Impact Of Pds On The Treatment Of Depression

The therapist who identifies the patient as having a PD in addition to the presenting depression has several choices. First, he/she can treat the depression and never deal with the Axis II problem. This might involve pharmacotherapy, psychotherapy, or a combination of both. Second, the therapist may decide that he/she needs to deal with the PD rather quickly, inasmuch as the Axis II disorder is stimulating and fueling the depression. Third, the depression may be the initial target of therapy, in that the therapist decides that the depression is exacerbating the PD symptoms. In most cases, however, the Axis I and Axis II disorders are bidirectionally stimulating, so that the Axis I disorder—in this case, the depression—exacerbates the Axis II disorder. In turn, the Axis II disorder fuels the depression. What occurs is a continuous loop, with each axis stimulating the other, with a net result in a loss of adaptation. The clinician is then left asking him/herself where to intervene in this loop.

In all cases, the depression needs to be the primary focus of the therapy for several reasons. First, depression is most likely what has brought the patient to therapy. Second, it is the subject of the initial therapy contract. Third, the depression may yield more easily than the PD to phar-macotherapeutic interventions. Fourth, most clinicians have more skill at treating depression than they have in treating PDs. Fifth, for the patient, relief of the depression lifting may be a satisfactory therapeutic outcome. Finally, as noted earlier, the easing of the depression in terms of depth, duration, or frequency may have a salutary effect on the Axis II disorder(s). A second factor to consider is that the treatment of the depression can be a skills-building area in which the patient gains skills that he/she may then apply to the more complex and difficult PD symptoms.

The presence of comorbid conditions greatly impacts and complicates the psychotherapy process, in that separate and unique characteristics of each disorder must be accounted for at every point in the therapeutic process. PDs negatively impact the overall appearance and manifestation of co-occurring depression and/or anxiety (Daley et al., 1999). Additionally, several studies have indicated that the presence of comorbid conditions significantly diminishes treatment effects (reviewed in Beck et al., 2004).

Patients with PDs typically do not believe they have interpersonal problems with others; instead, they blame problematic situations on others. These patients more likely believe that the difficulties that they experience both inter- and intrapersonally stem from their being victimized by others or by the "system." It is less likely that they are prepared or willing to assume personal responsibility for their difficulties, inasmuch as the behaviors noted in the PD diagnostic criteria sets are ego-syntonic for these individuals. There are, however, some patients with PDs who are aware of their problematic behaviors; however, they lack the skills and/or the motivation to cope effectively or to change behaviors. Given the aforementioned characteristics of depressed patients with comorbid PDs, it is understandable how such behaviors impede most therapeutic interventions, particularly when PDs are not identified or addressed. Assessing and conceptualizing problems become extremely fragmented, and the ability to establish a working alliance becomes increasingly difficult; as a result, treatment plan goals are not successfully set or ultimately met.

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