[Serious] Certified mental health providers, what is the most difficult disorder(s) to treat and why?

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[u/literal9]

Based on my professional experience, treating eating disorders can be very tricky. The disorder is very competitive by nature and can be worsened by people expressing concern for them. The disease tells the brain that getting sicker means they’re succeeding. It has incredibly high mortality rates and insurance (USA) is often reluctant to treat it. It requires a lot of specialized training for good reason.

[u/wischmopp → u/literal9]

I also feel like treatment protocols, even if they are the best we can implement based on empirical evidence and on our financial resources, are inherently in conflict with the nature of restrictive eating disorders. Especially inpatient treatment is laser-focused on fast weight gain. On one hand, this is absolutely necessary - not only because the patient might die if they remain at an incredibly low BMI, but also because research suggests that psychotherapy will not work if the body cannot spare the nutrients required to build new brain pathways.

On the other hand, it fucking sucks because the body will be transformed much faster than the mind can keep up with, so when you're discharged after 6 weeks, you're 10-15 pounds heavier but have not received nearly enough psychotherapy to make significant changes to your mindset yet. You're still in the same old head of yours, and that head of yours still hates "feeling fat" and is completely disgusted with your new body, so you'll slip right back into restriction. You're probably also traumatised by the fact that you had to completely give up control and bodily autonomy in treatment (if you refuse to eat a specific food item for any reason, you'll lose "privileges" that are necessary for your quality of life since the staff have no way to distinguish disordered reasons from non-disordered ones; "I legitimately always hated the taste and texture of peanut butter" looks like "I am scared of peanut butter because it's high-calorie", so you need to eat the peanut butter, and "I've been vegan for ethical reasons for way longer than I've had an eating disorder" looks like "I am restricting entire food groups due to my eating disorder", so you have to eat the cheese. And people watch you piss and shit, and you get strip-searched for heavy things you may have hidden in your underwear to obfuscate weight loss, and you're not allowed to walk, and I completely understand why this is necessary but I still hate it). Due to these negative experiences, you'll want to avoid going back to inpatient treatment for as long as humanly possible. All of this is extremely hard to deal with even if you DO realise that you desperately need help and even if you ARE highly intrinsically motivated to recover. I wish there was a way to treat the Being Horrified By Weight Gain Disorder in an inpatient setting better than "making them gain lots of weight and then throwing them out while they're still Horrified By Weight Gain, oh and they also have hospitalisation trauma now".

To a lesser degree, this also applies to outpatient treatment. Especially in cognitive-behavioural frameworks, therapy often focuses on "training yourself into healthier habits", it's a lot of "making a meal plan and sticking to it" and "writing food diaries and documenting your emotions and thoughts so you and the therapist can work on these specific emotions and thoughts. But this also means that you'll be asked to gain weight before the underlying reasons for your eating disorder can be adressed, which is often a complex interplay of childhood/teenage trauma, obssesive-compulsive-esque control issues, and horrible self-worth. I know that CBT is the gold standard for anorexia treatment and is backed by lots of empirical evidence, but from the perspective of a person who went through eating disorder therapy, has a B.Sc. in psychology, and has worked as a psychiatric nurse for 7 years now, I still wish there was a better way. For me personally, the meal plans and food diaries and cognitive interventions targeted at specific thoughs and behaviours with an ultra small scope did absolutely nothing until I finally got my therapist to address the foundational shit that caused all these thoughts and behaviours to begin with.

[u/lilybug981 → u/wischmopp]

I ran into issues when my mental health was being taken seriously by doctors during the process of getting diagnosed with C-PTSD. I had grown up with food insecurity due to simple poverty, and had lost my ability to properly feel hunger. I had also recently had my heart get damaged by a virus and had dropped weight I couldn't afford to lose from illness. While I'd otherwise physically recovered, I couldn't gain weight. So, while being treated for PTSD, my weight was flagged.

When the concern of an eating disorder was expressed, my doctors couldn't just take my word that I wasn't experiencing anything of the sort. They could act on me telling them I couldn't eat more because I just wasn't hungry; I was prescribed an antidepressant that is known to increase appetite and cause weight gain. I probably helped my own case by welcoming that over being distressed. Still, my food intake had to be tracked and I had to talk in depth about my emotions surrounding food.

Everyone involved kept sheepishly trying to assure me that they weren't accusing me of lying, and I kept telling them that I understood they had to make sure. I could have been lying, I could have been in denial, and how else could they know for sure? If I had an ED and it was overlooked, it would have been immensely harmful. The mood when it was finally decided that I do not have an ED was very celebratory.

[u/insanelysane1234 → u/lilybug981]

Same. People often suspected I have an ED, but it's all cptsd related.

That's one of the harder changes to get to stick long term. The hunger and appetite just drops to 0 once there's the tiniest bit of stress in my life. So for about two years now I'm constantly gaining a couple of kilos (literally never more than 3) and then losing them again.

I do take vitamins and supplements daily now and that definitely helped with health related issues to the low weight like hair loss, bad skin and such.

Thank you for sharing, I feel more seen now in a task that feels not just undoable sometimes, but unbearable all the time. Like fuck, I just want to able to eat like a normal person please 🙏

[u/stresstwig → u/insanelysane1234]

My dad's wife insisted I had an ED in the 00s when it was just anorexia or bulimia or ED-NOS (and my actual doctors weren't concerned about what I was eating or my weight!!!!) and then about ten years ago ARFID came onto the scene and I absolutely hate that she was technically right. My diet isn't restricted because of control, it's because I literally cannot force myself to eat certain things. My throat closes up, I panic, it's a whole fuckin mess.

I hate that the name of it is "avoidant/restrictive food intake disorder" bc it makes it sound like a choice, but it's really, really not. It's like severe sensory processing issues that affect what I can eat, plus anxiety dialed up to twelve about Bad Texture and Bad Taste.

.... it flared up at dinner tonight for the first time in years and I am not coping well with it 😅

[u/Silver_West_4950 → u/lilybug981]

C-PTSD and bipolar 2 here. This was me almost word for word.

[u/ITriedSoHard419-68 → u/wischmopp]

Especially inpatient treatment is laser-focused on fast weight gain. 

This approach is also extremely shoddy when it comes to disorders like ARFID, where weight often just does not work as a measurement. People always associate eating disorders with being underweight, especially since that's the express goal of most of them, but people with ARFID are often at average or even overweight even when admitted for inpatient. This is because despite often eating very little, people with ARFID are uniquely drawn to heavily-processed foods because they often have sensory issues and these foods have consistent textures and are the same every time. Like anorexics, they also tend to go long periods of time without eating, which slows down their metabolism, but unlike anorexics they generally don't limit how much they're eating in one sitting or gravitate towards low-carb foods. So you get people who've absolutely tanked their metabolisms through borderline starvation then flood their systems with heavily processed, high-carb foods that said metabolism can't keep up with. Because of this dynamic, people with ARFID can often easily meet weight milestones that other eating disorder sufferers tend to struggle with, meanwhile they're not actually getting better because their nutrition, blood sugar, metabolism, and eating habits are all still thoroughly fucked. Worse, tying their 'success' to the numbers on the scale creates a pipeline straight to other, weight-based eating disorders like anorexia and bulimia. It trains them to care about weight when they may not have before, without giving them any other tools. There are absolutely cases where weight gain needs to be the number one priority, I’ve seen what that looks like, but that’s not the majority of cases and at that point it’s crisis management rather than sustainable treatment or a measure of progress. There’s so much more to eating disorders and nutritional health than numbers on a scale and once a measure becomes the target it ceases being a good measure.

[u/aurelin → u/ITriedSoHard419-68]

The other issue with this approach is that it is another way in which people can only get some ED-focused treatments once they've gotten REALLY sick. When I was in active ED, I couldn't access any of the treatments because I wasn't sick enough yet. 

This is fkd up because the earlier it's addressed the better someone's chances are for recovery. But if anorexic people can only get anorexia treatment once they fully match the criteria, their chances are much worse. 

[u/ITriedSoHard419-68 → u/aurelin]

For real. The first doctor I went to about my eating concerns told me I didn’t qualify for an ED diagnosis because I didn’t report losing weight. I’d had these disordered eating patterns since I was 8; I sure HOPE I haven’t lost weight compared to my eight-year-old self. I'd also been so underweight my entire childhood that my doctors didn't even feel safe putting me on stimulants for my ADHD because of the weight loss they can cause and I couldn't afford to lose weight; I just didn't have a "healthy" baseline to compare to because my issues started so young. Never mind that the specific eating disorder in question was also known to cause weight gain as per my above comment. The next time I talked to a professional about it, it was an eating disorder specialist who actually knew what she was doing, and it’d gotten so bad at that point that she immediately referred me to inpatient. I was at a "healthy" weight at the time, for the first time in my life, but I was eating around one meal every two days and dealing with frequent hypoglycemic episodes.

[u/Zealousideal_Bag778 → u/wischmopp]

100% agree.

Currently in a relapse, although never really recovered just yoyo'd between went from restricting and binging.

Finally found a therapist willing to move from CBT to trauma so hopefully will actually recover 

[u/radknees → u/Zealousideal_Bag778]

Wishing you health and healing, internet stranger ❤️

[u/ipsofactoshithead → u/wischmopp]

What needs to happen is that people need to be inpatient for a year tbh. Get them on stable footing before booting them. This will never happen though because insurance won't cover it.

[u/jellifercuz → u/ipsofactoshithead]

In patient for a year would also mean they would likely lose their job, housing, and perhaps their custody of their children. That would be very hard to come back from.

[u/BitterGenX → u/wischmopp]

Thank you for sharing your experience

[u/Sinisterfox23 → u/wischmopp]

God, my partner could have written this exact thing. Same experiences you stated. Ever hear of Renfrew Center(US)? Yeah, the treatment protocols are so obviously detrimental to the emotional well-being of the patient. My partner has been a vegan since a young child, absolutely for ethical reasons. It was really hard for her to try and convince them it wasn’t a disordered behavior. I doubt she did convince them.

That’s amazing you went into psych nursing. Im glad there are thoughtful people like you in the field.

[u/Expensive_Hat_7435 → u/literal9]

Lot of people with eating disorders are also not getting the help they need because health care professionals pay attention to weight a lot even though it’s gone somewhat better direction. But still many people who are not underweight don’t get help until they’ve struggled for years. And the longer you have eating disorder the worse the odds to get better are. It’s the worst for people with non-restrictive eating disorders because they aren’t seen as concerning, but also people with restrictive eating disorders who used to be on the heavier side are in much danger. Often people are dismissive because they assume it’s healthy weight loss, and these people aren’t often taken seriously soon enough

[u/PeterLemonjellow → u/Expensive_Hat_7435]

It never occurred to me that I could possibly have an eating disorder. Our society has had me convinced for four decades that I'm just a loser piece of shit and if I didn't want to be fat then I wouldn't be. It's always confused me so badly, because I just eat when I'm hungry and I eat until I'm full. Trying to diet was always about how much suffering I could endure, because I was always, always hungry.

Turns out that when you finally earn enough money in the US that you can afford therapy, the issue may not be your stomach at all but your brain. My relationship with food and many other things is not based in reality, but I had now way of knowing that because my perceptions are so skewed. I'm in a treatment program now and have a much better understanding of what "normal" eating habits are, and how I've never had them. Medications are helping, too. By the end of this year I'd love to be under 300 pounds... but we'll see. I'll take this as slow and steady as I need to to make sure it's a lasting change.

Eating disorders and mental health in general are so poorly understood in the US. It's infuriating, because it feels like my whole life has been stolen by people blaming me for being sick. I didn't get compassion from anyone... until I could afford to purchase it. Absolutely disgusting culture we've grown in America...

[u/13millimeters → u/PeterLemonjellow]

I just wanted to say I hear and I see you, and you're right to be angry.

[u/PeterLemonjellow → u/13millimeters]

Thank you, I appreciate that (you sound like my new therapist!)

[u/Big-Salt-Energy → u/Expensive_Hat_7435]

35 years with anorexia but I have learned to use different coping methods that are not so destructive and I'm holding my own. I must be doing something right, but everyone else I know with the disorder has sadly died, either from starvation or suicide. It's a beast.

[u/Schwammel → u/Expensive_Hat_7435]

Oh it's fun when you are obese with atypical bulimia (more purging than binging) and everyone, especially doctors, is delighted and congratulate on the weight loss. Yeah!

[u/Carbonatite → u/Schwammel]

One of the most extreme eating disorders I've ever seen flew completely under the radar because she was obese. She literally stopped eating - like would regularly go 3-4 days without any solid food and then eat a couple hundred calories the next day. But because she was fat when she started out, nobody clocked how absurdly dangerous her behavior was. All that mattered was that she was fat and then she was less fat. She lost 60 pounds in less than half a year by just straight up not eating, I think about 8 months in to everything she had lost something like 75 lbs. Just incredibly unhealthy.

Like when I lost 10 pounds in a month it triggered an entire series of diagnostic tests to figure out what medical issue was causing it. When she lost 10 pounds in a month people just praised her discipline. It was wild and really taught me just how much society hates fat people - you can be actively killing yourself in front of all your friends and the only thing you'll hear from the people around you (including doctors) is "nice job, keep going!"

[u/ThymeLordess → u/Expensive_Hat_7435]

As a psych/eating disorder dietitian I agree. People that are normal weight/overweight do not get treated the same with eating disorders and that is a shame. The rationale is that what people are dying from is usually related to malnutrition, but I assess malnourished patients that are not underweight every day. The real problem is that there just aren’t enough eating disorder programs to go around. If there were we would not have to prioritize only the patients that are closer to death.

[u/OverlordSheepie → u/Expensive_Hat_7435]

My blood tests came back normal so most of my medical professionals (my GP and psychiatrist who doesn't specialized much in EDs) dropped any kind of concern or urgency with my worsening health. I'm thankful that my therapist and dietician are on top of it and are doing their best to help me and improve my diet.

Edit: It's well known that blood tests can come back normal even at extremely low weights or severe malnourishment because the body is very adaptable, especially in younger patients like myself. I see it constantly in ED circles with patients much more severe than me who are also still getting back normal blood testing.

[u/ishka_uisce → u/literal9]

Yeah I find eating disorders definitely the hardest cases after narcissism. I've had very modest success with binge eating clients, but I wouldn't accept anorexia or restricted eating clients because they need an MDT and specialists and I'm just not equipped for it.

[u/Nice_cuppa → u/literal9]

I had bulimia for 20 years, started when I was a teen. I managed to keep it under the radar for the whole time. My family never knew. They just thought I had a naturally very fast metabolism. I was a master of hiding the signs. It may seem odd but what eventually healed me was living in a city with a large African American population. Just seeing all these women, many of whom were very large, just existing in society in the clothing they wanted to wear, with no shame in their bodies and also being subjects of desire was a mind blowing concept for me. Also, dating a black man who absolutely adored my curves that I had desperately tried to starve out of existence for so long was transformative. Learning to see my body and those of others in a completely new light was a gift for me. I had grown up in a white, upper class environment in the late 1990/early 2000s going to all girls schools. The pressure to be skinny was immense. I look back on how skinny I was and I cringe. I longed to be tall and waifish but instead I’m petite and hourglass shaped. Now I have finally learned to revel in my body. I know I’m never going back. I’m so grateful. 

[u/MrMojoFomo → u/literal9]

Anorexia is the single deadliest mental disorder 

[u/RaiseMoreHell → u/literal9]

It also doesn’t help that people have to eat in order to survive, so there’s no option for “simply” (in quotes because we know it’s never actually simple) quitting.

[u/werewere-kokako → u/[deleted]]

Were they actually overweight or did she perceive them as being overweight?

[u/ITriedSoHard419-68 → u/literal9]

From a patient perspective, I think ARFID is an especially tricky one in this category. Its outward symptoms and behaviors can look extremely similar to Anorexia Nervosa, but the psychology behind it is completely different to the point some experts argue it doesn’t fit among eating disorders at all and should be reclassified. Even eating disorder specialists have an extremely hard time with it because the underlying issues and drivers are fundamentally different and require different approaches. The diagnosis is also extremely new, so there isn’t really a streamlined and well-researched treatment protocol for it yet, leading professionals to have to borrow from the Anorexia playbook to middling success. It tends to overlap heavily with autism, which complicates things even further. And when unchecked ARFID gets so bad it loops around into another eating disorder, forget it.

[u/kidfromdc → u/literal9]

I have ARFID and since the diagnosis is new, the research and treatment plans are LACKING. I went to a treatment center and they basically had me do all the same workshops and therapies as the people with anorexia except for the body image stuff. Checked out AMA and am just trying to figure out what works best for me on my own now

[u/_m0ridin_]

As an infectious disease doctor - delusional parasitosis is such a challenging disorder. Quite difficult to get anywhere with a patient when they are convinced there is some external reason for their internal sensations.

I have very rarely felt truly threatened or in physical danger in my 10+ years as a doctor - but almost every time has been in an encounter with a delusional parasitosis patient.

[u/Creative-Train-2886 → u/_m0ridin_]

As a dermatologist I was going to say the same. These patients often specifically refuse to see mental health professionals. It has to be a careful nuanced discussion and even then, only after building major rapport. We’re on the same side- I want you to get better too.

[u/whatisitallabout123 → u/Creative-Train-2886]

I went to the dermatologist with dry flaky skin and acne looking sores, so they treated me first for eczema, then the next visit they called it acne conglobata, then the next vist it was eczema again.

It would only flair up every 3 weeks so what was showing on the skin was different every visit.

After years of rinse and repeat diagnosis I suggested that maybe it wasn't bacteria or fungus causing the outbreaks, maybe they could look at demedexosis or something not as common because the flairs seemed to match egg hatching cycles.

They took a biopsy from my almost bald scalp and sent it away. When I got the results the requisition was labelled to check for "follicultis vs delusional parisitosis".

I've switched dermatologists and they put me on low dose accutane, but nothing seems to help and it just keeps spreading.

I had never heard of delusional parisitosis and it was never discussed, so it was a shock to think it was all in my head.

But when I started treating my rosacea with Rosiver cream the sores all moved to my chest and back. No one can diagnose what it is, but it keeps moving and my skin looks like a war zone.

[u/KvellOnWheels → u/whatisitallabout123]

Uh. Hopefully a derm can chime in here but this sounds exactly like my experience with pp rosacea from demodex.

Insurance wouldn’t cover soolantra or sulfur wash and the De La Cruz sulfur ointment was pretty harsh (but effective).

So I’m using Rid Lice Lotion. The moment I started treating them, it moved to my face and back. I spot treat with the RID.

Dr. Bronners tea tree soap for the body.
Diluted tea tree oil in my body lotion.

Nightly Rid on my face and moisturize with LRP cicaplast ot whatever it’s called.

Hypochlorous acid on my eyelids at night to deal with the dry eye symptoms.

I’m so sorry you’re dealing with this!
Hope you find relief.

[u/WishIWasThatClever → u/whatisitallabout123]

Have you considered a rheumatologist?

[u/BG-0 → u/whatisitallabout123]

My sister had what seemed like eczema at times, with varying kinds of breakouts all across her body, years of specialist visits, treatments and tests, nothing conclusive ever found, eventually they put her on cytostatic treatment and it's been gone since

[u/Sneaky-Support → u/_m0ridin_]

I have delusional parasitosis but have never been at an intense enough stage that I tried seeking an infectious disease doctor for it. It is thoroughly unpleasant. I just got my first full night's rest in 2 or 3 days due to feeling bugs crawling on me every time I tried sleeping.

I would certainly never condone threats towards a doctor (and certainly not over refusing to believe something), but I can empathize with the extreme stress some of those clients must have felt; I'm sorry you had to be on the receiving end of that

Edit: Thank you everyone for your comments 💜

[u/what_a_bird → u/Sneaky-Support]

Question for you (if you don’t mind answering!), Im a wound care nurse and have a patient I take care of with the same delusion. They have large wounds caused by trying to remove what they perceive are worms and bug eggs. Oftentimes they’ll see pieces of bandages or old skin and are fearful that they’re eggs, and point to them trying to convince me that their presence is “proof”. I try to remain gently reassuring of my assessments and explain that I don’t see anything that looks like worms or eggs to me and everything is okay, but I know what they’re seeing is extremely distressing and real to them. Do you have any advice on how I can explain things in a way that is respectful to their perceptions without confirming delusions? Is there anything that you wish providers did or didn’t say to you during treatments?

[u/Sneaky-Support → u/what_a_bird]

Oh wow it's actually really cool that you're asking this! This is so sweet. It's a really delicate situation to navigate. Have you heard of the LEAP method? It's a great way to talk to someone with delusions. You already have the right mindset of respecting their perceptions without reinforcing those delusions.

Definitely the least helpful thing is when someone tells me flatly 'That's a delusion,' because it just makes me feel like I'm not heard, so I think that's a big one - letting them feel heard.

Honestly the only things that ever upset me have been being laughed at or belittled, but you seem like a very compassionate person.

If I can think of anything else to add I'll make another reply, but seriously thank you for asking!

[u/what_a_bird → u/Sneaky-Support]

Thank you so much for the LEAP method suggestion, that’s exactly what I need to familiarize myself with and will be so helpful! I’ve been flying by the seat of my intuitive pants and just tried to read their body language for what seemed to distress or comfort them with pretty good results, but have felt unprepared without a “protocol” or framework for my responses to such direct questions. I know it only takes one bad experience to potentially scare this patient away from further treatment, and they’ve been making such good progress so far. I imagine it takes a huge amount of bravery just to allow us to give them wound care, and I’m so proud of them for showing up. I’m so sorry you’ve ever had to experience being laughed at or belittled by anyone, especially if it was from healthcare providers. I wish people in general were more understanding and kind.

[u/Sneaky-Support → u/what_a_bird]

You're really making a difference in the world 💜 Thank you! Please poke me if you have any questions :) And yeah medical professionals can have a major impact, good or bad. I actually had a psychologist early on accuse me of faking the disorder because 'if you had these symptoms you'd be in the hospital right now' and it led to me dropping treatment for several years afterwards. Nevermind that I'd already been hospitalized 3 times for this disorder before ever meeting that psych lol

[u/what_a_bird → u/Sneaky-Support]

Ugh I’m so sorry you had those experiences…not all providers are good ones. I’m glad you kept working towards answers and effective treatments, it sounds like you’ve made such big strides and I hope you stay healthy and happy! Next time I work with this patient I’ll feel so much more confident thanks to your advice. Thank you for helping me help them.

[u/LukewarmTamales → u/what_a_bird]

I work at a vet's office and we had a client that was high on meth and was convinced the straw stuck on her dog's fur was worms crawling out of his skin. I took a piece of the straw and showed her what it looked like under the microscope next to a tapeworm proglottid so she could see the difference between the cells and that convinced her. 

Edit: I also made sure to not dismiss her. I was like "oh wow, that is strange, let's go look at see!" Even though it was obviously straw and she obviously needed to go take a nap. 

[u/what_a_bird → u/LukewarmTamales]

I love that you had a tapeworm lying around for a quick comparison lol

[u/throwherinthewell → u/Sneaky-Support]

Have you had a neurological work up? Sometimes some neuro diseases can make it feel like you have bugs crawling on you. It sometimes happens to me with my fibromyalgia.

[u/Sneaky-Support → u/throwherinthewell]

I appreciate you asking/checking! I'm diagnosed with schizophrenia, so I think it's just part of that, though it certainly could be something else I'm not aware of exacerbating that delusion

[u/throwherinthewell → u/Sneaky-Support]

Ah, I see. Take care of yourself then! Do some nice self-care things when you can.

[u/TheMapesHotel → u/_m0ridin_]

I'm a researcher and we have an insect and plant disease testing lab at work. They get samples alllllll the time from people with delusional parasitosis. People will send in hundreds of pieces of tape they claim at samples off their body and demand they be tested for parasites. The team in that lab said they actually get really excited the 1 in 100 times that someone sends a sample of fleas or something that is actually a real insect because the DP cases are so hard for them to manage. We don't have the capacity to test hundreds upon hundreds of samples for these folks so the team will tell them we will test up to 5 and they always are extremely upset.

[u/AmyInCO → u/_m0ridin_]

My brother had this. He used to bathe in bleach and lysol. He chopped up his furniture because he thought that it had parasites in it. And he blamed his dog's death on the parasites. It was horrible though that drugs seem to be helping a little it was hard to tell because he died of a heart attack not long after he got diagnosed and treated. 

[u/vamoosedmoose → u/_m0ridin_]

The feeling threatened part is very interesting since it’s not an explicitly violent disorder. Is it their anger at not being believed or frustration at symptoms that makes them threatening?

[u/Sneaky-Support → u/vamoosedmoose]

Not OP sorry, but it's definitely frustration. And frustration can turn into further delusions like thinking the doctors are part of the reason they have parasites. Psychotic disorders don't inherently cause violence, but they can bring out aggression in people who already have aggressive tendencies due to the significant stress it causes.

[u/AnnabethDaring → u/Sneaky-Support]

Saw your other response about a lack of sleep, and i can imagine that would add to their stress! Nothing in the world, i think, in terms of bodily feelings and negative side effects are as bad as a lack of sleep.

[u/SweetPickleRelish]

Putting organic brain issues like dementia and TBI aside, hoarding, somatization, and stalking are always very difficult. In my 10 years of experience I would say those are the clients I saw make the least progress.

Even my clients with intractable delusional disorder will be able to make positive adjustments in their lives while still living within their delusional system.

I have never been able to make progress with clients with hoarding, somatization (hypochondria), and stalking disorders. I think it’s just the nature of how the illness presents itself. Not only is the client lacking insight, but the more skills and reality checks you try to do, the more they grasp onto the problem.

But then also every therapist has their strengths and weaknesses so it could just be me.

[u/gothiclg → u/SweetPickleRelish]

My grandma hoards. It sucks so hard trying to convince them they need to emptying everything out and stop bringing a bunch of new bs in.

[u/roxskin156 → u/gothiclg]

My mom hoards on a lower level, and it's so hard to help or to be helped. Even if she wants to clean up and throw things away, everything triggers her OCD and could be important, she doesn't even want to throw away glass shards because it could be used for art she hasn't done in years. It's even more difficult knowing the reasons for this thought process and even having some myself. It's way more complicated than most people assume. I love her to bits though.

[u/TheBumblingestBee → u/roxskin156]

YES.

It is so, so hard to fight.

My mom grew up extremely poor. Her parents had 8 kids, who all slept in one bedroom. They barely had enough to eat, never mind anything else. She was the eldest, so basically co-mom; she felt the burden of trying to care for everyone else, and scrape out their survival.

She told a story of when they were given some bear meat, and were so glad to have something, but it turned out the meat was full of worms. Her mom looked at her, said, "Don't tell the kids", and they took out as many worms as they could, then cooked the meat for supper.

All this to say: she was intensely poor, and remained pretty poor much of her life (including during my childhood). She had every reason to end up stressed by the idea of getting rid of something that could theoretically be useful.

So she tended towards hoarding. So many half-empty shampoo bottles from 1985. Antibiotics prescribed to relatives who've been dead for 15 years. Boxes full of scraps of wrapping paper. Bottles of salad dressing older than some of her kids. Because someday we might need it.

Oof.

I also grew up very poor (not wormy bear meat poor, but not far from it). And wow it is hard to fight the hoarding, especially because stuff often does come in handy! So trying to find the likelihood of whether its handiness is reasonably foreseeable, etc.

[u/Absolutely_Fibulous → u/TheBumblingestBee]

My MIL grew up very poor, and while she hasn’t become a full-on hoarder to the point that she keeps garbage around, she has so much stuff and she is very possessive about it. She does all the laundry because no one else is allowed to touch her washer and dryer.

She has so much anxiety and I think about how much she could benefit from some therapy and maybe some meds, but she’s more of the “just suck it up” ideology.

[u/AnnabethDaring → u/TheBumblingestBee]

Yes. Poverty is one of the most traumatic things people can experience, it truly does things to the brain that are fascinating and sad. 🫶🏼 one is a poverty mindset, which, ironically,* keep*s people poor. They live in a world of “rainy days”, so the world keeps raining, even when simply moving to another town would be sunnier.

Immigrants coming to the states often have this mindset as well! Frugality can be good, but also keep us trapped. Hustling and working hard can be positive values, but can also lead to health complications and burnout 🫶🏼

My mom is an immigrant, i am too, but grew up mostly in the states! So i too understand this :)

With hoarding, i keep track of one thing— if it impedes on your quality of life, then it’s disorder. If you can’t see the floor bc of stuff, or get negative comments from any and all visitors, or can’t even find where you left basic things (wallet etc), then it’s time for a change. ☺️

[u/DorianPavass → u/gothiclg]

my ex hoarded and it is never a behavior I will ever tolerate or try to help fix again. She'd make big promises to get better and make plans with me for how I can help just to get upset and angry because I followed the plan. It attracted bugs to the point that rice in the sink triggers me because my brain goes "maggots!!! the maggots!!" even though I've never once had that problem before or after her.

Never get engaged with someone you haven't lived with before. I didn't know about the hoarding until I lived with her. Before she'd keep it just clean enough to move the entire hoard into one room to trick me. Then it got worse once I knew and she had tricked me into living there.

[u/2k21Aug → u/DorianPavass]

My moms hoarding has gotten much worse in her old age. Last time I visited there was a bedroom she wouldn’t let me in. I don’t even know if she can open the door.

[u/jalandslide → u/SweetPickleRelish]

From a hoarder: this is actually a relief to know working with a hoarder brain is difficult for therapists too. To work on my hoarding, for years, I have tried: talk therapy, DBT, EMDR, a therapist led psilocybin trip with a hoarding focus (Oregon) and it hasn’t improved. It’s a relief to know, it a beast to try and manage and improve-it matches my difficulties to try and get better. What has helped in the physical space is paying an organizer to come regularly many times for many years. For my brain, I just completed 18 weeks, 2 hr/week group that uses the Buried in Treasures format. It has helped. Although this part is finished, several of us from the group, get together on Google meets and each work on a home project together while we chat, encourage and help when we get stuck.

[u/ireallylovegoats → u/jalandslide]

My mom has a slew of mental health issues which essentially boil down to anxiety manifesting in different ways. Her main two issues are OCD and hoarding behaviors. She says she’s not a hoarder because she has usable space in her house and doesn’t just have little pathways. However, she has entire unusable rooms in her home because of the hoarding tendency.
It seems to stem from a childhood where she had little/no control over her life and her parents would frequently pack up and move with just what could fit in their car.

One of her counselors over the years had said that ocd and hoarding often comingle with people and it can be very treatment resistant unless they take medication. Unfortunately my mom is one of those who is not willing to take medication despite logically knowing it would likely help.

I really wish you luck in your treatment journey. I commend you on the depth and diversity of treatments you’ve sought out!

[u/The_Silver_Raven → u/jalandslide]

Thank you for sharing your perspective. We have a kind neighbor in his 70s who is absolutely a hoarder with a large active hoard, visible in his six vehicles (several of which do not run that I am aware of) and house windows. I have never seen him spend time with a family member. I want to be friendly to him and treat him well. It is helpful to know that I shouldn't expect this part of him to change. In some ways, that might make forming a relationship with him easier, because I can take "maybe eventually be able to help him" off the table mentally. 

Sorry if I am accidently being offensive in this reply. 

[u/Stella-Shines- → u/jalandslide]

It is really great at least that you ADMIT you have an issue and are TRYING to improve. I wish I could get my mom to this point.

Her hoard isn’t completely out of control (food items, animal droppings, dead animals are not included) but it is large and it impacts our day to day lives.

She owns the house I live in, I rent from her, and my entire garage is taken up by part of her hoard. The rest of it she keeps at my parents’ house, upstairs. The entire upstairs is taken up by her stuff. It really sucks because she has stuff we actually use and need access to up there buried under shit we don’t need that she is selling or “going to” sell on eBay/etc.

Getting rid of one or two, MAYBE three items per week is not sufficient for the amount of shit she has. And god forbid I try to talk about it. She’s 61, so it’s now looking like I’m just gonna have to deal with everything once she dies.

It’s so frustrating. And then I see those tendencies in myself somewhat now and then, and it scares me. It’s a sad and difficult disorder for sure.

[u/ishka_uisce → u/SweetPickleRelish]

I have really good success with my health anxiety clients. But that might be because I suffered severely from it for years and definitely see it differently to most therapists, I would say. I go straight to identifying the root fear (often loss of control, dependence on others, death, or some combination) and go from there. Trying to rationalise with the thoughts at a surface level will get you nowhere in many cases, or maybe to a slight remission before the next relapse.

Clients with significant narcissistic tendencies would be those I find most difficult. The ones who paint a world that's always been 100% unfair to them and bail when you start picking up on the fact that they may actually be the source of many of the problems.

[u/Warm_Molasses_258 → u/SweetPickleRelish]

The only thing that helped my hoarding problem was my late cat, Launch. She had real bad anxiety and would pee on everything that was out of place or cluttered. Because I despised the smell of ammonia, I learned to keep my apartment minimalist and spotlessly clean to keep my cat happy. I mean it, if you so much as left your clothes on the floor during a shower, she'd find a way to pee on them. After a while, the habits just stook, and even though she's gone, I still keep my place clean in her little kitty honor.

My car is a bit of a different story, though. I figured since there's only so much you can even fit in a four door sedan, what would be the problem? Until I had a come to Jesus moment when my brother filled two contractor bags full of garbage and I was trying to snatch dirty gas station receipts from his hands that I realized I had a trash hoarding problem in my car.

[u/BangBangMeatMachine → u/Warm_Molasses_258]

This gives me an idea for a new kind of service animal training.

[u/megmatthews20 → u/BangBangMeatMachine]

The number of hoarders that have dead animals in their trash piles is disturbingly high. Cat pee won't faze most of them.

[u/Terpsichorean_Wombat → u/Warm_Molasses_258]

This is really sweet. I love that you continue to honor her.

[u/Ok_Chance7699 → u/SweetPickleRelish]

I use to be a severe hypochondriac and the only thing that helped me was a very high dose ssri. For me it was a manifestation of OCD which is hard to treat w therapy.

[u/kathmhughes → u/Ok_Chance7699]

It wasn't like OCD at all for me, but just intense fear and anxiety. Same thing, SSRI fixed the anxiety and hypochondria completely. Been good for 6 years. 

[u/FairyOfTheNight → u/kathmhughes]

What ssri fixed it for you? I've tried many, many medications over the years that has not helped.

[u/kathmhughes → u/FairyOfTheNight]

Lexapro 20mg. Also gained 50lbs but got my life back. Am a better wife, mother, teacher, person. 

[u/HouPoop → u/Ok_Chance7699]

For me it was simply getting the OCD diagnosis that helped. I'm not cured, but I now understand it. I can see the OCD patterns and better break the cycle when my hypochondria flairs up.

[u/Terpsichorean_Wombat → u/SweetPickleRelish]

I watched an episode of "Hoarders" in which the home was being condemned by the city. They gave city officials a chance to speak about their perspective, and they stated that they had spent over $500,000 on that single family trying to address the problem through social interventions.

I know it's edited for TV, but some individuals really had constructed what appeared to be a bulletproof refusal to acknowledge a problem. It was sad, but I totally believe you on the intractability.

Is there a mental health version of non-curative palliative care? If so, what does it look like?

[u/xANTJx → u/SweetPickleRelish]

How do people with stalking disorders end up in therapy? I’ve been stalked before and I can’t imagine them 1) viewing their behavior as a problem, let alone 2) seeking help for it. Unless their parents forced them to go or something, but you can’t always force “competent” adults to do that

[u/-goodgodlemon → u/xANTJx]

Court ordered is likely

[u/anatomizethat → u/-goodgodlemon]

Yup. And if so, I'd say many of them learn how to be more proficient, rather than rehabilitating.

[u/Pretend-Marsupial258 → u/anatomizethat]

The same thing happens in couples counseling if it's an abusive relationship.

[u/Seeking_Starlight → u/Pretend-Marsupial258]

That’s why couples counseling is contraindicated in relationships with intimate partner violence. Therapists who take on these couples, rather then referring them each for separate individual counseling? Are not practicing ethically or safely.

[u/Tornado547 → u/xANTJx]

I saw one Reddit thread on one of those YouTube channels that reads out Reddit threads from a guy who started stalking his ex but sort of realized what he was doing halfway through and managed to get help of his own volition. I imagine that's a pretty exceptional case though.

[u/EtherealHappiness → u/Tornado547]

Bingo. They have to recognize they have a problem and wanna fix it. Most can’t see or accept they have an issue so they don’t stop or seek help and don’t get better.

[u/blumpkinspicecoffee → u/xANTJx]

I’ve never stalked anyone before but I think I’m maybe capable of it. And if I found myself ever engaging in that behavior I would def seek therapy with HASTE 😮‍💨

[u/ipsofactoshithead → u/SweetPickleRelish]

Speaking for myself, I have insane health anxiety and definitely have insight into what's going on. I basically just ERP myself whenever it happens ("yeah OCD, maybe I'll die, maybe I won't"). It sucks ass and is something I'll probably live with forever, but I'm nowhere near as anxious as I used to be.

[u/BudgetInteraction811 → u/SweetPickleRelish]

As a victim of stalking that’s actually super depressing news to hear. 😔

[u/toastthematrixyoda → u/SweetPickleRelish]

I got sick in my 20s. Then I got depressed. Doctors said there was nothing wrong with me physically. I tried every antidepressant and went to tons of therapy and just didn't get better. I kept getting worse. Doctors seemed to blow me off and wouldn't test me for anything. They kept referring me back to my psychiatrist.

Over a decade later, I was diagnosed with Rheumatoid Arthritis and hypothyroidism. I took medications for them. I got better finally.

I went back through my medical records, and for 10+ years, the word "somatization" was all through my chart. Seeing that made me sick to my stomach. I was really sick all that time, and they were essentially saying I was imagining it.

I don't know what you have seen when it comes to somatization, but some of us really are physically sick and will get better with the proper treatment. I'm grateful I stopped pursuing the mental health path and finally learned to advocate for myself. I'm sure every case is different but wanted to share my story in case it helps anyone. I will say that I never really sat around worrying about my illness, I didn't constantly google my symptoms or anything. But I was in constant pain that nobody believed me about.

[u/ElitistCuisine → u/toastthematrixyoda]

My experience exactly. I had a pretty good doctor for 1 year, but then I had to change insurances and lost him. Next doctor would not take my issues seriously. I once told him that a lot of my symptoms mimics fibromyalgia, to which he said “But you’re not a woman.” Goooooooooooood. Fuck him. I lost 8 years of my life trying to recover from pain and just being despondent.

Fast forward to the last year, I finally worked up the courage to try neurology again, and while she wasn’t able to confirm any diagnoses (but is leaning towards fibromyalgia), she took my pain seriously and believed me when I told her “There’s something wrong, and it’s not in my mind.” I’m still in pain but - for once in a long while - I feel some hope.

Oh yeah, and that shit-ass doctor also put in my medical file “History of Psychosis” despite me never having gone through psychosis. Why did he do it? He misunderstood what I was talking about when describing my experience with depersonalization. It took YEARS to get that off my fucking file.

[u/TroublesomeFox → u/SweetPickleRelish]

Re the somatic disorder - how do you know for sure it's somatic? I was told that my pain was somatic and basically caused by anxiety and stress and it turned out in the end that literally all of my "somatic" issues were caused by the fact endometriosis had literally glued my fucking pelvis together. If I hadn't have had a scan for a miscarriage they'd still be calling it anxiety now. 

[u/FerretBusinessQueen → u/TroublesomeFox]

Mine was a metal allergy from an implant I’d had with a product that had nickel in it I was told would be “negligible” with no side effects even though I had a nickel allergy. Had to go to Boston after seeing many doctors in my area and they finally agreed to take it out. 7 years handicapped placard free now.

[u/Alicatsidneystorm → u/TroublesomeFox]

Sorry to hear I met a gal in hospital who had endometriosis and she was getting absolutely dismissed. I think is she had a lot of complaints which were all legit. I still text her years later she finally did get someone to take her seriously. It was absolutely tragic.

.

[u/nowaynoday → u/SweetPickleRelish]

Hey I got my hypochondria under control. It was combination of existential therapy and DBT. Basically, first had let me accept horror inside me and my control cravings, and second gave me some instruments to deal in it at the moment. But it took some personal growth.

[u/dan7899 → u/SweetPickleRelish]

What do you mean by ‘stalking disorder’?

[u/SweetPickleRelish → u/dan7899]

This is a good question. I wrote "stalking disorder" for simplicity, but that's not a real thing. Stalking is a behavior that can be driven by like 5 different disorders. I just didn't want to go into all that because in my experience all stalkers have been equally hard to treat. For me at least.

[u/Chemistry-Least → u/SweetPickleRelish]

How do you differentiate between somatization and chronic pain?

[u/ichibanyogi → u/Chemistry-Least]

You can have both chronic pain and a somatic disorder.

In my understanding (actual therapist feel free to step in and correct me!), somatization dx requires an intense focus/rumination on symptoms that goes above an beyond just having symptoms. The symptoms themselves can be from a physically real other illness, like cancer, fibro, etc., or even physical symptoms where the underlying cause can't be sorted, but the important piece for dx of somatization is the fixation on the symptoms impacting the patient's life.

[u/blu9bird]

anorexia is really difficult on many levels and dangerously lethal. cant help patients who don’t want the help and want to continue losing weight. even when we get court ordered tube feeds, they achieve BMI 18, get discharged, and immediately start restricting again. also really difficult because they typically decompensate on an inpatient psych unit, but medical floors don’t want a psych patient and try like hell to get them off their service and on to psych. too medically sick for psych floor, too psychiatrically sick for medicine floor.

[u/GhostOrchid22 → u/blu9bird]

I've had two people close to me diagnosed with anorexia, and I despise how it's viewed in popular culture. One of my family friends was a child, and it took 2 years in and out of the hospital- and endless fights with insurance- to get him on the road to recovery after almost dying twice. And I don't think he will ever not be anorexic. It hurts so much to see him almost kill himself, and as you said, the moment the feeding tube was removed and he was put in outpatient, he relapsed again. So many people would say to his parents, "Just make him eat!" to their despair.

[u/DorkasaurusRex → u/GhostOrchid22]

This reminded me of a customer I had a few years ago. I work at a food store and a mother was asking me if we still had a certain snack in stock. I led her to it and she thanked me profusely with slightly teary eyes and she told me her daughter had an eating disorder and she was actually willing to eat those snacks. The daughter wasn't with her at the time, but I think of both of them every now and then and hope that she was able to continue recovering. The combination of relief that we had the snacks, the sadness about her daughter, and just the EVERYTHING was so palpable.

[u/coolio_Didgeridoolio → u/GhostOrchid22]

The line about “I don’t think he will ever not be anorexic” hits me so hard. You might have only meant it in the physical sense of him constantly being underweight and starving himself, I don’t know. But I’ve always thought, in the case of friends I’ve had who struggle with eating disorders, that anorexia is an addiction, and in the same sense that former-alcoholics who have been sober for decades still call themselves addicts.

My friends who have had anorexia will always be anorexic. Even when they’re not underweight. Even when they are eating regularly. That thought process and that headspace will never leave them. And it’s so difficult to deal with it because I can see them trying but they will always be battling those thoughts.

[u/GhostOrchid22 → u/coolio_Didgeridoolio]

I meant, as you said, his brain is hardwired for it. I've sat with him in the hospital so his parents can have a break, and even in his best moments, the need to deny nutrition was constant. A wonderful kid, extremely smart and talented, but he can't turn off this part of himself. And he has two wonderful, loving parents- his mom is a doctor - and they would do anything to trade places with him.

[u/FueledbyBlackCats → u/GhostOrchid22]

I lost my shit on several loved ones when I struggled with disordered eating and was told "just eat!" over and over again like that thought had never occurred to me.

I'm curious as to how they think "making" someone eat would go. You'd catch a charge for force-feeding someone, even in a clinical setting. I've never been inpatient but I assume force-feeding isn't part of a treatment plan.

[u/blu9bird → u/FueledbyBlackCats]

For some patients who are literally on the brink of death, we take them to court and do something called “treatment over objection” where a judge decides basically if the patient is sick enough to warrant taking away their rights and forcing treatment in order to save their life as they do not have the capacity to be making rational medical decisions for themselves. this usually includes tube feeds as a court ordered treatment plan until they achieve a certain weight.

[u/-Tricky-Vixen- → u/FueledbyBlackCats]

One time while I was still actively struggling (now recovered years later wahoo yippee hooray), I had other problems. Beloved dad turned to me and said, "Have you tried eating something every time you get one of those symptoms? To see if it breaks the cycle?" I just stared at him in disbelief like no??? dear father you know I'm anorexic???

[u/BoozeWithCoffee → u/blu9bird]

This is so very true. I was being treated at at a dual diagnosis center for alcoholism. I was there for four months. They dismissed me because it became obvious that I am suffering from anorexia. They said I needed a higher level of care.

The problem was no eating disorder clinic would admit me because I am an alcoholic.

It's all so messed up.

[u/Greasy007]

Personality disorders (particularly BPD, NPD, and ASPD) because they can significantly complicate the therapeutic relationship, which is often one of the most important components of successful treatment

[u/thesweetestberry → u/Greasy007]

My sister had BPD. It’s truly awful.

[u/Easy-Permission8889 → u/thesweetestberry]

I have it and consider it pure emotional agony. It's kind of hard to treat sometimes, despite knowing everything I need to do. It just feels useless sometimes.
Edit: I edited bc perhaps I could've phrased this differently. When I say it's hard to treat I mean it's hard for the individual to go through DBT, and can be hard to form a therapeutic alliance. Also given how intensive DBT Is, I used the word extremely, because it is extreme. There is so much for the person to work on for quite some time. DBT is what has a high success rate for managing symptoms. Ask anybody who went through therapy for BPD and it's no walk in the park.

[u/thesweetestberry → u/Easy-Permission8889]

Knowing how much my sister struggled with it, my heart goes out to you. I hope a better treatment (or even a cure!) is on the horizon. I watched my sister live in misery and just suffer every second of every day. It took a fucking ton of courage for her to keep going. I am truly sorry you have BPD. It’s so unfair.

[u/Easy-Permission8889 → u/thesweetestberry]

Thank you kind stranger 💗

[u/Bo_Universe → u/thesweetestberry]

DBT is an extremely effective treatment and is THE cure. It an intense therapy modality designed FOR pw/BPD by a woman who suffered from it. 72% of patients w/BPD who complete DBT enter remission or even complete recovery. It has entirely changed my life.

[u/BellaBigNose → u/Bo_Universe]

I’ve been at it for 12 years so lol here’s hoping

Edit: DBT did change my life and also the disorder is really hard to deal with! It’s not like you learn a new tool and you’re cured. You have to actively work everyday

[u/WallyOgden → u/Bo_Universe]

DBT can be highly effective for BPD as well as many other mental health issues, but it isn't the only effective treatment for BPD. There is a research base developing that people with BPD can have good success with other treatments like TFP (transference focused psychotherapy), MBT (mentalization based therapy), Schema Therapy, and General Psychiatric Management. DBT is more widespread and therefore often more accessible than these treatments (as most of them are newer) but it is not the only option by far. These other treatments can also be highly effective for other personality disorders. I don't knock DBT at all, but I want to make people aware that there are also other options.

[u/magnusthehammersmith → u/Easy-Permission8889]

And all the stigma around it makes it way worse too

[u/Easy-Permission8889 → u/magnusthehammersmith]

Yeah. I once heard a psych nurse say he hates working with BPD people and that they're basically the devil.
I've also heard from another guy it's just ptsd with the "excuse to be abusive"
I didn't tell him I was BPD, he just randomly brought it up one day in a group I was in and I barely knew him at all. I was like yikes, better not tell people I have it anymore generally.

[u/Bonjourlavie → u/Easy-Permission8889]

My doctor kindly suggested not to disclose my diagnosis unless necessary. I had no idea that doctors would treat me differently because of it

[u/Easy-Permission8889 → u/Bonjourlavie]

Yeah unfortunately I am trying to be very careful on who I tell about it. It's just that I have horrible self harm scars, which often screams "I have BPD!!" to literally everybody and will forever unless I got a shit ton of laser or tattoo cover ups and even then I don't think that would completely remove my scars but I'm not sure. My logic during the times I've SH was simply put, fucked. They're extremely noticeable and I often get commentary on them.

[u/fuckifiknow1013 → u/Greasy007]

I got diagnosed with BPD last December at 27. My favorite part was my therapist telling me I need to get 5 of the 9 criteria and I got all 9. I asked her if I won a prize for getting all 9 instead of just 5 (she knows I'm a huge smart ass) The worst is knowing what I'm doing during episodes and being so dissociated from my body I can't control what I'm doing, regardless of how much I scream internally to stop... Lots of emdr sessions for me to work through everything.

I think the worst part about healing, for me personally, is the imposter syndrome. I told my therapist it's not fucking fair that I'm hitting the goals I set for myself with therapy, that I'm actively making a difference with the BPD. And I feel like I'm faking having BPD because therapy is being so successful. She told me that it's part of it. The imposter syndrome will come back as I get a better handle on it. Then she reminds me I scored all 9 criteria and not the bare minimum. Which does help a lot. I got really lucky with my therapist though. She specializes in BPD, and she calls me out on my bullshit when I try. She knows I know the answers I need to give to get out of therapy, and that I don't want to but I will try. She's also super cool because my husband can text her about my episodes to give us both more info on how to tackle the things my brain erases.

One of our pets died last night. So I've spent all of today fighting the urge to blow up the planet and run away to dissociation Disneyland

[u/seitan_worshiper → u/fuckifiknow1013]

I’m really sorry about your pet :( I am glad you have a good support system. 

[u/quillseek → u/Greasy007]

Can you say more? As a layperson I'm not sure I understand. What do you mean by "complicate?"

[u/jamie_plays_his_bass → u/quillseek]

Someone with BPD might commonly have lots of difficulties in their interpersonal relationships: socially, romantically, and in work if they have a job. It is very common that they come to therapy and every week have a very intense disagreement or difficulty that arose, and want to discuss that, whether it is to vent their anger or to get be validated for their reaction.

The problem with this is that often their story rarely centres them in the narrative, things just “happen” to them, or are caused by external influences which you and they have no control over. Sometimes they will pressure you for your perspective on their experience, and will often expect it to fully align with what they feel. Disagreeing, expressing empathy/curiosity about the “other” or highlighting that you can’t see the entire experience can result in a really significant rupture where they can feel rejected. 

This is very challenging to navigate therapeutically. You can be pulled into a dynamic with the client where they are expecting validation without being challenged, and their reactions can be very uncomfortable and critical, both personally and professionally. What you want for your client is to help them build coping skills to manage these events without you, or the ability to reframe these experiences, or to build their understanding of why this keeps occurring for them, and what their potential role is in perpetuating these events that happen everywhere they go.

Often someone with a diagnosis of BPD has had some very significantly traumatic experiences that lead to this. As much as they are “choosing” to act this way, it is because this way of living has helped them survive. Unfortunately, it also comes with enormous downsides that can undermine their happiness, mental health, and capacity to connect with others in a healthy way. 

[u/kaaron89 → u/jamie_plays_his_bass]

This is such a helpful description, thanks for putting this out there. I'm pretty sure my mom has BPD and she's unfortunately no longer in my life because of it. At one point she asked if we could do separate sessions with the same therapist to see if the therapist could help mediate. My session went really well. Then when it was my mom's turn, she got very angry with the therapist and then quit. Your explanation helps me understand why this happened.

[u/jamie_plays_his_bass → u/kaaron89]

I am glad you found it helpful to read. It can be so challenging having someone in your life who can be emotionally volatile and has these extreme triggers that make sustaining a healthy relationship so hard. I hope you’ve been able to get some decent support since. 

[u/le_sighs → u/jamie_plays_his_bass]

I had a partner I now suspect had BPD, which I didn’t suspect at the time, only because I didn’t know about it then. He once nearly got into a physical altercation with a coworker, in front of others. Which I only knew because he told me about it. His boss brought it up as a reason he wasn’t getting promoted. We talked about it, and you could see he was ashamed and wanted to be better.

6 months later, he swore none of that ever happened, and that I made up all of it. He would do the same with anything that happened in our relationship.

I can absolutely see how therapy wouldn’t help.

[u/jamie_plays_his_bass → u/le_sighs]

Therapy can absolutely help, but it requires both the psychologist and client being able to tolerate a very significant and prolonged discomfort, as well as navigating some very challenging and prickly disagreements. 

Or, a total change in approach using something like DBT (dialectical behaviour therapy). I would never say “therapy wouldn’t work”, every case comes with its specific challenges. I’m sorry you had to experience that in your relationship though. 

[u/ashbash-25 → u/le_sighs]

Unfortunately disassociation is apart of the disorder for many as well. So is lying to avoid abandonment- a core fear for people with BPD.

[u/AgentKnitter → u/quillseek]

I have BPD.

The key elements of BPD are difficulties regulating emotions and experiencing really intense emotions. Because most BPD patients have also have significant trauma histories, you have a lot of trauma responses as well as the intense emotions - and this is a difficult combo because it's hard to regulate your emotions when outside of your window of tolerance.

I describe it as the part of my brain that determines how intense an emotional response should be, the volume knob, is busted and stuck at maximum volume. So even when something warrants a minor or moderate emotional response, my brain is stuck at 11 and blasts out that emotion full bore. What I have had to train myself to do is to let the emotional burst play out without responding to it with actions. (Mixed success to be honest. Its fucking hard to not act when you are overwhelmed with a strong emotion like anger or fear).

The other really tricky parts of BPD are the intense fear of abandonment, "splitting" and your brain wanting to treat the world in strict black and white terms, not wanting to accept the shades of grey, and struggling to maintain and build interpersonal relationships.

The latter has caused a lot of difficulties for me professionally. I struggle with maintaining jobs because no one wants to work with someone who can be really clingy and then tomorrow be a spiky ball of rage. It has been shit and I can also understand where I have basically shot myself in the foot.

DBT has been really helpful in giving me tools and processes to understand what my brain is doing and having better tools to manage crisis, and better awareness and tools to manage interpersonal issues.

[u/Wonderful_Low_89]

Alzheimer’s with behaviors is extremely difficult. When they reach advanced dementia, they have terrible memory especially of recent events. They can forget their own name and no longer recognize their own living space or anyone around them. “With behaviors” means they tend to be defiant and contrary rather than cooperative so it is extremely difficult to get them to do anything even for their own wellbeing. Simple tasks like getting them to eat, bathe, and toilet is challenging sometimes. You cannot reason with them.

[u/jabbitz → u/Wonderful_Low_89]

We are going through this with my MIL. She’s been in a hospital in a locked room with a guard because the nursing home couldn’t handle her anymore. We’re still paying the nursing home daily rate because they say theyll have her back once they find a way to manage her but who knows when that will be. Probably when shes so far progressed she’s basically a vegetable anyway.

Shes top of the list for a spot on an acute cognitive ward but last we heard they cant send her there until some other people leave, because apparently they think it will be a bad mix.

Anyway, this shit is awful and society is not set up to help people in this situation

[u/Additional_Crab_7911 → u/Wonderful_Low_89]

Currently helping my MIL through dementia. She’s moderate right now, but will always think she’s only just beginning to get it! She’s always been a strong independent lady so I suspect she will become more ‘willful’ and obstinate with time.

[u/agentscullysbf → u/Wonderful_Low_89]

You can’t reason with them the way you would with a normal person but I’ve learned some tips and tricks where you’re sneaky and make them think the task is there idea

[u/Wonderful_Low_89 → u/agentscullysbf]

Yes exactly. Teepa Snow has some great advice on YouTube.

[u/maggazine → u/Wonderful_Low_89]

My Grandma kept hiding donuts under the bathroom sink and would accuse me of "fucking her over" and get kind of agressive if I tried to stop her. There is no reasoning at a certain point.

[u/fattybuttz → u/Wonderful_Low_89]

My step-grandma had Alzheimer's and she thought she was a 12 year old little girl and that my grandfather was an old man who kidnapped her. She kept making up schemes to get away. She stole the car one time and drove until she didn't know where she was and the police found her (extremely dangerous because she also forgot that you're supposed to STAY stopped at red lights and would use them like a stop sign), and then another time she snuck out of the house in the middle of the night and ran away. We ended up having to put her in a facility for her own safety.

[u/BitterGenX → u/Wonderful_Low_89]

Yep a heart breaking illness. My nan saw her own mother deteriorate with Alzeimers and then was diagnosed herself a few years later. She wrote with soap on the wall 'HELP ME!!!' in her care facility and kept trying to escape. She ended up bed ridden for years before she passed. I really hope they find a cure. 

[u/Whoreganised_ → u/Wonderful_Low_89]

Had a few of these patients as a nurse on med/surg wards. My fondest memory was the old fella who needed the bed rails up/bed alarm because he was a falls risk. So he was laying there with his legs over the bed rail yelling with the bed alarm going constantly the entirety of my late shift.

He thought he was in a shit hotel with shit service (public hospital in Australia, so free) and he wanted to “check out”. My shift buddy and I were like…let’s roll with this.

We were like, sir, we agree - this IS a shit hotel and yep the service IS shit but how bout you try and get some sleep here for free before you check out tomorrow lol

[u/HopefulLesbian → u/Wonderful_Low_89]

My mom called me in tears, sobbing because she was helping my grandmother (on my dad’s side, so her MIL), to bathe. She had extremely bad dementia and was very defiant. My mom was breaking down because my grandmother was accusing her of sexual assault because she and the nurse were having to basically physically force her to shower. One of my greatest fears is that I will get it when I get older.

[u/Gullible-Spare-749]

i’m a therapist and honestly for me it’s chronic depression. all of the things that would help with being depressed are too difficult for people with chronic depression to find the motivation for, and upkeeping positive habits is constant. medication is a band-aid and honestly just numbs some people even more. it’s really hard to treat people who believe to their core there is no point and can’t find joy in life, and i really wish there was more i could do for them

[u/0range_julius → u/Gullible-Spare-749]

I'm typically a very optimistic and generally happy person, but I went through a 6-month depressive episode a few years back. From the very beginning, I perceived it as something temporary, and I coasted on the blind faith that someday I would get better. I never even considered that it might not be temporary. I just remember feeling, often, that that little thread of optimism was the only thing dragging me through time until the day I'd feel something again. And eventually, it did. If I hadn't had that shred of hope, if the depression had been chronic, if I had been less happy in the time period leading up to it, if I had had more stresses in my life... I just know I wouldn't have made it through that.

[u/pseudologician → u/0range_julius]

I deal with chronic depression and that little thread can disappear for weeks at a time which is when it's hardest. But I try to hold onto what I remember it feeling like when I can, a small hope for hope itself I guess 🤍

[u/AnxietyOctopus → u/0range_julius]

So I lack the emotional thread you’re talking about, but I’ve had some success (not dead yet!) with a logical one. I’ve had major depressive episodes since I was about eleven years old, so I’m pretty well versed in the pathology, at least how it presents for me. One thing that’s been really helpful is just understanding and accepting that my brain is lying to me. That I can feel deeply, with the kind of certainty some people have about religion, that I am undeserving of love and will exist in this hopeless pit of misery until I die, AND that all my loved ones will be better off when that happens, BUT believing that doesn’t mean it’s real.
So when I’m in the worst of it I grit my teeth and accept that I’m not a good judge of reality at the moment, and that crazy people don’t get to make life altering decisions.
So in no way do I feel that faith that things will get better, but I can at least force myself to believe that I’m incapable of making realistic predictions about the future.
That’s been enough to keep me alive so far. Also drugs! The medication I’m on has kept the worst at bay for almost ten years now. Every so often a doctor asks me if I’d like to try tapering off, and I vehemently refuse.

[u/-Tricky-Vixen- → u/Gullible-Spare-749]

I experienced severe chronic depression for probably at least a decade, mixed in with an ED and anxiety.

I am now experiencing something that is thought to be either bipolar with psychotic features or schizophrenia.

Hearing my friend in the depression weeds right now just like I was a couple of years ago... I pick now over depression, thanks. I'll take the 'delusions' even if they are actually false. I'll take the frightening-but-euphoric "ups" too. It's much easier to emotionally manage being commanded to kill oneself than to just want to, oneself, all the time. At least the commands or suggestions, I know they aren't mine. At least when I do give in, it won't be because I wanted to.

(I'm in hope quetiapine makes Them shut up before They do actually make me kill myself. I'm increasing the dose as per doctor's orders. Tempting to just take the functioning hit and increase it far more rapidly, but anyway. Doing my best.)

[u/matchy_blacks → u/Gullible-Spare-749]

I had chronic depression for twenty years and TMS saved my life. I think it’s more widely talked about now than it was ten years ago when I started getting treatments, but I shout it out every chance I get. The “risk” felt so low to me that I figured I’d just try it and if it was terrible, I’d just end my life after the first week. It was not terrible, and I’m still here. I seem to need to do it once every two years, and I still take psych meds, but it took the constant dark cloud out of my life.

[u/I-Ask-questions-u → u/Gullible-Spare-749]

A coworker of mine had chronic depression to the point where he didn’t want to be around anymore. We pushed him to get help and he didn’t the thing where the magnets go in your brain multiple times a week. It essentially cured his depression. He of course has to get ahold of his anxiety but he said it’s gone

[u/3opossummoon → u/Gullible-Spare-749]

Thank you a ton for acknowledging this, I feel like a lot of people underestimate depression and how insidious it can really be, especially when chronic/treatment resistant.
I got diagnosed with depression for the first time when I was 9 and had my first suicide attempt at 12. I'm 31 now and have 2 attempts, one inpatient stay, and something like 6 different antidepressants under my belt. Wellbutrin has been a real ass saver, I highly recommend trying just one more option to everyone out there struggling.
It's like having to keep a really shitty pet now, one that some days mostly sleeps and doesn't bother you too much but some days it shits all over the rug after puking in your shoes and eating your favorite hoodie. Except it can also talk and keeps telling you that you're awful and to kill yourself. It's kinda like having the worst parrot EVER.
Thankfully I've reached this point and I'm happier with my life than I've ever been despite a few hitches in the long term plans recently. That fucking parrot is still hanging out though, and some days it just won't stop screeching.

[u/LesChatsnoir → u/Gullible-Spare-749]

A touch of hope for you (and others): medication saved me. Not therapy, not talking, not groups. Medication. The other things helped to an extent, but it’s literally night and day for me being on the right meds. No more pervasive suicidal depression - so strong it was ALL I could think about. Less anxiety. Less agitation. More mental room for things. I’m not discounting other options, but just noting that sometimes medication is an answer. Wishing all who suffer better days ahead.

[u/101lurker]

I would say any disorder that they are not willing to admit the problem. That would be substance use, restrictive eating disorders, personality disorders or folks that engage in emotional avoidance. That limits so much of the work that we can do if they are willing to feel their feelings.

[u/dopaminetract → u/101lurker]

Building on that: Some people have more rigid ideas about what our list of mental health labels mean, and most people have at least some preconceived hierarchy of what labels they dislike or feel more neutral or positive towards. 

People with significant mood cycling symptoms that don't like mood labels can prefer to see their symptoms through the lens of trauma or ADHD. People with significant ADHD can resist treatment for it and prefer to see their issues as willpower, mood, even autism. Sometimes people with OCD symptoms only want to work on their cycling mood, anxiety, or ADHD. 

It's quite common to identify with half of what many bystanders would label as troubling symptoms (called ego-syntonic symptoms) and only want treatment for things you don't identify with or like. 

Once someone's begun identifying with a symptom or placed a stigmatizing label on it, it's a long process trying to reframe and relabel those issues so they can see the ways they're connected to the problems they do see as troubling.

[u/_pickledpickles]

The disorders that patients are in denial about. It could be any disorder. Examples include a bipolar patient insisting they have ADHD, someone who has a personality disorder they refuse to go to therapy for, people not taking their medications because they feel better (spoiler alert, they felt better because of the medications), patients who think that meds do all the heavy lifting and they don’t have to change anything else, patients who cannot or will not change their environment/situations contributing to the symptoms so they’re stuck in a loop.

A lot of patient success isn’t just their medications, it’s their readiness to change and apply that change. If that is lacking, there’s only so much a pill will fix. Then I’m the bad guy when the meds aren’t fixing their broken marriage, trauma history, bad work environment, etc.

[u/Commercial_Doughnut6 → u/_pickledpickles]

This for sure. I have a client with OCD who insists they have a specific personality disorder instead. No matter how many times myself or their med provider has explained that they don’t meet the diagnostic criteria for that personality disorder, they continue going about sessions explaining why it’s important to them that we no longer try to discuss ocd treatment because they need to be treated for said personality disorder. They also are in the process of tapering off meds for ocd against prescriber’s judgment because they read that meds don’t help with the personality disorder they believe they have.

[u/_pickledpickles → u/Commercial_Doughnut6]

It’s tough because you want to respect someone’s autonomy while trying to make sure that they’re making a well informed decision :(

[u/MbMinx → u/_pickledpickles]

I was active in the early 2000's on a mental health support board. Explaining to folks that the reason they feel better was because their meds were working was maddening. Right there with it was trying to explain that medication isn't going to stop their boss from being a jerk, or their spouse from being an AH, or life from happening...yes, you feel better, but you need to address the twisted thought and belief patterns you've lived with for decades.

[u/SignificantCricket → u/_pickledpickles]

Delusional disorder certainly fits under this umbrella, as lack of insight is usually a key part of it - even if it is not “the most difficult” disorder, as people with it can be functional in mundane areas of their lives relatively unconnected to the delusions. 

However it is usually intractable once it has started, and can be exhausting for family, next door neighbours, public services and others dealing frequently with the sufferer. It has never been well understood by the public anyway, and the boom in conspiracy theory thinking among the public these days makes people with it less noticeable, unless you are someone a sufferer is bothering with more distinctive complaints all the time. 

The small amount of literature about it always describes it as “under-researched” and with low recovery rates for most subtypes, and that’s the ones who are even engaging with psychiatric services enough to end up in studies.

[u/quillseek → u/_pickledpickles]

How do you help people who are in the "cannot" change their environment/situation camp, compared to the "will not" camp?

[u/smashablanca → u/quillseek]

Not the person you asked but in both instances you can focus on harm reduction. This is particularly helpful when someone lives in an abusive household. You come up with strategies to stay safe until they're able to leave.

[u/_pickledpickles → u/quillseek]

There is only so much someone can do, finances are a limiting factor for many. It comes down to pursuing what we can change (medications, therapy to change our thought patterns and behaviors, maybe moving elsewhere, a break up, a job change, etc) then learning to accept/adapt to the things that we can’t change.

Even little things like cutting down on screen time, being well hydrated, having a balanced diet, exercising, decreasing or discontinuing substance use, and getting good quality sleep are all changes that everyone can make, poor mental health or not. These little changes alone can make a big difference sometimes.

For those who will not change or don’t want to, I just provide gentle reminders that I cannot force them to do anything that they don’t want to do, medications are voluntary in outpatient settings. It is a repeated mantra, don’t try harder than the patient. We just meet someone where they’re at, present their options/provide education, and go from there.

[u/punninglinguist → u/_pickledpickles]

Do you encounter a profile of patient who actually become worse with therapy? Like, there's a stereotype that if a narcissist goes to therapy, they just pick up the language of therapy and use it as another tool to exploit people. Is that (or something similar) true in your experience? 

[u/_pickledpickles → u/punninglinguist]

It depends on a lot of factors, like are they aware that there’s a problem, are they being forced to go to therapy by their partner/parent/court ordered, are they lying to their therapist, are they willing to change and take accountability, etc.

I had one patient who got worse after going to therapy because it triggered her PTSD too much so she has avoided it since then.

Getting worse after therapy seems to be a rare occurrence overall.

[u/peachtreecounseling]

OCD has been the most challenging for me.

[u/_sciencebooks → u/peachtreecounseling]

As a psychiatrist, I’ve also found that the really severe cases are some of the hardest to treat in the field.

[u/Freckled_and_Ginger → u/peachtreecounseling]

Watching my friend slide deeper into OCD is heartbreaking and frustrating.

[u/Boogiewoohie]

Anorexia

[u/body-asleep- → u/Boogiewoohie]

I saw a case where the restrictions got so extreme that they stopped drinking water :(

[u/SuperCooch91 → u/body-asleep-]

A mentor of mine saw a case where the patient wouldn’t even swallow their own spit. That one haunts me.

[u/Less-Engineer-9637 → u/SuperCooch91]

I know a girl that started blood letting, she was bulimic and weighed what she brought back up. If it didn't match the weight of the food she consumed you can guess the rest.

[u/lovelycosmos → u/Less-Engineer-9637]

Wait so she threw up and weighed the volume of what she had thrown up?

[u/Less-Engineer-9637 → u/lovelycosmos]

Yes. Bulimia isn't just about getting rid of food from your stomach by vomiting. It gets worse than that for so many people.

[u/KoaliaBear → u/Less-Engineer-9637]

That is horrifying. I hope she got help.

[u/body-asleep- → u/SuperCooch91]

That's heartbreaking. I hope the patient is at peace now

[u/GinLibrarian → u/body-asleep-]

When my restriction is at its worst, I do this. It’s awful. Amazing how your brain can be so adamant about not doing such innate things.

[u/No-patrick-the-lid → u/Boogiewoohie]

It's also the most deadly, isn't it?

[u/TCAAPix → u/No-patrick-the-lid]

35% mortality if I remember my treatment correctly. Worst part is that you can get better, be healthy for years, then something happens, and you're right back where you started. 3 years of treatment, 4 years of being "okay", and then I got cheated on.

[u/Fun-Ball-441 → u/Boogiewoohie]

I can’t seem to find the article now but in Sweden we have a very successful treatment for anorexia that included sauna after meals or something similar.

[u/skanedweller → u/Fun-Ball-441]

Would* be curious to read more about this.

[u/FriktionalTales]

It kind of depends on what you mean "to treat" and what you mean by "difficult." I swear, I'm not trying to be pedantic, let me explain.

Eating disorders are very difficult to treat in the classic sense of "demonstrate long term behavioral improvement." But what makes them even harder is the very real concern of increased mortality rates. Not from suicide like you see in MDD or PTSD where we have risk assessment tools and screeners, but from medical complications related to the disorder.

Personality disorders tend to be very difficult to treat not just because of high resistance and dropout rates, but also clinician burn-out, threats, board complaints, etc. They have tools at their disposal to force a clinician to stop or at the very least reconsider their willingness to continue.

PTSD can be difficult to treat because of comorbid (co-occuring) substance use disorders, hostile attribution bias/paranoia, and an overactive amygdala which desperately clings to fear.

All in all though, these are generalizations because no two people will present the same disorder the same way. There's a lot of cultural, environmental, and personal factors that influence if a certain individual (rather than their disorder) is going to be more/less difficult to treat.

[u/Possible_Ad_4094 → u/FriktionalTales]

Personality disorders tend to be very difficult to treat not just because of high resistance and dropout rates, but also clinician burn-out, threats, board complaints, etc. They have tools at their disposal to force a clinician to stop or at the very least reconsider their willingness to continue.

This is one of our biggest challenges at the VA. Unlike the private sector, we cannot fire a patient under any circumstance. When managing a patient with a severe personality disorder, we see everything from stalking to assault to harassment. We also see admin challenges. These patients go to their Congressperson and other representatives, filing complaints against every single staff member, which we are obligated by law to respond to. This monopolize admin time and hurts other patients access to care. Maybe 1 in 10,000 display this behavior, but it's enough to burn out anyone. I told a patient that is was inappropriate to send 10+ emails to staff per day and that his confrontational tone would hinder progress. For 6 months, he sent near daily multiple-page complaints about me to congress and 5 different oversight authorities. Everyone agreed with me, but it's still taken hundreds of hours away from other patients.

[u/_PirateWench_]

Licensed provider with 10+ yrs of experience here, but baring things like TBIs or dementia, I would guess eating disorders and delusional disorders. EDs have the highest mortality rate and the triggers are everywhere you look bc food is fundamental. Delusional disorders aren’t well treated with antipsychotics bc it’s a cognitive processing thing, not hallucinations. Trying to just reason someone out of a delusion is not very likely.

For me personally, I have a hard time with developmental delays and refuse to work with kids. I just have a hard time breaking large abstract concepts down to super small digestible pieces that someone with those issues can understand. I don’t think they’re generally hard to treat, just not within my skill set.

[u/kathatter75 → u/_PirateWench_]

I applaud you for knowing what you’re not built for and not trying to do it anyway.

[u/Commercial-Durian-31]

There’s a lot of good insight in this thread, all of which I agree with, so I’m going to throw in something I haven’t seen yet.

Dependent personality disorder.

A pillar for mental health/helping professionals is empowering clients to make decisions for themselves, often centring clients as the “experts of their situation.” Often times we see clients who, for whatever reason only they truly understand, are not in a place where they can engage with your help(or help in general). In those instances, you/your organization might have policy in place that helps them transition out or at least gives them space. These policies help prevent burnout, as it can get pretty exhausting pouring yourself into someone who’s not ready to receive that energy.

But what happens when you encounter someone who is ready to receive help, but is pathologically unable to adhere to the expected ways of how adults care for themselves, and almost compulsively unable to respect professional and social boundaries.

We go into these professions because we want to help people- within professional boundaries. But often the familiarity created in these relationships makes it easy for a professional to accidentally over extend themselves. People with DPD unintentionally exploit this, especially if a professional is newer and hasn’t had the opportunity to grow their professional backbone.

I’ve worked with plenty of people with borderline personality disorder, but it was only during working with someone with a mix of Karen tendencies and dependent personality disorder did I start reworking my resume and shopping around for other opportunities. The constant texts and calls, the guilt trips, the inability to give any inch because they will take 100 miles, the time wasted focusing on helping problem solve a simple issue, and the emotional labour required throughout.

This person burnt out several professionals and peer volunteers, because it is very difficult to transition someone out of your care who is consistently showing up and requesting more help. It’s a hard ethical justification, so it’s easier to walk away for a different opportunity, or go on stress leave.

For a professionals mental health, it’s also disheartening to get to the point where you can’t take it anymore, so you just hot potato this individual to the next unsuspecting service provider; but sometimes that’s the only ethical way to preserve your ability to show up for your clients and the people in your personal life.

[u/GuaranteeThis1261 → u/Commercial-Durian-31]

I gasped out loud at this because I have Dependent Personality Disorder lol. I RARELY see it talked about all that much anywhere (FB, Reddit, Tiktok, etc.) because it’s not as common of a diagnosis compared to other disorders; so I love when I randomly come across it being discussed. There’s very little resources for it, limited amount of research done on it, almost no public awareness for it. Support groups are basically nonexistent. The handful of online groups through Facebook and Reddit only a couple hundred members and not very active. I’ve never met another person in real life diagnosed with it. Every person I’ve met and told about my diagnosis have all asked what it is because they had never heard of it before. I also had never heard of it before I was diagnosed with it. I’ve had 1 mental health worker who straight up told me I was her first client she’s had with DPD. I’ve also had another separate therapist who during our first visit together while going over my diagnosis, literally pulled her phone out in front of me and said she had to Google DPD because she didn’t know what it was😫 Most professionals have next to know education on it or experience with people with it. I’m fascinated to hear your experience with your client, so thank you for that!!
I personally do NOT get dependent on therapists or feel over-attached to mine and I could easily cycle to a new provider with ease if needed. My dependence is more focused on 1 single person. I’ve been solely over-dependent on my husband the last 7 years. Before him it was my mother. I’ve been in therapy since age 17 (I’m 30 now, diagnosed DPD at 20). I’ve had at least a dozen different types of mental health providers I’ve seen through the years and haven’t gotten attached to a single one of them. However, I have heard of people with DPD who do get attached to therapists and it’s a common phenomenon in the DPD community. Thank you for sharing your insight and I appreciate you bringing a lil more awareness to the world about the disorder🙂

[u/Commercial-Durian-31 → u/GuaranteeThis1261]

Thank you for sharing your insight, it’s great learning more about this condition from someone living with it- it’s so so true what you are saying, there’s just not enough awareness or support, which contributes to the struggle for professionals and clients alike. If both could be aware and supported, it would create better outcomes for everyone.

[u/Dandelion-Fluff-]

Anything where self awareness is distorted or not really present. Really smart, talented folks who can talk about the same life-wrecking beliefs, behaviours, or distorted perspectives for years without being able to understand their own role in their suffering. 

[u/LeGrandLucifer]

Depends on what you mean by difficult and what you include in mental health.

• Intellectual disability isn't something you treat so much as manage but those patients can be some of the most difficult ones you'll have to deal with.
• Drug addiction isn't exactly a mental health disorder but if you want to include it then it's almost impossible to treat. Impossible without the patient's consent.
• Cluster B personality disorders. No matter what they tell you to try and shift responsibility, they are not treatable with medication. Medication will help deal with other disorders such as anxiety which exacerbate the conditions but you can't treat Borderline, Narcissistic, Antisocial and Histrionic personality disorders with medication. You need therapy and the active, good faith participation of the patient, which you are unlikely to get unless their condition is making them extremely miserable and you're able to get them to both be perceptive enough and have enough humility to admit that their behavior is the source of their misery. And even then the odds of success aren't great.
• This last one is a case-by-case situation, but schizophrenia. Believe it or not, most cases of schizophrenia are treatable, often easily. Yes, you'll be told about how the problem is that they'll stop taking their medication due to side-effects but though it's an issue, it's not bad enough that I would consider it in the "most difficult disorders to treat." However, there are two situations where it can be an absolute nightmare. The first one is where the patient refuses to believe they're sick or worse, believe their medicated, healthy state is wrong. The latter is especially common with mystical delusions: They think the medication is poison to prevent them from hearing God's voice or talking with angels or something like that. You will need to use force to medicate them and if they do eventually take them willingly, they will immediately stop taking them as soon as they get an opportunity. The second situation is someone who's extremely psychotic and resistant to treatment. It happens. We try all the meds and nothing works properly. Then we try electroconvulsive therapy and it doesn't work either. So we get a patient who's barely functional with little to no contact with reality who can be a danger to others or themselves, usually the latter. The only option left at that point is long term care.

I think you'll see a pattern in my comment and in others: Conditions which cannot be treated without the active consent and participation of the patient. The top comment right now is eating disorders and that's another one. And note that I'm not counting things like dementia.

[u/TiaNightingale]

Alzheimer's. It was both frustrating and heartbreaking. Client I worked with would get extremely angry and upset at all the staff and tell us we kidnapped her. An hour later she'd be crying saying her children are trying to help her and acknowledging this is a metal health facility. She tried to hit the chef multiple times for various small reasons, but also at times would be extremely sweet. It's horrific to watch them regress in real time.

[u/AristotlesBoyPussy]

Any disorder where refusing to take your medication and/or paranoia about taking medication is a factor.

[u/jjsap06]

I work in PHP/IOP eating disorder treatment. High rate of relapse and very tricky but recovery is possible, lots of inner work and finding healthy coping mechanisms. Also many co-occurring alongside the ED like ASD, BPD, ADHD, OCD alongside depression and anxiety. Lack of understanding from many including in the medical community and stigma also complicates recovery. Love my work but it can be challenging.

[u/seeshellovesthesea]

Borderline personality disorder. The deeply held core beliefs and complex trauma make it very difficult to address and heal. It is not a defect in the individual but childhood programming and trauma that create an identity that is difficult to break away from.

[u/Fleur921]

Schizoaffective disorder is a really hard one as well. The meds stink, the dx is complex, the differential is hard to approach and you truly have the worst of two worlds: Bipolar disorder and Schizophrenia. Edited to say- you have some of the most difficult symptoms from each of the above diagnoses.

[u/jemjerrica]

Part of addiction is relapse—it’s not addiction if it’s easy to quit. This means that it can feel really hard to work with because progress can be so up and down; sometimes you’re not really sure if the work is making a difference and the stakes feel really high since addiction is so damaging to people’s lives and wellbeing.

[u/coldcoffeethrowaway]

The hardest for me to treat isn’t necessarily any particular disorder, but people who don’t want to be in therapy and aren’t ready or willing to open up.

Besides that, I treat eating disorders, and they are particularly difficult to treat, and personality disorders can be difficult, too.

I actually really enjoy working with people who have experienced psychosis (such as in bipolar disorder or schizophrenia) as long as they are properly medicated and have some insight. If they aren’t medicated and don’t have insight, it is very difficult.

[u/Content-Car8811]

I’m not a mental health professional, but I work in an adjacent field (I’m a neurologist, mostly research oriented) but my research has lots to do with the mechanics of the brain and mood disorders.
I followed someone for a year (car accident vic with severe concussion) and borderline personality disorder.
My close friend was her attending (psychiatrist), so we often shared notes.
This cocktail of TBI plus BPD was incredibly difficult to treat, extremely difficult to make progress on…
I’ve treated a number of people with acute TBI and depression, it makes me wonder about “chicken and egg”.

[u/ifearbears]

Personality disorders can be incredibly challenging to work with, but antisocial PD combined with a victim complex in particular is quite tough. Many clients have a trail of people they’ve hurt behind them with no acknowledgement that they did anything wrong. Rather, they believe they were the ones who were wronged, and when confronted with reality can cycle through every possible excuse, explanation, etc. to attempt to flip the script back in their favour. You can “get to know” a client who realistically does not exist, you simply know their “therapy persona”. If you discover this and attempt to deconstruct it, severe anger emerges. Incongruence is constant for these clients. How can you treat someone who is completely unwilling to entertain the idea that they may not be the victim, but rather the abuser?

[u/jackalope920]

Personality disorders and eating disorders are the most treatment resistant. A lot of folks would say schizophrenia or bipolar two because they are so destructive but those disorders respond well to traditional treatments when followed.

[u/Few_Cup3452 → u/jackalope920]

I agree. Before working in a psych ward, I thought bipolar was the worst. Id had some scary situations with bipolar ppl growing up.

At work, they are good and friendly patients.

[u/ThankeeSai → u/Few_Cup3452]

We're great when we take our meds.

[u/vayyiqra]

The most frustrating for both sides of the treatment might be severe OCD or related conditions (hoarding, health anxiety, body dysmorphic disorder). Eating disorders can be similar and even worse because they're more dangerous, but I don't deal with severe EDs myself, like the kind that need hospitalization. That sounds nightmarish for everyone.

Schizophrenia and other psychotic disorders can be highly disabling but they can be treatable to a great extent with medication. I can't prescribe myself but it's always seemed to me that medication for the above conditions is more limited in how much it helps..

[u/Jaekbad]

I would say any serious psychiatric illness where there is a comorbid personality disorder (e.g. schizophrenia with antisocial personality disorder, anorexia with cluster C personality disorder, FND with cluster B personality disorder, and so on).

The other thing I would say is where there is severe CPTSD with cooccurring personality disorder (eg NPD/ASPD/OCPD) and intellectual disability, which is not uncommon given how often people with ID are victimised by those around them.

[u/heyitspokey]

In my experience

Long-term solitary confiment + schizophrenia

Long term alcohol/substance use disorder + schizophrenia

Anorexia

Animal hoarding

Compulsive lying + extreme cognitive dissonance that's rare, but not isolated to only one disorder