«Scaringly Safe»: Therapeutic Processes in Longstanding Eating Disorders With Comorbid Avoidant Personality Disorders in the Recovered Case of Jade

Personality disorders (PD) are highly prevalent among patients with eating disorders (ED) and are often associated with unfavorable treatment outcomes. This may be due to poor engagement in therapy, interpersonal difficulties hampering the treatment alliance, and emotional instability overshadowing the ED symptoms. However, the patients' perspectives on these processes are understudied. To illustrate the potential of addressing personality vulnerabilities and relational issues in ED treatment, we present the case of Jade, a 29-year-old female with longstanding bulimia nervosa, major depressive disorder, and posttraumatic stress disorder following childhood maltreatment. Jade had been diagnosed with multiple PD such as paranoid, borderline, and avoidant PD, and at the time of treatment, she fulfilled the diagnostic criteria for the latter. Jade participated in a 12-week Cognitive Behavioral Therapy (CBT) inpatient program in a specialized ED unit. The treatment focused on the complex symptom interplay, specifically connecting early memories to current reactions, coping strategies, and relationship patterns. Jade normalized her eating patterns and trauma symptoms decreased. She highlighted being able to trust the staff and the treatment program as a prerequisite for ED improvement. Her narrative was triangulated with real-time self-report data examining ED symptoms (EDE-Q), interpersonal patterns (IIP-64), and trauma symptoms (PSS-SR) at assessment, admission, discharge, and 1-year follow-up. Jade was fully recovered from the ED at 1-year follow-up, however, the avoidant PD persisted. Considering the frequent ED-PD co-occurrence, the patient perspective may provide valuable insight to reduce long-term suffering by guiding tailored treatment approaches to improve outcomes for these difficult-to-treat patients. Trial Registration: NCT02649114.