Patients with PDs as part of the clinical picture are challenging, resistant, and often difficult to treat. They generally require more resources in terms of time, energy, and support systems, as well as longer duration of therapy than other patients. Therapist reactions to these patients range from empathy to hostility, from fondness to aversion, and the many feelings in between. PDs, by definition, are inflexible, pervasive, stable, and enduring, and lead to clinically significant distress or impairment in functioning (American Psychiatric Association, 2000).

Individuals with PDs are typically unaware of the extent of their disorder, despite the sometimes overwhelming effects of their behaviors on themselves and on those around them. In fact, PDs are considered ego-syntonic to the individual; that is, patients' patterns of thinking, feeling, and relating seem comfortable and familiar to them. When the diagnostic picture is complicated by a comorbid depression, whether MDD, dysthymia, or a DPD, treatment is equally confused and complicated.

This chapter has focused on these comorbid disorders and a discussion ofhow the basic cognitive-behavioral therapy (CBT) model may be adapted for persons with these chronic, severe, and often disabling disorders. Our goal has been to provide clinicians with guidelines in understanding, applying, and conceptualizing these disorders, and in to preparing appropriate treatment planning measures for patients. We discussed several aspects of therapy, with definitions and highlights regarding various issues that may arise when working with these patients. Finally, we offered a number of case examples to illustrate the disorders and the treatment.

Empirical support for the treatment of PDs is sparse, with the exception of BPD. Ideally, as we obtain better recruitment strategies, other PDs can be studied.

Finally, the depression that is often the referral focus, and the first focus of treatment, is central. For this disorder, CBT has many interventions. It is the adaptation of "standard" CBT that makes it effective for treating the comorbid disorders.


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