Antisocial personality disorder (ASPD) has a characteristic pattern of socially irresponsible, guiltless and exploitative behavior. The disorder is associated with other addictive and mental disorders and medical comorbidities. ASPD usually begins in early life, typically around eight years of age and is termed as conduct disorder in childhood, which generally changes to ASPD at the age of 18 years if the antisocial behaviors are persistent. The disorder tends to improve with advancement in age though it can be chronic and lifelong for most individuals. The earlier the disorder sets in, the poorer the prognosis. Other factors that moderate the disorder include employment, marriage, and early adjudication in the early years of life and degree of socialization (Black, 2015). Symptoms include failure to sustain consistent jobs, failure to conform to the law, manipulating others for personal gain, failing to develop interpersonal relationships that are stable and deception of others. According to the DSM-5 criteria for a diagnosis of ASPD needs a history of childhood CD.
The client, in this case, is a 32-year-old Hispanic female called Rhonda who presents in the clinic for her first appointment, where she reports of being at the end of her rope and does not know what else to do. She has very few friends and feels that everyone has abandoned her. She reports that she helps other people, but it does not seem to work. Her financial situation at the moment is also precarious. She says to have always been in trouble when she was a kid. She is single and has no children. She is in her current job for two weeks only and says she was fired from her previous job since her coworkers were jealous of her.
Rhonda has had various incarcerations for offenses and has been arrested many times for fighting. On mental status assessment, she is oriented to time, place and person. She has a clear, coherent, directed, spontaneous and goal-directed speech. She reports having a terrible mood; her affect is labile and changes rapidly depending on the topic of discussion. She has regular eye contact but appears to stare at times. She denies auditory/visual hallucinations, and no delusional or overt paranoia thought processes noted, and she denies any homicidal or suicidal ideation.
According to the information provided in the scenario, Rhonda would be given a diagnosis of antisocial personality disorder. The reason for selecting this decision is because she portrays most symptoms of classifying this disorder as per DSM-5 criteria. These symptoms include failure to sustain her employment, failure to conform to the law as she has been arrested severally, manipulating others for personal gain like where she expects her friend to loan her to buy a car, failing to develop interpersonal relationships that are stable as seen in her being single at the age of 32 and with no child (Dunbar and Sias, 2015). The hope was to come up with a diagnosis that suits Rhonda, and it was not different from my expectation.
My first decision in managing Rhonda is to refer her to a psychologist for psychological testing. The reason for selecting this decision is to get clarification regarding Rhonda’s diagnosis since a psychologist will be in a position to elicit the specific symptoms of ASPD which the PMHNP may not be able to extract and rule out traits that are related to other personality disorders. It can be challenging to make a diagnosis for clients with ASPD since they use manipulation and deceit to evade the diagnostic criteria. A psychologist is, therefore, best suited to clarify the diagnosis since he/she will easily avoid the manipulation of the client. The reason is that he/she will efficiently study the client’s psychology and be able to handle him until a definite diagnosis is arrived. The hope was to get a precise diagnosis for Rhonda so that appropriate treatment measures can be given. There was no difference between my decision and what I hoped to achieve since an accurate diagnosis was arrived at where after the psychological battery was performed the highest score was for ASPD.
The second decision is to refer Rhonda for group-based cognitive behavior therapy. The reason for selecting this decision is because it has been found useful in the management of ASPD though the improvement in all the signs/symptoms is doubtful. The approach is promising as it adapts concepts that address both the individual and his/her environment. The therapy also increases emphasis on how to develop a trusting relationship between the client and the counselor as well as other group members. This way, the client will be in a position to trust people thus develop lasting social relationships. The therapy is also useful as it focuses on daily struggles and a protocol that is so specific is put in place to address anger and violence. The hope while making this decision was to have Rhonda improve in the signs/symptoms that she has for her not give up as she reported to feel like. I also hoped that she would develop trust in people so that she can easily socialize. There was no difference between the results of the decision and what I expected to achieve as Rhonda was able to interact with other group members and the counselor with time and her symptoms improved.
Impact of Ethical considerations on treatment plan and communication with clients and their family
The treatment of psychiatric patients requires that ethical considerations are put into mind just like for treatment of any other patients. Various ethical considerations might impact the treatment and communication with this patient mainly because she has mistrust. One is autonomy. This patient will have diminished autonomy as she will not be in a position to make any decision by herself. The other ethical related issue is informed consent. The reason is that it may be difficult to explain to the patient of the conclusions that one has arrived at so that she can agree or disagree with them due to the trust issues. The client may also be very manipulative such that the PMHNP may have a challenge convincing her to take up treatment. Beneficence and non-maleficence are other ethical issues that may impact the treatment of this client. There should be a balance between the interventions given and the potential benefits to the patient. For instance, the use of pharmacotherapy may not be useful for this client, and there would be no need to give her any drugs. It is, however, important to explain this to her so that she does not feel as if she has not been treated.
Narcissistic Personality Disorder
Narcissistic Personality Disorder (NPD) is a psychological disorder which is defined by a pattern of fantasies of unlimited power or importance, grandiosity and the need for special treatment or admiration that is persistent (Lucille and Tamara, 2016). The interpersonal, effective, core cognitive and behavioral features include volatility, impulsivity, low self-esteem, attention seeking and unstable interpersonal relationships which result in a pattern of interpersonal difficulties, significant psychosocial distress and occupational problems.
According to DSM-5, NPD is classified as a cluster B personality disorder which is emotional, dramatic and erratic which include borderline, antisocial and histrionic personality disorders. For one to be diagnosed with NPD, DSM-5 requires that for one to be diagnosed with NPD, he/she must meet the following criteria; impairments in personality functioning to include self-functioning and interpersonal functioning such as reference to others for self-definition, goal setting is in relation to gaining approval from others, has no empathy and having superficial intimate relationships. Another criterion is pathological personality traits in domains such as antagonism which involves grandiosity and attention seeking (American Psychiatric Association, 2013). Besides, the impairments in personality, both functioning and the individual are stable all the time and consistent, they are not understood as normative and are not because of the direct effects of any substance.
Treatment of NPD involves psychotherapy and pharmacologic therapy, which appears to vary widely. The first line treatment is psychotherapy as it is most helpful. Including family members or significant others is beneficial. Psychotherapy aims to assist the individual in learning to relate better with others to have more enjoyable, intimate and rewarding relationships (Luis, Triebwasser & Siever, 2011). The therapy also helps one to understand the roots of emotions and what drives one to compete mistrust people and despise oneself and others. Psychotherapy has been shown to help individuals accept responsibility and learn to take and keep real personal relationships and collaboration with colleagues, recognize and accept one’s specific abilities and understand and tolerate the impact of issues that are related to one’s self-esteem (Caligor et al., 2015). Pharmacotherapy is recommended to be included when there are other mental health problems such as depression or anxiety where antidepressants and anxiolytics can be administered.
A client who I believe had NPD is a 40-year-old married man who once visited a private practice psychotherapist after his general practitioner referred him. He had complained of problems with his wife where he felt he could not stand living with him. He is a business-man who was very successful, highly competitive who reports of enjoying social gatherings, where he thinks that he tends to be the center of attention among everyone. He also states of having challenges at work, where he believes he has the most superior ability to solve problems yet his colleagues do not always give him a chance. He has come for treatment since he is wondering whether or not he should continue staying in his marriage. He says he lost sexual interest in his wife since their early years in marriage. He has kept many lovers throughout their marriage, whom he has supported, housed and then cut off and replaced. He feels that these arrangements had no impact on his marriage.
The symptoms presented by this client are representative of NPD since he has grandiosity where he feels to be the center of attraction, he is pre-occupied with success and feels powerful like where he perceives to be so superior at his workplace. He also feels he is unique and cannot be able to live with his wife. He also lacks empathy since he has deprived his wife of sex since their early years in life, but he can maintain other lovers one after the other. He does not mind about his wife’s feelings and even intends to stop living with her. He is also dramatic, and his goals seem to be based upon approval by others (Kacel, Ennis and Pereira, 2017). He also has a superficial intimate relationship which he is not able to maintain and keeps getting lovers one after the other.
American Psychiatric Association, (2013). Personality disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing, Inc; 2013.
Black D. W., (2015). The Natural History of Antisocial Personality Disorder. Can J Psychiatry. 2015 Jul; 60(7): 309–314. doi: 10.1177/070674371506000703
Caligor E., Kenneth N. Frank L. E. & Yeomans (2015). Narcissistic Personality Disorder: Diagnostic and Clinical Challenges. Published Online:30 Apr 2015https://doi.org/10.1176/appi.ajp.2014.14060723
Dunbar E. & Sias S., (2015). Antisocial Personality Disorder and Clinical Supervision. ACA VISTAS. Article 85.
Kacel E. L., Ennis N., & Pereira D. B., (2017). Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness. Behav Med. 2017 Jul-Sep; 43(3): 156–164. doi: 10.1080/08964289.2017.1301875
Lucille C. & Tamara B. L., (2016). Narcissistic personality disorder: When it’s all about “me” Nursing Made Incredibly Easy!: January/February 2016 – Volume 14 – Issue 1 – p 36–42 doi: 10.1097/01.NME.0000475165.10782.87
Luis H. Triebwasser R. J., Siever L. J., (2011). Evidence-based pharmacotherapy for personality disorders. International Journal of Neuropsychopharmacology, Volume 14, Issue 9, 1 October 2011, Pages 1257–1288, https://doi.org/10.1017/S1461145711000071