Purpose:Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.Scenario:
Vee is a 26-year-old African-American woman who presents with a history of non-suicidal self-injury, specifically cutting her arms and legs, since she was a teenager. She has made two suicide attempts by overdosing on prescribed medications, one as a teenager and one six months ago; she also reports chronic suicidal ideation, explaining that it gives her relief to think about suicide as a way out.
When she is stressed, Vee says that she often zones out, even in the middle of conversations or while at work. She states, I dont know who Vee really is, and describes a longstanding pattern of changing her hobbies, style of clothing, and sometimes even her job based on who is in her social group. At times, she thinks that her partner is the best thing thats ever happened to me and will impulsively buy him lavish gifts, send caring text messages, and the like; however, at other times she admits to thinking I cant stand him, and will ignore or lash out at him, including yelling or throwing things. Immediately after doing so, she reports feeling regret and panic at the thought of him leaving her. Vee reports that, before she began dating her current partner, she sometimes engaged in sexual activity with multiple people per week, often with partners whom she did not know.
Questions:
Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers.
Describe the presenting problems.
Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.
Discuss which cluster the primary diagnosis belongs to.
Formulate and prioritize a treatment plan.
Personality Disorders
NUR 530 Psychopathology
Week 5
St Thomas University
Outline
An Overview of Personality Disorders
Cluster A Personality Disorders
Paranoid, schizoid, schizotypal
Cluster B Personality Disorders
Antisocial, borderline, histrionic, narcissistic
Cluster C Personality Disorders
Avoidant, dependent, obsessive-compulsive
Personality
Disorders:
An Overview
The nature of personality disorders
Enduring, inflexible predispositions
Maladaptive, causing distress and/or
impairment
High comorbidity
Poorer prognosis
Ego-syntonic: Unlike other disorders,
often feel consistent with ones
identity; patients dont feel that
treatment is necessary
10 specific personality disorders organized
into 3 clusters
Personality
Disorders:
An Overview
DSM-5 personality disorder clusters
Cluster Aodd or eccentric cluster
Cluster Bdramatic, emotional, erratic
cluster
Cluster Cfearful or anxious cluster
Personality
Disorders:
Facts and
Statistics
Prevalence of personality disorders
Affects about 1% of the general
population
Origins and course of personality disorders
Thought to begin in childhood
Tend to run a chronic course if
untreated
May transition into a different
personality disorder
Personality
Disorders:
Facts and
Statistics
Gender distribution and gender bias in
diagnosis
Antisocialmore often male
Histrionicmore often female
Comorbidity is the rule, not the exception
Personality disorders under study
Sadistic: Enjoy inflicting pain
Passive-aggressive: Defiant, undermine
authority
Further research is needed
Cluster A:
Paranoid
Personality
Disorder
Overview and clinical features
Pervasive and unjustified mistrust and
suspicion
The causes
Biological and psychological
contributions are unclear
Early learning that people and the
world are dangerous
Cluster A:
Paranoid
Personality
Disorder
Treatment options
Few seek professional help on their
own
Treatment focuses on development of
trust
Cognitive therapy to counter
negativistic thinking
Lack of good outcome studies
Cluster A:
Schizoid
Personality
Disorder
Overview and clinical features
Pervasive pattern of detachment from
social relationships
Very limited range of emotions in
interpersonal situations
The causes
Etiology is unclear
Childhood shyness
Preference for social isolation
resembles autism
Cluster A:
Schizoid
Personality
Disorder
Treatment options
Few seek professional help on their
own
Focus on the value of interpersonal
relationships
Building empathy and social skills
Lack of good outcome studies
Cluster A:
Schizotypal
Personality
Disorder
Overview and clinical features
Behavior and dress is odd and unusual
Socially isolated and highly suspicious
Magical thinking, ideas of reference,
and illusions
Many meet criteria for major
depression
Some conceptualize this as resembling
a milder form of schizophrenia
Cluster A:
Schizotypal
Personality
Disorder
The causes
A phenotype of a schizophrenia
genotype?
More generalized brain deficits
Treatment options
3050% meet criteria for major
depressive disorder
Main focus is on developing social skills
Address comorbid depression
Medical treatment is similar to that
used for schizophrenia
Treatment prognosis is generally poor
Cluster B:
Antisocial
Personality
Disorder
Overview and clinical features
Failure to comply with social norms
Violation of the rights of others
Irresponsible, impulsive, and deceitful
Lack of a conscience, empathy, and
remorse
Sociopathy and psychopathy
typically refer to this disorder or very
similar traits
May be very charming, interpersonally
manipulative
Cluster B:
Antisocial
Personality
Disorder (APD)
Relation with early behavior problems and
conduct disorder
Early histories of behavioral problems,
including conduct disorder
Callous-unemotional type of
conduct disorder more likely to
evolve into APD
Families with inconsistent parental
discipline and support
Families often have histories of
criminal and violent behavior
Neurobiological
Contributions
and Treatment
of Antisocial
Personality
Prevailing neurobiological theories
Underarousal hypothesiscortical
arousal is too low
Cortical immaturity hypothesis
cerebral cortex is not fully developed
Fearlessness hypothesisfail to
respond to danger cues
Grays model: Inhibition signals are
outweighed by reward signals
Neurobiological
Contributions
and Treatment
of Antisocial
Personality
Treatment
Few seek treatment on their own
Antisocial behavior is predictive of
poor prognosis
Emphasis is placed on prevention and
rehabilitation
Often incarceration is the only viable
alternative
May need to focus on practical (or
selfish) consequences (e.g., if you rob
someone, youll have to serve time)
Development
of Antisocial
Personality
Genetic influences
More likely to develop antisocial
behavior if parents have a history of
antisocial behavior or criminality
Developmental influences
High-conflict childhood increases
likelihood of antisocial personality in
at-risk children
Neurobiological influences
Antisocial traits are not well explained
by neuropsychological research
Development
of Antisocial
Personality
Arousal theory
People with antisocial personalities are
chronically under-aroused and seek
stimulation from the types of activities
that would be too fearful or aversive
for most
Psychological and social influences
In research studies, psychopaths are
less likely to give up when goal
becomes unattainablemay explain
why they persist with behavior (e.g.,
crime) that is punished
Development
of Antisocial
Personality
An integrated model
APD is the result of multiple
interacting factors
Impaired fear conditioning: Children
who develop APD may not adequately
learn to fear aversive consequences of
negative actions (e.g., punishment for
setting fires)
Mutual biologicalenvironmental
influence
Early antisocial behavior alienates
peers who would otherwise serve
as corrective role models
Antisocial behavior and family
stress mutually increase one
another
Development of
Antisocial Personality
© 2019 Cengage. All rights reserved.
Cluster B:
Borderline
Personality
Disorder
Overview and clinical features
Unstable moods and relationships
Impulsivity, fear of abandonment, very
poor self-image
Self-mutilation and suicidal gestures
Comorbidity rates are high with other
mental disorders, particularly mood
disorders
Cluster B:
Borderline
Personality
Disorder (BPD)
The causes
High emotional reactivity
Runs in families
May have impaired functioning of
limbic system
Early trauma/abuse plays a causal role
for some
Cluster B:
Borderline
Personality
Disorder
Triple vulnerability model of anxiety
applies to BPD too:
generalized biological vulnerability
(reactivity)
generalized psychological vulnerability
(lash out when threatened)
specific psychological vulnerability
(stressors elicit borderline behavior)
Cluster B:
Borderline
Personality
Disorder
Treatment optionsfew good outcome
studies
Antidepressant medications provide
some short-term relief
Dialectical behavior therapy is most
promising treatment
Focus on dual reality of
acceptance of difficulties and
need for change
Focus on interpersonal
effectiveness
Focus on distress tolerance to
decrease reckless/self-harming
behavior
Cluster B:
Histrionic
Personality
Disorder
Overview and clinical features
Overly dramatic, sensational, and
sexually provocative
Often impulsive and need to be the
center of attention
Thinking and emotions are perceived
as shallow
More commonly diagnosed in females
Cluster B:
Histrionic
Personality
Disorder
The causes
Failure to learn empathy as a child
Sociological viewproduct of the me
generation
Treatment options
Focus on grandiosity, lack of empathy,
unrealistic thinking
Little evidence that treatment is
effective
Cluster B:
Narcissistic
Personality
Disorder
Overview and clinical features
Exaggerated and unreasonable sense of
self-importance
Preoccupation with receiving attention
Lack sensitivity and compassion for
other people
Highly sensitive to criticism; envious
and arrogant
Cluster B:
Narcissistic
Personality
Disorder
The causes
Failure to learn empathy as a child
Sociological viewproduct of the me
generation
Treatment options
Focus on grandiosity, lack of empathy,
unrealistic thinking
Little evidence that treatment is
effective
Cluster C:
Avoidant
Personality
Disorder
Overview and clinical features
Extreme sensitivity to the opinions of
others
Highly avoidant of most interpersonal
relationships
Are interpersonally anxious and fearful
of rejection
Low self esteem
Cluster C:
Avoidant
Personality
Disorder
The causes
Numerous factors have been proposed
Difficult temperament and early
rejection
Treatment options
Several well-controlled treatment
outcome studies exist
Treatment is similar to that used for
social phobia
Treatment targets include social skills
and anxiety
Cluster C:
Dependent
Personality
Disorder
Overview and clinical features
Reliance on others to make major and
minor life decisions
Unreasonable fear of abandonment
Clingy and submissive in interpersonal
relationships
Cluster C:
Dependent
Personality
Disorder
Causes
Still largely unclear
Linked to early disruptions in learning
independence
Treatment options
Research on treatment efficacy is
lacking
Therapy typically progresses gradually
Treatment targets include skills that
foster independence
Cluster C:
ObsessiveCompulsive
Personality
Disorder
Overview and clinical features
Excessive and rigid fixation on doing
things the right way
Highly perfectionistic, orderly, and
emotionally shallow
Obsessions and compulsions are rare
Cluster C:
ObsessiveCompulsive
Personality
Disorder
The causes
Largely unknown
Weak genetic link
Treatment options
Data supporting treatment are limited
Address fears related to the need for
orderliness
Rumination, procrastination, and
feelings of inadequacy
Summary of Personality
Disorders
DSM-5 includes 10 personality disorders
Fall into cluster A, B, or C
The causes of personality disorders
Start in childhood, but are difficult to specify
Treatment is difficult and prognosis poor
References
American Psychiatric Association (2013).Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5).
American Psychiatric Association (2018). What are Personality Disorders?
Retrieved from: https://www.psychiatry.org/patientsfamilies/personality-disorders/what-are-personality-disorders
Fox, D. (2014). The Clinicians Guide: Diagnosis and Treatment of
Personality Disorders. Eau Claire, WI: PESI Publishing and Media
Hirata, D. (2016). They Say I Have Borderline Personality Disorder. Self
Published
Samuels, J. (2011). Personality disorders: epidemiology and public
health issues. International Review of Psychiatry, 23(3), 223-233.
Sperry, L. (2016). Handbook of Diagnosis and Treatment of DSM-5
Personality Disorders (3rd ed.). New York: Routledge.
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