interpersonal skills to deal with unpleasant feelings and conflict. Thus, they become easily frustrated with therapy process and leave before they are able to reap the benefits.

In addition, some people with personality disorders engage in behaviors that are self-destructive. This may include self-injury or substance use, but also includes counter-therapeutic behaviors such as dishonesty, or the unwillingness to follow treatment recommendations.  All these difficulties are factors that can complicate treatment.

Likewise, the presence of acute conditions, such as a substance use disorder, an eating disorder, or a manic episode of a Bipolar Disorder, can complicate the treatment of a personality disorder.  For instance, when someone is in an acute manic phase of a Bipolar Disorder, their thoughts are racing and disorganized. This makes it difficult to explore the relationship patterns associated with their personality disorder.  Similarly, a person with an eating disorder may be severely underweight and malnourished. These conditions may negatively affect the brain's ability to think clearly. I can also impair the ability to accurately perceive and interpret their surroundings. Moreover, an eating disorder can be life-threatening.  Quite obviously, life-threatening behaviors must be prioritized over interpersonal difficulties.  It is not difficult to imagine how each of these co-occurring disorders would negatively impact attempts to explore relationship patterns that may be causing the client difficulties.  In general, the more severe and acute conditions must be prioritized.  Once the person is stabilized, the underlying personality issues can be addressed.