Mental Health Providers Share The Most Difficult Disorders They’ve Ever Treated

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.

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?

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.

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.

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.

The saddest i’ve ever been for a client was meeting a 19 year old who has “reality monitoring” issues. basically she can’t tell the difference between her dreams/imagination/memories and the real world.

for instance yesterday she was upset because she remembered her senior year of highschool she didn’t see her friend. to her - that was real life, happening right now.

imagine having to relive the bad moments of your life in 4k, to the point it takes over whats actually happening in front of you.

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.

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.

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.

Clients who have spontaneous confabulations (false memories that they believe to be true) are very difficult to work with. they will often become paranoid of those around them and lack insight into their condition. these are usually people who have korsakoff’s syndrome or an ABI.

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.

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.

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

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.

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..

Severe OCD. It starts off with rational fears at the very beginning until it balloons to be larger than anything you could imagine. And it's incredibly challenging to break through the psychological spirals folks can have. It can be absolutely debilitating for many. It's one of the few diagnoses that being admitted into inpatient treatment has the potential to do more harm than good, so there's a lot of risk analysis that has to be done to ensure they're getting the right level of care. But what's extra challenging is if the OCD is debilitating enough it leads them to having ideation of harming themselves or others. That can happen too.

Individuals that have egosyntonic personality disorders, especially in cases of severe narcissism and antisocial personality disorder. In all other cases, the patient is experiencing emotional distress and wishes for it to end. When it comes to egosyntonic disorders, the patient believes that he or she is completely right and that other people are the reason for this condition. He or she rarely seeks for any treatment without an order of court, employer, or spouse who is threatening to get a divorce because of him/her. The whole process of therapy involves a lot of openness and trust, but the main characteristic of such disorder is manipulation and fragility of ego, which makes introspection an attempt to ruin one's life.

Anything that has an underlying medical reason that is driving it; no amount of therapy can touch those.

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.

Because most disorders are on a spectrum, most of them are challenging on the more extreme ends of the spectrum. That being said, one I struggle the most to work with is Borderline Personality Disorder.