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 don’t 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 that’s 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 can’t 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 one’s
identity; patients don’t feel that
treatment is necessary
• 10 specific personality disorders organized
into 3 clusters
Personality
Disorders:
An Overview
• DSM-5 personality disorder clusters
• Cluster A—odd or eccentric cluster
• Cluster B—dramatic, emotional, erratic
cluster
• Cluster C—fearful 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
• Antisocial—more often male
• Histrionic—more 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
• 30–50% 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 hypothesis—cortical
arousal is too low
• Cortical immaturity hypothesis—
cerebral cortex is not fully developed
• Fearlessness hypothesis—fail to
respond to danger cues
• Gray’s 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, you’ll 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 unattainable—may 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 biological–environmental
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 options—few 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 view—product 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 view—product 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 Clinician’s 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.