Decision Tree: Personality Disorders
As described by the American Psychiatric Association (APA) (2013), ‘‘personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’’. There are different types of personality disorders classified into three clusters. Cluster A individuals are described as the odd or eccentric, cluster B as the dramatic, emotional, or erratic and cluster C as the anxious or fearful. The purpose of this paper is to discuss the case study of a young woman with personality disorder. This paper will explore threes decisions relating to differential diagnosis, psychotherapy and psychopharmacology based on the presented clinical manifestations.
The clinical manifestation presented in the case study are indicative of more than one personality disorder, specifically borderline personality disorder (BPD) and antisocial personality disorder (ASPD). Patients exhibits a fear of abandonment which aligns with BPD. The patient mentioned an interpersonal relationship involvement which she exhibited idolization for the man of her interest, and now is devaluing the man. This is also evident in BPD as outlined by diagnostic criteria set forth by the APA (2013).
My diagnosis for this patient is ASPD, because the client exhibits clinical manifestations of ASPD than BPD. One of the reasons that led me to the diagnosis of ASPD is the client’s lack of remorse. The client stole from a friend, instead of being sorry, client’s blames friend instead. Client exhibits lack of respect for social norm and failure to comply with the law as evidenced by more than one record of arrest. The client fails to upholding financial obligation and is deceitful. Client shows irresponsibility evidenced by inability to keep a job. These presentations are evident in clients with ASPD as outlined in the DSM-5.
The two personality disorders which are classified as cluster B personality disorders by the APA (2013) have clinical manifestations which overlap, thus needs to be ruled out as differential diagnoses for each other. As described on the DSM-5 diagnostic criteria, BPD and ASD have similar features of impulsivity, aggression and manipulative behaviors, which client exhibits in the case study. The differing manifestation between the two is that in BPD, clients seek out interpersonal relationship, while ASPD client is unable to form any attachment to relationship. Clients with BPD exhibit self-mutilating behaviors and self-aggression, while in ASPD, aggression is directed on others. In ASPD clients are egocentric (also seen in narcisstic personality disorder), while BPD clients have a poor image of self.
Since the client exhibits symptoms which are synonymous with one more than personality disorder, specifically borderline and antisocial; the best decision is to opt to conduct a psychological testing. This will to further help the practitioner to decipher between the two diagnoses or conclude that patient indeed has the two personality disorders which is a possible occurrence. Psychological testing can be in the form of rating scales which includes questionnaires, checklists e.t c. According to Sadock, Sadock and Ruiz (2014), these scales are useful for monitoring patient overtime or to provide a comprehensive assessment information that was not obtained during a routine clinical interview.
There is limited evidence from existing literatures on the effectiveness of medications to target the core symptoms of ASPD. Khalifa et al. (2010) mentions that pharmacological interventions are not to be considered as monotherapy but as adjunctive intervention to target associated symptoms of ASPD such as depression, aggression etc. The option of Haldol, an antipsychotic medication can be used to address aggression but does not treat the core features of the disorder such as lack of remorse, deceitfulness. Furthermore, the plethora of side effects known to be caused by the medication can increase noncompliance. Psychotherapy can be beneficial, but psychodynamic is not appropriate for this patient because it may require patient to address emotional states. According to Hesse (2010), probing about ‘feeling states’ is unhelpful because the ASPD client may have difficulty accessing such state and may become aggressive when made to confront personal shortcoming.
In decision three, the recommendation is for a group-based cognitive therapy. Latuda an antipsychotic can be used to treat aggression but not the core symptoms of ASPD. Dialectical behavioral therapy will be more appropriate in the client with BPD than in ASPD. The most cited effective psychotherapeutic approach used in ASPD is cognitive behavioral therapy (CBT). This approach helps the client address distorted beliefs about self, others and the world. CBT can be used to enhance social and intrapersonal functioning.
A group setting may be beneficial for these clients as they may be able to learn from others experience or information shared about self. Psychotherapy for ASPD should be met with skepticism, but Hesse (2010) suggested that approaches that includes employing moral reasoning, cognitive behavioral approach, applying a social information processing approach, and planning for relapse prevention should be used. Additionally, the clients need a high level of external structure that includes supervision of the patient and reinforcement of positive social behaviors to yield increased outcomes for ASPD clients (Hesse, 2010).
Ethical and Legal Considerations
Due to the clinical manifestation of ASPD, some clinicians believe that it is hopeless to treat ASPD clients due to their clinical manifestation of aggression, deceitfulness and manipulation. Clients tends to be noncompliant, fueling the clinician’s pessimism. Existence of pessimism can hinder practitioners from upholding the ethical principles to do no harm and to do the best for the patient to full capacity. Hatchet (2015), implores clinicians to turn to published studies to become more aware of treatment options and to avoid expert opinions or clinical myths in regards to treating clients with ASPD. For these clients, autonomy may be purposely compromised to prevent harm to the patient and to others. This is seen in cases where patient refuse to comply with treatment plan or ordered into treatment and remain in treatment until deemed fit to come out of treatment.
It is essential for the practitioner to be knowledgeable about personality s disorder to effectively care for the patient. The practitioner should explore various options of medication, used to target accompanied symptoms. Psychotherapy, even though some might argue of its effectiveness, should not be ruled out. Assessment tools should be used to guide the clinicians, in diagnosing, especially with disorders that have overlapping symptoms.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Khalifa, N., Duggan, C., Stoffers, J., Huband, N., Völlm, B. A., Ferriter, M., & Lieb, K. (2010). Pharmacological interventions for antisocial personality disorder. The cochrane database of systematic Reviews, (8). Doi: 10.1002/14651858.CD007667.pub2
Hatchett, G. T. (2015). Treatment guidelines for clients with antisocial personality disorder. Journal of mental health counseling, 37(1). Retrieved from Walden University Database
Hesse, M. (2010). What should be done with antisocial personality disorder in the new edition of the diagnostic and statistical manual of mental disorders (DSM-V)? Biomed central medicine, 8(66). DOI: 10.1186/1741-7015-8-66
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.