A Woman with a Personality Disorder Essay

Introduction

The client in this case study is a 32-year-old woman who presented with symptoms such as being manipulative, exploitative, deceitful, and blaming other people for her mistakes. The client also does not have remorse as she is not sorry for not paying back her friends’ money but instead blames them. The patient also manifests irresponsibility in her job and finances and breaks the law in terms of stealing, being imprisoned for 120 days, and engaging in unnecessary fights. The disorder also began manifesting during childhood as she stated that she started having problems as a kid. There are various types of personality disorders and the client manifests symptoms of antisocial personality disorder. DSM-5 criteria stipulate symptoms of antisocial personality disorder to manifest as a pattern of social recklessness, exploitative, guiltless behavior, and being manipulative (Back et al., 2015). Additionally, people with this disorder disregard and violate the rights of other people; the diagnosis should be done when the person is aged 18 years and above, and the behavioral misconduct should present before the person is 15-years-old. Moreover, people with an antisocial personality disorder do not adhere to the law and set regulations; have difficulties sustaining employment; are unable to sustain relationships; and often manipulate and deceit others for their personal gain. This paper will decide the diagnosis for this client and then make two decisions about the client’s treatment plan. The paper will also discuss the ethical aspects applicable and relevant to the client’s treatment plan.

Decision Point One

The diagnosis for this client is an anti-social personality disorder. This is because the client manifests symptoms consistent with the symptoms of this disorder. According to the DSM-5 criteria, symptoms of antisocial personality disorder include disregard for the law and social norms; persistent lying to exploit other people; being disrespectful and callous; violating the law and rights of other people; impulsiveness and inability to plan; aggression and violence; lack of empathy; irritability; poor interpersonal relationships; failure to fulfill financial or work obligations; and engaging in risky and irresponsible behaviors (Ekselius, 2018). The client in this case study manifests symptoms such as inability to maintain relationships with her friends and boyfriend; lack of remorse; engaging in violent behaviors such as where she thrashed a lady with a baseball bat; being irresponsible in her finances; inability to maintain employment; breaking the law, for example by stealing and illegal possession of a gun and illegal drugs; and blaming her friends for her mistakes.

By selecting the diagnosis of antisocial personality disorder, it is expected that this is the correct diagnosis for this client and hence it will facilitate the development of the appropriate treatment plan.

Decision Point Two

The appropriate decision is to refer the client to a psychologist for psychological testing. The reason for selecting this decision to have the client undergo a comprehensive assessment. The comprehensive assessment will involve the administration of psychological tests to have a standardized and objective assessment of the client’s behavior. Therefore, the client will be administered with numerous clinical tests and inventories to enable identification of any cognitive problem, behavioral problem, or any other mental or personality disorder (Bornstein, 2015).

By referring the client to a psychologist for psychological testing, the expectation is that the diagnosis of antisocial personality disorder will be ruled out or confirmed. This is because psychological testing is used to observe and measure the behaviors of clients in order to arrive at a diagnosis and develop the appropriate treatment plan (Waugh et al., 2017). The second expectation is that the psychological tests will reveal and identify other comorbidities and mental issues the client may have.

As expected, the findings from the comprehensive psychological battery test showed that the client exhibited symptoms of multiple personality disorders. The highest score for this client was in antisocial personality disorder. Therefore, this confirms the diagnosis of antisocial personality disorder for this client. However, the client may also be having other comorbidities as demonstrated by symptoms of multiple personality disorder.

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Decision Point Three

The appropriate decision is for the client to be referred to a group-based cognitive behavior therapy (group -BT). Group-CBT was selected due to its efficacy in the treatment of personality disorders like an antisocial personality disorder. According to Bateman et al (2015), CBT treats personality disorders by addressing the maladaptive belief system, contextual and environmental factors that maintain the problematic behaviors, as well as the skill deficits that lead to maladaptive responses. CBT used several techniques to modify these factors and it thus involves the use of techniques such as behavioral modifications, cognitive restructuring, psycho-education, exposure, and skills training (Naza & Ramganesh, 2017). Moreover, the CBT will highlight the importance of the client having a supportive and definite therapeutic relationship to motivate her to make changes. Naza & Ramganesh (2017) further explains that group-CBT can help clients with personality disorders to acquire social skills as they interact with other group members during therapy sessions.

Delectations of this decision expects that Rhoda will manifest significant symptom improvement because group-CBT will help her change the maladaptive thinking/belief pattern and adopt a positive thinking pattern and learn social skills; this will facilitate the client’s behavior change and help her adopt socially acceptable behaviors (Bateman et al., 2015).

Ethical Considerations

Ethical considerations for Rhoda include autonomy, informed consent, and confidentiality. First, the PMHNP should seek informed consent from the client to help her make informed treatment choices (Trull et al., 2018). Secondly, the PMHNP should respect the client’s autonomy to ensure she accepts treatment voluntarily. Moreover, it is important for the PMHNP to always maintain the client’s confidentiality and not divulge information about the client’s diagnosis to unauthorized parties. It is also important for the PMHNP to manage boundaries during the treatment since the evidence shows that individuals diagnosed with personality disorders are likely to have boundaries issues (Trull et al, 2018).

Conclusion

The client’s diagnosis is antisocial personality disorder as indicated by traits and symptoms like the inability to sustain employment; inability to adhere to rules; lack of remorse; and inability to maintain healthy relationships, among other symptoms. The second decision involves referring the client for psychological testing to make sure that the client is assessed comprehensively to confirm or rule out the diagnosis of antisocial personality disorder. The last decision involves referring Rhoda for a group-CBT to ensure behavior change and improve her social skills. Ethical considerations relevant when treating Rhoda include autonomy, informed consent, managing boundaries, and maintaining the confidentiality of the client’s health information.

References

Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The Lancet. 385(9969), 735-743.

Back D. (2015). The Natural History of Antisocial Personality Disorder. Can J Psychiatry, 60(7), 309–314.

Bornstein R. (2015). Personality Assessment in the Diagnostic Manuals: On Mindfulness, Multiple Methods, and Test Score Discontinuities. J Pers Assess, 97(5), 446–455.

Ekselius L. (2018). Personality disorder: a disease in disguise. Ups J Med Sci, 123(4), 194–204.

Nazar N & Ramganesh E. (2017). Cognitive Behavior Treatment of Personality Disorders. International Journal of Humanities and Social Science Invention, 6(11), 20-29.

Trull T, Freeman L, Tayler V, Choate A, Helle A & Wycoff A. (2018). Borderline personality disorder and substance use disorders: an updated review. Borderline Personal Disord Emot Dysregul, 5(15).

Waugh, M. H., Hopwood, C. J., Krueger, R. F., Morey, L. C., Pincus, A. L., & Wright, A. G. (2017). Psychological assessment with the DSM–5 Alternative Model for Personality Disorders: Tradition and innovation. Professional Psychology: Research and Practice, 48(2), 79.

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SUBJECTIVE

Rhonda is a 32-year-old Hispanic female who presents to your office for her initial appointment. When you ask what brought her to your office, she states: “I’m at the end of my rope, I don’t know what else to do.” She then bursts into tears. Rhonda explains that she has very few friends left, and everyone seems to have “abandoned” her. Rhonda explains that she goes out of her way to help other people, and to be nice to them, but this does not seem to help.

Rhonda then stands up and begins to pace around your office at times using wild hand gestures to explain the circumstances that led up to her making the appointment with you. She describes the recent breakup with her boyfriend as traumatic and explains “when we first met, he was the best guy in the world. He treated me well. But he just became a complete monster! Even though he broke off the relationship with me, I was glad to see it end. I hate his guts!”

Rhonda explains that her current financial situation is also precarious. She states that she recently purchased an automobile and is not certain how she is going to pay for it. She states that she had a car that was repossessed last year at that time, and that she borrowed some money from a friend to help pay for the car; the friend later turned around and accused her of theft. “It was my friend’s fault. She told me she would loan me the money and then backed out. I only took the money because she said she would loan it to me … people just can’t go back on their word like that when other people are counting on them.”

Rhonda reports that she was “always in trouble” as a kid. She states that people were always picking on her, to which she adds: “the other kids my age were just stupid. They didn’t know how to have fun.” She says “I have always been impulsive, but it’s fun. Sometimes people can be such prudes … you only go around life once, so you have to make the best of it.”

OBJECTIVE

Rhonda is currently single. She has no children. Educationally, she had completed two semesters toward her Bachelor of Arts degree in fine arts. Rhonda currently works as a waitress at a local restaurant. She has held this job for about 2 weeks. Prior to this, Rhonda worked as a housekeeper for a local hotel chain. She states that she was fired from this job because her coworkers were jealous of her and “planted” evidence of her stealing from hotel patrons. She was also arrested for cashing checks under an alias, for which she spent 120 days in jail.

Rhonda has a history of multiple incarcerations for offences ranging from larceny to possession of controlled substances to possession of an illegal firearm. She was also arrested several times for fighting and on at least one occasion, used a baseball bat to beat up a girl who she thought was trying to “set her up” with the police.

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MENTAL STATUS EXAMRhonda is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. She reports her mood as “terrible!” Affect is labile and seems to change rapidly with the subject being discussed. Her eye contact is normal, but at times, she appears to stare at you. Rhonda is oriented to person, place, and time. She denies visual/auditory hallucinations, no overt paranoia or delusional thought processes noted. Rhonda denies any suicidal or homicidal ideation.

Decision #1 Antisocial Personality Disorder

Decision #2:  Refer to psychologist for psychological testing

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

The psychologist’s report indicates that a comprehensive psychological battery was performed for the purposes of diagnostic clarification. The end result suggested that Rhonda has traits of multiple personality disorders, but scores highest in antisocial personality traits, suggesting antisocial personality disorder. When Rhonda returns to the office, you review the psychologist’s report with her. Rhonda seems upset, but also states “well, that’s why I am here, to get better … what do I need to do?”

Decision #3: Refer to group based Cognitive-behavior Therapy

Guidance to Student

Referral to a psychologist was appropriate for the purposes of diagnostic clarification. Psychological tests can help tease out the actual personality disorder that Rhonda has. In this case, Rhonda’s symptoms are most consistent with antisocial personality disorder, but as you can see, she has signs/symptoms of other personality disorders.

Of the available choices, group-based cognitive behavior therapy may be useful in treating individuals with this personality disorder, but all “improvement” in signs/symptoms should be met with great skepticism.

Dialectical behavior therapy is ineffective in people with APD.

Beginning Latuda is not appropriate, as there are currently no FDA-approved medications to treat APD. Also, prescribing medications to someone with antisocial personality disorder could lead to misuse or diversion.

Examine Case 1: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

Decision #1: Differential Diagnosis
Which Decision did you select?
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
Decision #2: Treatment Plan for Psychotherapy
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
Decision #3: Treatment Plan for Psychopharmacology
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also, include how ethical considerations might impact your treatment plan and communication with clients and their families.

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