Prior to beginning work on this discussion, please read Chapters 3, 4, and 17 in DSM-5 Made Easy: The Clinician’s Guide to Diagnosis; Cases 18, 19, and 20 from Case Studies in Abnormal Psychology; and Chapter 1 in Psychopathology: History, Diagnosis, and Empirical Foundations. It is recommended that you read Chapter 1 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises.
For this discussion, you will choose from one of the three “You Decide” case studies included in Case Studies in Abnormal Psychology. The case study you choose for this discussion will also be the case study you will use for your Psychiatric Diagnosis assignment in Week Six.
In your initial post, you will take on the persona of the patient from the case study you have chosen in order to create an initial call to a mental health professional from the patient’s point of view. In order to create your initial call, evaluate the symptoms and presenting problems from the case study, and then determine how the patient would approach the first call.
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Create a document that includes a transcript of a call from the patient’s point of view based on the information in the case study including basic personal information and reasons for seeking out psychotherapy. The call may be no more than 5 minutes in length. Once you have created your transcript you will create a screencast recording of the transcript using the patient’s voice. Based on the information from the case study, consider the following questions as you create your recording:
- What would the patient say?
- What tone of voice might he or she use?
- How fast would the patient speak?
- Would the message be understandable (e.g., would it be muffled, circumstantial, tangential, rambling, mumbled, pressured, etc.)?
Quick Guide to the Personality Disorders DSM-5 retains the 10 specific personality disorders (PDs) that were listed in DSM-IV. Of these, perhaps 6 have been studied reasonably well and have a lot of support in the research community. The rest (paranoid, schizoid, histrionic, and dependent PDs), while perhaps less well founded in science, retain their positions in the diagnostic firmament because of their practical use and, frankly, tradition.
Speaking of tradition, ever since DSM-III in 1980 the personality disorders have been divided into three groups, called clusters. Heavily criticized for a lack of scientific validity, the clusters are perhaps most useful as a device to help us call to mind the full slate of PDs.
Cluster A Personality Disorders People with Cluster A PDs can be described as withdrawn, cold, suspicious, or irrational. (Here and throughout the Quick Guide, as usual, the link indicates where a more detailed discussion begins.)
Paranoid. These people are suspicious and quick to take offense. They often have few confidants and may read hidden meaning into innocent remarks.
Schizoid. These patients care little for social relationships, have a restricted emotional range, and seem indifferent to criticism or praise. Tending to be solitary, they avoid close (including sexual) relationships.
Schizotypal. Interpersonal relationships are so difficult for these people that they appear peculiar or strange to others. They lack close friends and are uncomfortable in social situations. They may show suspiciousness, unusual perceptions or thinking, eccentric speech, and inappropriate affect.
Cluster B Personality Disorders Those with Cluster B PDs tend to be rather theatrical, emotional, and attention-seeking; their moods are labile and often shallow. They often have intense interpersonal conflicts.
Antisocial. The irresponsible, often criminal behavior of these people begins in childhood or early adolescence with truancy, running away, cruelty, fighting, destructiveness, lying, and theft. In addition to criminal behavior, as adults they may default on debts or otherwise behave irresponsibly; act recklessly or impulsively; and show no remorse for their behavior.
Borderline. These impulsive people engage in behavior harmful to themselves (sexual adventures, unwise spending, excessive use of substances or food). Affectively unstable, they often show intense, inappropriate anger. They feel empty or bored, and they frantically try to avoid abandonment. They are uncertain about who they are, and they lack the ability to maintain stable interpersonal relationships.
Histrionic. Overly emotional, vague, and desperate for attention, these people need constant reassurance about their attractiveness. They may be self-centered and sexually seductive.
Narcissistic. These people are self-important and often preoccupied with envy, fantasies of success, or ruminations about the uniqueness of their own problems. Their sense of entitlement and lack of compassion may cause them to take advantage of others. They vigorously reject criticism and need constant attention and admiration.
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Cluster C Personality Disorders Someone with a Cluster C PD will tend to be anxious and tense, often overcontrolled.
Avoidant. These timid people are so easily wounded by criticism that they hesitate to become involved with others. They may fear the embarrassment of showing emotion or of saying things that seem foolish. They may have no close friends, and they exaggerate the risks of undertaking pursuits outside their usual routines.
Dependent. These people so much need the approval of others that they have trouble making independent decisions or starting projects; they may even agree with others whom they know to be wrong. They fear abandonment, feel helpless when they are alone, and are miserable when relationships end. They are easily hurt by criticism and will even volunteer for unpleasant tasks to gain the favor of others.
Obsessive–Compulsive. Perfectionism and rigidity characterize these people. They are often workaholics, and they tend to be indecisive, excessively scrupulous, and preoccupied with detail They insist that others do things their way. They have trouble expressing affection, tend to lack generosity, and may even resist throwing away worthless objects they no longer need.
Other Causes of Long-Standing Character Disturbance Personality change due to another medical condition. A medical condition can affect a patient’s personality for the worse. This would not qualify as a PD, because it may be less pervasive and not present from an early age.
Other mental disorders. When they persist for a long time (usually years), a variety of other mental conditions can distort the way a person behaves and relates to others. This can give the appearance of a personality disorder. Especially good examples include dysthymia, schizophrenia, social anxiety disorder, and cognitive disorders. Some studies find that patients with mood disorders are more likely to show personality traits or PDs when they are clinically depressed; this may be especially true of Cluster A and Cluster C traits. Personality pathology noted in depressed patients should be reevaluated once the depression has remitted.
Other specified, or unspecified, personality disorder. Use one of these categories for personality disturbances that do not meet the criteria for any of the disorders above, or for PDs that have not achieved official status.
All humans (and numerous other species as well) have personality traits. These are well-ingrained ways in which individuals experience, interact with, and think about everything that goes on around them. PDs are collections of traits that have become rigid and work to individuals’ disadvantage, to the point that they impair functioning or cause distress. These patterns of behavior and thinking have been present since early adult life and have been recognizable in the patient for a long time.
Personality, and therefore PDs, should probably be thought of as dimensional rather than categorical; this means that their components (traits) are present in normal people, but are accentuated in those with the disorders in question. But for good reasons and bad, DSM-5 has retained the traditional categorical structure that has been used for more than 30 years. There are promises that this will change in the coming years; indeed, DSM-5 devotes a long portion of its Section III (material not officially approved for use) to exploring alternative diagnostic structures. However, the experts will first have to agree as to which dimensions to use, then how best to measure and categorize them, and then how to interpret the results. In the meantime, we will continue to muddle along pretty much as before.
As currently defined in DSM-5, all PDs have in common the following characteristics.
Essential Features of a General Personality Disorder There is a lasting pattern of behavior and internal experience (thoughts, feelings, sensations) that is clearly different from the patient’s culture. This pattern includes problems with affect (type, intensity, lability, appropriateness); cognition (how the patient sees and interprets self and the environment); control of impulses; and interpersonal relationships. This pattern is fixed and applies broadly across the patient’s social and personal life.
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The Fine Print The D’s: • Duration (lifelong, with roots in adolescence or childhood) • Diffuse contexts • Distress and disability (work/educational, social, and personal) • Differential diagnosis (substance use, physical illness, other mental disorders, other PDs, personality change due to another medical condition)
The information PDs convey gives the clinician a better understanding of the behavior of patients; it can also augment our understanding of the management of many patients.
As you read these descriptions and the accompanying vignettes, keep in mind the twin hallmarks of the PDs: early onset (usually by late teens) and pervasive nature, such that a disorder’s features affect multiple aspects of work, personal, and social life.
Diagnosing Personality Disorders
The diagnosis of PDs presents a variety of problems. On the one hand, they are often overlooked; on the other, however, they are sometimes overdiagnosed (borderline PD is, in my opinion, a notorious example). One (antisocial PD) carries a terrible prognosis; most, if not all, are hard to treat. Their relatively weak validity suggests that no PD should be the sole diagnosis when another mental disorder can explain the signs and symptoms that make up the clinical picture. For all of these reasons, it is a good idea to have in mind an outline for making the diagnosis of a PD.
1. Verify the duration of the symptoms. Make sure that your patient’s symptoms have been present at least since early adulthood (before age 15 for antisocial PD). Interviewing informants (family, friends, coworkers) will probably give you the most valid material.
2. Verify that the symptoms affect several areas of the patient’s life. Specifically, are work (or school), home life, personal life, and social life affected? This step can present real problems, in that patients themselves often don’t see their behavior as causing problems. (“It’s the world that’s out of step.”)
3. Check that the patient fully qualifies for the particular diagnosis in question. This means checking all the characteristics and consulting all 10 sets of diagnostic criteria. Sometimes you have to make a judgment call. Try to be as objective as possible. As with other mental disorders, with enough motivation you can usually force a patient into a variety of diagnoses.
4. If the patient is under age 18, make sure that the symptoms have been present for at least the past 12 months. (And be really, really sure that they aren’t due instead to some other mental or physical disorder.) I personally prefer not making such a diagnosis at such a tender age.
5. Rule out other mental pathology that may be more acute and have greater potential for doing harm. The flip side is that other mental disorders are also often more responsive to treatment than are PDs.
6. This is also a good time to review the generic features for any other requirements you may have missed. Note that each patient must have two or more types of lasting problems with behavior, thoughts, or emotions from a list of four: cognitive, affective, interpersonal, and impulsive. (This helps ensure that the patient’s problems truly do affect more than one life area.)
7. Search for other PDs. Evaluate the entire history to learn whether any additional PD is present. Many patients appear to have more than one PD; in such cases, diagnose them all. Perhaps more often, you will find too few symptoms to make any diagnosis. Then you can add to your summary note something to the effect: schizoid and paranoid personality traits.
8. Record all personality and nonpersonality mental diagnoses. Some examples of how this is done are shown in the vignettes that follow.
Although you can learn the rudiments of each PD from the material I present here, it is important to note that these abbreviated descriptions only begin to tap their rich psychopathology. If you want to make a study of these disorders, I strongly recommend that you consult standard texts.
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CLUSTER A PERSONALITY DISORDERS
The PDs included in Cluster A share behaviors generally described as withdrawn, cold, suspicious, or irrational.
F60.0 [301.0] Paranoid Personality Disorder
What you notice most about patients with paranoid PD (PPD) is how little they trust—and how much they suspect—other people. The suspicions they harbor are unjustified, but because they fear exploitation, they will not confide in those whose behavior should have earned their trust. Instead, they read unintended meaning into benign comments and actions, and they will interpret untoward occurrences as the result of deliberate intent. They tend to harbor resentment for a long time, perhaps forever.
These people tend to be rigid and litigious, and may have an especially urgent need to be self-sufficient. To others, they can appear to be cold, calculating, guarded people who avoid both blame and intimacy. They may appear tense and have trouble relaxing during an interview. This disorder is especially likely to create occupational difficulties: Patients with PPD are so aware of rank and power that they frequently have trouble dealing with superiors and coworkers.
Although it is apparently far from rare (it may affect 1% of the general population), PPD rarely comes to clinical attention. When it does, it is usually diagnosed in men. Its relationship (if any) to the development of schizophrenia remains unclear, but if you find that it has preceded the onset of schizophrenia, add the specifier (premorbid).
Essential Features of Paranoid Personality Disorder In many situations, these patients demonstrate that they distrust the loyalty or trustworthiness of others. Because they suspect that other people want to deceive, hurt, or exploit them, they hesitate to share personal information. Unjustified suspicions about the faithfulness of spouse or partner, or even the (mis)perception of hidden content in everyday events or speech, can lead to the bearing of grudges or to rapid response with anger or attacks in kind.
The Fine Print The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders; mood, anxiety, and psychotic disorders; posttraumatic stress disorder; schizotypal and schizoid PDs)
Coding Note If PPD precedes the onset of schizophrenia, add the specifier (premorbid).
Dr. Schatzky A professor of dermatology at University Hospital, Dr. Schatzky had never consulted a mental health professional. But he was well known to the staff at the medical center and notorious among his colleagues. One of them, Dr. Cohen, provided most of the information for this vignette.
Dr. Schatzky had been around for several years. He was known as a solid researcher and an excellent clinician. A hard worker, he supervised fellows working on two grants and carried more than his share of the teaching load.
One of the trainees working in his lab was a physician named Masters. He was a bright, capable young man whose career in academic dermatology seemed destined to soar. When Dr. Masters got an offer from Boston of an assistant professorship and his own lab space, he told Dr. Schatzky that he was sorry, but he would leave at the end of the semester. Furthermore, he wanted to use some of their data.
Dr. Schatzky was more than upset. He responded by telling Dr. Masters that “what happened in the lab stayed in the lab.” He wouldn’t allow anyone to “rip him off,” and he told Dr. Masters that he would be
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blackballed if he tried to publish papers based on their findings. Furthermore, Dr. Schatzky told him to keep away from the students until he left. This outraged the other dermatologists. Dr. Masters was one of the most popular young teachers in the department, and the notion that he shouldn’t have any contact with the students seemed punitive to all and little short of an assault on academic freedom.
The other dermatologists discussed the situation in a department meeting when Dr. Schatzky was out of town. One of the older professors had volunteered to try to persuade him to let Dr. Masters teach anyway. Subsequently, Dr. Schatzky refused with the response, “What have I done to you?” He now seemed to think that the other professor had it in for him.
This professor told Dr. Cohen that he wasn’t really surprised. He’d known Dr. Schatzky since college, and he’d always been a suspicious type. “He won’t confide in anyone without a signed loyalty oath,” was how the other professor put it. Dr. Schatzky seemed to think that if he said anything nice, it would somehow be turned against him. The only person he seemed to trust completely was his wife, a rabbity little creature who had probably never disagreed with him in her life.
At the meeting, someone else suggested that the department chairman should talk to him and try to “jolly him along a bit.” But Dr. Schatzky had little sense of humor and “the longest memory for a grudge of anyone on the face of the planet.”
In the collective memory of all the staff, Dr. Schatzky had never had mood swings or psychosis, and at department dinners, he didn’t drink. “Never out of touch with reality, only nasty,” said Dr. Cohen.
Evaluation of Dr. Schatzky I begin with a disclaimer: From the information available in this vignette, it would appear that Dr. Schatzky had never been interviewed by a mental health professional. Any conclusions must therefore be tentative. Clinicians simply have no right to make definitive diagnoses of patients—or just plain people—for whom they haven’t gathered adequate information.
That said, Dr. Schatzky’s symptoms had apparently been quite constant and present throughout his entire adult life (at least since college). His problems involved both his thinking and his interpersonal functioning, which in turn led to problems with his work and personal life.
What symptoms of PPD did Dr. Schatzky have? Without cause, he suspected young Dr. Masters of planning to “rip off’ his data (criterion A1). His colleagues noted his long-standing concerns about the loyalty of associates (A2). He would never confide in others (A3), and he refused to let Dr. Masters teach, which sounds a lot like holding a grudge (A5). (However, he had apparently never questioned the loyalty of his wife, which would be another common symptom of this PD.) So we can find a total of four symptoms, which is what’s required for a diagnosis of PPD.