Question
personality disorder 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 really 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. MENTAL STATUS EXAM Rhonda 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 Point One- Antisocial Personality Disorder Decision Point Two- 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 Point Three- Begin Latuda 40 mg orally daily 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 o you expected to achieve with Decision #2 and the results of the Decision. Why were they different? • Decision #3: Treatment Plan for Psychopharmacology o Why did you select this Decision? Support your response with evidence and references to the Learning Resources. o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources. o 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 family.
Answer
personality disorder A woman with a personality disorder
A 32-year-old Hispanic female arrives for her first psychiatric interview. Her chief complaint is that she thinks she has reached the “end of her rope” and needs assistance. The patient’s mood is erratic as she depicts her feelings of inadequacy due to the lack of friends. Her financial situation is perilous as a result of her purchasing of a car she cannot afford, as well as her inclination to blame everyone else for her financial woes and expectation of a bailout. She is prone to blaming others for her circumstances and has a criminal record, the most current being fraud (Laureate Education, 2017a). In this week’s case study, I will participate in a decision-making simulation examining the patient’s diagnosis and therapy and any ethical considerations that may be necessary for the client and their family.
Decision # One
Based on the patient’s interview and assessment, an anti-social personality disorder is the most appropriate diagnosis.
Rationale
The client exhibits symptoms that are comparable to those seen in several personality disorders. However, according to the DSM-5, Rhonda’s symptoms are most consistent with an anti-personality disorder diagnosis (DeLisi et al., 2018). To be diagnosed with ant-social personality disorder (APD), a person must exhibit a pervasive pattern of behavior that includes flouting and disregarding other people’s rights as evidenced by failure to conform to social norms, deception, impulsive behavior, aggressiveness, recklessness, being negligent, and sociopathic behavior. Rhonda meets the first criterion for APD diagnosis, as illustrated by her assertion that she was “always in trouble, always impulsive,” finding it hilarious and believing people were prudes. Most notably, Rhonda has a long history of incarceration for various charges such as battering a female with a baseball bat, cashing a check under an alias, unauthorized possession of a handgun, and controlled substances. Furthermore, in order to be diagnosed with APD, a person must be at least 18 years old. In this case, Rhonda is 32 years old .Finally, she meets criterion D since her anti-social behavior is unrelated to schizophrenia or bipolar disorder (American Psychiatric Association, 2013).
Decision # Two
Personality disorders with anti-social tendencies, known as cluster B disorders, may significantly overlap with other diseases such as psychosis. As per the current study, an anti-social personality disorder can emerge as subtypes related to other personality disorders that overlap traits, making them comorbid but not identical (Fisher & Hany, 2019). Therefore, individuals with Anti-social personal disorder must also be recognized in order to provide appropriate classification and treatment solutions. Therefore, based on evidence-based information, the second decision was to refer the client for a full psychological assessment for diagnostic assessment. The results were validated by literature in that the client demonstrated symptoms of various personality disorders; nevertheless, it affirmed the primary diagnosis of anti-social personality disorder (APD).
Decision #3
With a precise diagnosis, the best approach for this client would be to refer her to group-based cognitive-behavioral therapy (CBT). Despite the reality that several treatments have been considered, ASPD is challenging to treat. Early therapeutic intervention with group-based cognitive behavioral therapy, according to the literature, is the cheapest and most effective strategy to treat anti-social personality disorder. If psychotherapy shows inconclusive or unsatisfactory results, drugs are deemed ineffective for this disorder. What’s more worrisome is that administering medications may result in over-use or reliance in persons with an anti-social personality disorder.
Ethical Concerns
Some patients with personality disorders may seek professional help for underlying mental illnesses such as anxiety or depression. It is critical that the clinician does not exclude a patient from getting assistance because they will not benefit from therapy due to the personality disorder. While psychological counseling is ineffective in individuals with ASPD, medications are highly suggested to address other underlying conditions such as aggressiveness and impulsive behavior (Fisher, & Hany, 2019). Patients with an anti-social personality disorder may also require early intervention for substance abuse, stabilization, and detoxification. Because of the complexity of this ailment, it is believed that less constrained conditions are preferable; hence, outpatient treatment may be the best option if possible. If inpatient care is required for whatever reason, there ought to be a defined endpoint with the treatment’s goal specified. Organizations are also encouraged to create a set of specific guidelines for dealing with aggressiveness and violence.
Conclusion
In conclusion, Rhonda, a 32-year-old woman who presented to the office for an initial appointment displaying symptoms suggestive of various personality disorders, was diagnosed with anti-personality disorder after a psychiatrist administered an in-depth diagnostic test on which she scored the highest on anti-social personality disorder. And since there is no approved pharmaceutical intervention in treatment mode, referring Rhonda to CBT is the recommended therapeutic choice for her situation. Furthermore, the entire treatment method displayed critical communication skills and medical ethical principles of beneficence and non-maleficence.
References
Fisher, & Hany. (2019). Antisocial personality disorder – StatPearls – NCBI bookshelf.
Laureate Education. (2017a). A woman with personality disorder [Interactive media file]. Baltimore, MD: Author.
DeLisi, M., Drury, A. J., Caropreso, D., Heinrichs, T., Tahja, K. N., & Elbert, M. J. (2018). Antisocial Personality Disorder with or without antecedent conduct disorder: The differences are psychiatric and paraphilic. Criminal Justice and Behavior, 45(6), 902-917.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.