Comorbidity General Issues

The comorbidity of personality disorders with other psychiatric disorders and with other personality disorders presents a special challenge and problem for clinicians and researchers. Since the multiaxial system was created, the DSM has inadvertently put personality disorders in a somewhat secondary status by placing them on Axis II, an afterthought to an Axis I assessment. It has even been suggested that clinicians have long been trained to focus on Axis I pathology, as if it is more important than identifying Axis II personality disorders (e.g., Paris, 2003). Paris has also noted that it is all too common to see a diagnosis on Axis I or multiple diagnoses on Axis I with the notation, 799.9 Diagnosis Deferred on Axis II. Yet, whereas Axis I anxiety attacks or depressive episodes may be relatively transitory, all the personality disorders are characterized by their chronicity and pervasive impact on the individual's life. Thus, focusing diagnosis and subsequent treatment plans on adventitious, episodic Axis I pathologies without consideration of patients' special vulnerabilities due to their poorly developed personality structures is a mistake, one that invites psychotherapeutic failure.

The mounting evidence suggests that the consequences of failing to identify and attend to personality disorders among older patients are steep, including a lengthier therapy, more frequent treatment failures, and unnecessary complications to the therapeutic relationship (Sadavoy, 1999). A further complication is that because older patients have likely exhibited their dysfunctional personality traits for much of their adult life (and in some cases may have benefited from their interpersonal style), it is increasingly likely that they will not view their personality as part of the problem and may not even be cognizant of any personality pathology. Many problems that occasion a mental health evaluation in personality disordered older persons may be overshadowed by the signs and symptoms of an Axis I pathology, such as depressive episodes, anxiety problems, or somatoform disorders. Perhaps even worse, the problems may be seen as stemming directly from Axis III medical problems rather than being identified as manifestations of an underlying personality disturbance.

There is a confluence of factors for many clinicians' reluctance to diagnose personality disorders, particularly in older persons. Some prominent reasons include the lack of awareness of the problem in the older cohort (Kroessler, 1990) and the poor fit of some diagnostic criteria among older adults (Rosowsky & Gurian, 1991). Another reason for the reluctance of clinicians to diagnose personality disorders may be the negative connotations associated with them such as their chronic-ity, their immalleable genetic temperamental basis, and their generally poor prognoses. For some clinicians, a personality disorder diagnosis perhaps means admitting defeat before even beginning therapy (e.g., Paris, 2003), and the prognosis might seem even more hopeless in the face of advancing age. As discussed later in this book, it is critically important for clinicians to be aware of Axis II personality disorders and their traits or features and include them in the case formulation and treatment planning.

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