The Treatment of Personality Disorders with 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 on Axis II can be reliably paired with at least one Axis I disorder (Cloninger, 2007, p. xi). Therefore, we conclude our section on the treatment of personality disorders by revisiting this important topic, specifically focusing 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. Therefore, a thorough evaluation is necessary. The co-occurrence of different disorders may affect what type of treatment is recommended, and may 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.

Often people with both an Axis I disorder and an Axis II personality disorder seek treatment because the acute symptoms of the Axis I disorder (such as anxiety or depression) are causing them distress. Recall, some people with personality disorders seem less bothered by their personality disorder than the people with whom they must interact, or are unaware of the impact of their disorder on their lives. When someone is seeking treatment for the symptoms of an acute Axis I disorder, the presence of a personality disorder on Axis II will likely complicate the treatment process for any number of reasons. 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, and/or it may be occurring in 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 alcohol abuse may be much more difficult for someone with a Borderline Personality Disorder because of these problems with emotional dysregulation 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 personality disorders are extremely distrustful, so that they have a hard time trusting their treatment providers. Others have a pattern of first idealizing their treatment provider, and then becoming quickly disillusioned by them, so that they may leave therapy prematurely. In addition, a therapist must often address unpleasant topics such as a client's negative behavior, in an honest and forthright manner which can certainly cause the client to experience some discomfort, frustration, or annoyance. Therefore, in order to successfully participate in therapy a person must be able to tolerate small amounts of discomfort, even momentary anger, in order to benefit from the therapy. As you may recall, some people with personality disorders become easily frustrated and anger quickly. Many people with personality disorders lack the necessary skills to deal with these unpleasant feelings and with interpersonal conflict in an effective manner. Thus, they become easily frustrated with therapy process and leave before they are able to reap the benefits of treatment. In addition, some people with personality disorders engage in behaviors that are self-destructive, such as self-injury or substance use, or engage in counter-therapeutic behaviors such as dishonesty, or fail to comply with treatment recommendations. All these difficulties are factors that can complicate treatment of both Axis I and Axis II conditions.

Likewise, the presence of an acute Axis I condition, 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, making it difficult to explore the relationship patterns associated with their personality disorder. Similarly, if a person with an eating disorder is severely underweight, the malnourishment can negatively affect the brain functions that are needed to think clearly, and impair their ability to accurately perceive and interpret their surroundings. Moreover, an eating disorder can be life-threatening so its treatment 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.