Case Study – Personality Disorders

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Chaotic lifestyles, chronic life interruptions, fractured support systems, and frayed identities collectively describe some of the characteristics of individuals who suffer with personality disorders. Individuals with personality disorders are similar to children navigating through life confused and unsure. Even when surrounded by family and friends, individuals who suffer with personality disorders may feel isolated and alone. As a future professional in the field of psychology, assigning a diagnosis of personality disorder may be very complex.

For this Application, review the case study. Consider important client characteristics for developing a personality disorder diagnosis. Think about your rationale for assigning a particular diagnosis on the basis of the DSM-5.

The Assignment

  • A DSM diagnosis of the client in the case study
  • An explanation of your rationale for assigning the diagnosis on the basis of the DSM
  • An explanation of what other information you may need about the client to make an accurate diagnosis based on the DSM diagnostic criteria

3-4 Pages. APA Format. In-text Citations and Examples.

Support your writing with specific references to all resources and current literature used in its preparation.

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Personality Disorders Personality Disorders Program Transcript MALE SPEAKER: Tell you the truth, I don't even want to be here. My mother, she nags. She pushed me to come. Of course she's 86. She nags and complains about everything. I came just to keep her quiet. FEMALE SPEAKER: You mentioned that she's concerned about your not having very many friends. MALE SPEAKER: I don't have a girlfriend. That's what bothers her. She comes over to my apartment, starts talking how I don't take care of myself, How I need to meet someone, get married. FEMALE SPEAKER: Sounds like you're dealing with some frustration, some annoyance. What do you think about it when she's talking about these things? MALE SPEAKER: She's my mom. I know she cares, but a woman. I've been alone too long to change now. I don't want a relationship. I never have. It's not a big deal. FEMALE SPEAKER: What about your other friends? How would you characterize your social life? MALE SPEAKER: I mean, I know people. They're friends. FEMALE SPEAKER: But what do you like to you when you guys get together? MALE SPEAKER: I don't need other people to do things. I can be my own best friend. I like my privacy. FEMALE SPEAKER: What about the rest of your family? Do you spend a lot of time with them? Are you close with them? MALE SPEAKER: My mom's my family. I don't care about my father or my sister. FEMALE SPEAKER: How about when you were in school and college? How would you describe your social life back then? Students often have opportunities to socialize, activities, making friends. MALE SPEAKER: I didn't have much use for all that. I was busy studying. You don't get on the dean's list by playing around. FEMALE SPEAKER: No, you don't. And what was your major? ©2013 Laureate Education, Inc. 1 Personality Disorders MALE SPEAKER: Electrical engineering. I didn't finish, though. I went three semesters. That was it for me. Trust me, I learned a lot more when I stopped going to classes. The other students, they were completed idiots. I'm not kidding. I taught myself everything I do now at my job-- math, statistics, computers, data analysis. You want to know how long my commute is? 10 steps. 10 steps, my bedroom to my desk. I do all my job right there at home. It's perfect. FEMALE SPEAKER: So besides work, what do you like to do in your free time? MALE SPEAKER: World of Warcraft, an online role playing game. 20 levels, incredibly complex. It has the most incredible special effects. I've been playing it for years, and I still get shivers every time I turn it on and hear that theme music. FEMALE SPEAKER: What do you like about it so much? MALE SPEAKER: It's hard to explain if you've never played it. Basically you go exploring and you get to create your own fantasy world, whatever it is. Sky's the limit. FEMALE SPEAKER: And how do you feel as you're playing it? MALE SPEAKER: You know how they say there's nothing left, nothing more left to explore or discover on earth except maybe at the bottom of the ocean? But I've always imagined myself making some great new discovery. You know, like-- I don't know. Something great. This game lets me do that. FEMALE SPEAKER: It sounds like you spend a lot of time playing it. MALE SPEAKER: It's time well spent as far as I'm concerned. FEMALE SPEAKER: Let's go back to your family a little bit. You had mentioned some strong feelings about your father, your sister. MALE SPEAKER: My father. You want to know why I didn't have any friends when I was young? My old man. I'd be hanging out in the yard with some kids in the neighborhood, throwing the ball around, goofing off, and he'd come out and start yelling at me for no reason. He's just make up an excuse. His voice. It was like having razor blades thrown at you. And after that, nobody would be hanging out in the yard anymore. Just me. And at night, sometimes I was afraid just to come out of my room because I didn't know how he was going to be. Was I going to get a smile or the back of his hand? ©2013 Laureate Education, Inc. 2 Personality Disorders Personality Disorders Additional Content Attribution IMAGES: Images provided by http://www.istockphoto.com/ MUSIC: Creative Support Services Los Angeles, CA Dimension Sound Effects Library Newnan, GA Narrator Tracks Music Library Stevens Point, WI Signature Music, Inc Chesterton, IN Studio Cutz Music Library Carrollton, TX Special Thanks: Fairland Center/Region One Mental Health ©2013 Laureate Education, Inc. 3 RESEARCH ARTICLE . Temperament and Maltreatment in the Emergence of Borderline and Antisocial Personality Pathology during Early Adolescence Martina Jovev PhD1,2; Trudi McKenzie MA3; Sarah Whittle PhD3; Julian G. Simmons PhD3; Nicholas B. Allen PhD1,3; Andrew M. Chanen MBBS, PhD, FRANZCP1,2 ██ Abstract Objective: The present study utilized a prospective, longitudinal design to examine the role of temperament and maltreatment in predicting the emergence of borderline (BPD) and antisocial (ASPD) personality disorder symptoms during adolescence. Method: Two hundred and forty-five children aged between 11 and 13 years were recruited from primary schools in Melbourne, Australia. Participants completed temperament, maltreatment, BPD and ASPD symptom measures, and approximately two years later, 206 participants were again assessed for BPD and ASPD symptoms. Results: The findings indicate that childhood neglect is a significant predictor of an increase in BPD symptoms, while childhood abuse is a significant predictor of an increase in ASPD symptoms. Moreover, abuse and neglect acted as moderators of the relationship between temperament dimensions and increase in BPD and ASPD symptoms, respectively. Abuse was associated with an increase in BPD symptoms for children with low Affiliation, while neglect was associated with an increase in ASPD symptoms for children with low Effortful Control. Conclusions: The current study contributes much needed prospective, longitudinal information on the early development of symptoms of BPD and ASPD, and supports importance of both temperamental and environmental factors in predicting the emergence of these mental health problems early in life. Key Words: personality, temperament, neglect, abuse, adolescence ██ Résumé Objectif: La présente étude a utilisé une méthode prospective longitudinale pour examiner le rôle du tempérament et de la maltraitance dans la prédiction de l’émergence des symptômes d’un trouble de la personnalité limite (TPL) et d’un trouble de la personnalité antisociale (TPA) durant l’adolescence. Méthode: Deux cent quarante-cinq enfants de 11 à 13 ans ont été recrutés dans des écoles primaires de Melbourne, en Australie. Les participants ont répondu à des mesures des symptômes du tempérament, de maltraitance, du TPL et du TPA, et environ deux ans plus tard, 206 participants ont de nouveau été évalués pour les symptômes du TPL et du TPA. Résultats: Les résultats indiquent que la négligence dans l’enfance est un prédicteur significatif d’une augmentation des symptômes de TPL, alors que l’abus dans l’enfance est un prédicteur significatif d’une augmentation des symptômes de TPA. En outre, l’abus et la négligence servaient de modérateurs à la relation entre les dimensions du tempérament et l’augmentation des symptômes de TPL et TPA, respectivement. L’abus était associé à une augmentation des symptômes de TPL pour les enfants ayant une faible affiliation, tandis que la négligence était associée à une augmentation des symptômes de TPA pour les enfants ayant un faible contrôle volontaire. Conclusions: La présente étude apporte une information prospective et longitudinale très nécessaire sur le développement précoce des symptômes de TPL et de TPA, et confirme l’importance des facteurs du tempérament et de l’environnement pour prédire l’émergence de ces problèmes de santé mentale en début de vie. Mots clés: personnalité, tempérament, négligence, abus, adolescent Jovev et al 1 Orygen Youth Health Research Centre, Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia 2 Orygen Youth Health Clinical Program, Northwestern Mental Health, Melbourne, Australia 3 Department of Psychological Sciences, The University of Melbourne, Melbourne, Australia Corresponding E-Mail: achanen@unimelb.edu.au Submitted: February 17, 2013; Accepted: May 9, 2013 220 J Can Acad Child Adolesc Psychiatry, 22:3, August 2013 Temperament and Maltreatment in the Emergence of Borderline and Antisocial Personality Pathology during Early Adolescence Introduction L ittle is known about the childhood antecedents of most personality disorders (PDs) (Cohen & Crawford, 2005). The Children in the Community (CIC) study remains the only prospective, longitudinal, community-based study to examine PD symptoms from childhood through to adulthood (Cohen, Crawford, Johnson, & Kasen, 2005) but this study did not measure antisocial features until participants were aged 18 years (Cohen & Crawford, 2005). Even so, the CIC findings suggest that mean levels of non-antisocial PD traits peak during early adolescence (9-12 years) and follow a linear decline through to 25-28 years of age (Johnson et al., 2000a). This is consistent with a normative pattern whereby the transition from adolescence to adulthood is characterized by decreases in negative affectivity and behavioural disinhibition (Roberts, Caspi, & Moffitt, 2001; Robins, Fraley, Roberts, & Trzesniewski, 2001). Many individuals, however, exhibit no change from adolescent levels or may change in a direction opposing the overall population trend (Johnson, Hicks, McGue, & Iacono, 2007). Indeed, 21% of the CIC sample exhibited an increase in PD symptoms over a decade of follow-up assessments (Johnson et al., 2000b), becoming more deviant relative to their age peers (Crawford et al., 2005). Thus, as the tide of ‘normative’ PD traits recedes, in part due to maturational or socialization processes (Cohen et al., 2005), a group is revealed that perhaps conforms more to descriptions of ‘adult’ PD and is more familiar to practitioners and researchers in adult mental health settings (Chanen & McCutcheon, 2008). Temperament is one individual difference variable that might be a good candidate for predicting such an ‘at risk’ developmental trajectory. Temperament is generally defined as constitutionally based differences in reactivity and regulation that are observable from early in life and have strong biological origins (Goldsmith et al., 1987). It has been implicated in the emergence of a broad range of adolescent mental health problems (Sanson, Letcher, & Smart, 2008). Previous research commonly reports four broad temperament dimensions (Putnam, Ellis, & Rothbart, 2001). Surgency (SUR) refers to a tendency to seek out and enjoy intense experiences, together with a lack of shyness and fear, and is positively associated with the personality factor of extroversion (Putnam et al., 2001). Negative Affect (NA) refers to expressed and felt irritability, sadness and frustration in response to limitations, and is associated with the personality dimension of neuroticism (Rothbart & Ahadi, 1994). Affiliation (AF) relates to a desire for, and pleasure in, warmth and closeness with others and is aligned with the personality factor of agreeableness. Effortful Control (EC) refers to the ability to inhibit a dominant response in order to produce a more socially appropriate and/or goal-directed, non-dominant response (Rothbart, Ahadi, & Evans, 2000), and maps reasonably well onto the adult personality dimension of conscientiousness (Putnam et al., 2001). J Can Acad Child Adolesc Psychiatry, 22:3, August 2013 Understanding the childhood antecedents of borderline personality disorder (BPD) and antisocial personality disorder (ASPD) is of particular importance because they are both associated with severe functional impairments and have disproportionate effects upon the health and justice systems (Coid et al., 2009; Lenzenweger, Lane, Loranger, & Kessler, 2007). It is generally agreed that these disorders emerge during adolescence or early adulthood (APA, 2000) and contribute to serious psychosocial consequences both during adolescence and in later in life (APA, 2000; Chanen, Jovev, & Jackson, 2007; Winograd, Cohen, & Chen, 2008). Moreover, their temporal stability, functional impairments, and related characteristics are similar to those observed in adult populations (Chanen et al., 2004; Chanen et al., 2007; Chanen, Jovev, McCutcheon, Jackson, & McGorry, 2008). Research has robustly associated high negative affect, and low effortful control, agreeableness and conscientiousness with BPD (Joyce et al., 2003; Paris, 2005; Saulsman & Page, 2004). Although similar traits have been associated with ASPD, this disorder also appears to be uniquely associated with low negative affectivity (Liest & Dadds, 2009). While temperamental extremes have been considered among the best candidates for developmental antecedents of adult PDs (Mervielde, De Clercq, De Fruyt, & Van Leeuwen, 2005), no studies have prospectively assessed the role of early adolescent temperament in the etiology of PD symptoms or disorders. Adolescent temperament extremes are likely to confer vulnerability for later personality pathology, at least in part, via their interaction with other etiological factors. Aversive life experiences represent an obvious candidate for such a moderating influence. Childhood abuse and neglect are specific adverse life experiences that have a robust empirical association with the development of adult psychopathology in general (Fergusson, Horwood, & Lynskey, 1996; Mullen, Martin, Anderson, Romans, & Herbison, 1993), with some evidence supporting the idea that this relationship is causal (Kendler et al., 2000). Furthermore, childhood abuse or neglect are both risk factors for both adolescent and adult PD (Cohen et al., 2005). Children with documented childhood abuse or neglect have an increased risk for a range of PDs, including ASPD and BPD, after controlling for offspring age, parental education, and parental psychiatric disorders and symptoms of other PDs (Johnson, Cohen, Brown, Smailes, & Berstein, 1999a). Childhood physical abuse, sexual abuse, and neglect might be differentially associated with PDs, and suggest that it is important to investigate specific etiologic models for each of the PDs. With regard to ASPD and BPD, after symptoms of other PDs were accounted for, documented physical abuse was associated with elevated ASPD symptoms, sexual abuse was associated with elevated BPD symptoms, and neglect was associated with elevated symptoms of ASPD and BPD. 221 Jovev et al The present study utilized a community-based, prospective, longitudinal assessment of both PD symptoms and temperament features beginning early in adolescence. The study specifically focused upon BPD and ASPD symptoms, with the primary aim being to examine the influence of early maltreatment and temperamental antecedents in predicting the emergence of these PD symptoms. Particularly, the degree to which four dimensions of temperament (NA, SUR, AFL and EC) predict emerging symptoms of ASPD and BPD during early adolescence was examined. It was hypothesized that low AFL, low EC and high SUR would be significant predictors of increases in both BPD and ASPD symptoms, while high NA would be a predictor of increased BPD symptoms only. It was further hypothesized that the levels of abuse and neglect would moderate the relationship between temperament and change in ASPD and BPD symptoms, such that the presence of early abuse or neglect would increase the strength of the relationships between temperament and change in symptoms. Consistent with the findings of the CIC study, it was expected that across the sample, measures of BPD and ASPD symptoms would decrease from baseline to follow-up two years later. Father’s education was utilized as an index of general family socioeconomic status. Of our sample, 0.5% of fathers were primary school educated only, 40.1% were high school educated, 18.1% received vocational training (TAFE: Training And Further Education) and 41.2% were university educated. In regard to ethnicity, 87.3% of the sample self-identified as Australian, 6.9% as Australian-European, 3.7% as Australian-Asian, 1.6% as Australian-American and 0.5% as Australian-Middle Eastern. Method The BPD and ASPD subscales of the Children in the Community Self Report Scale (CIC-SR) were used to dimensionally assess BPD and ASPD symptoms in the sample. The CIC-SR was developed as an age-appropriate measure of PDs for the CIC sample (mean age=13 years). The CIC study’s original assessment of PDs took place in 1983 and the scale has been modified on subsequent occasions to reflect the most recent DSM system revisions. The development of the CIC-SR, is described in detail by Crawford and colleagues (Crawford et al., 2005), and it has been repeatedly validated in longitudinal analyses (Bernstein, Cohen, Skodol, Bezirganian, & Brook, 1996; Bernstein et al., 1993; Crawford, Cohen, & Brook, 2001; Johnson et al., 1999a; Johnson et al., 1999b; Kasen et al., 2001). Participants: Sampling and Recruitment Study participants were drawn from a larger study (see Yap et al., 2008a for details). Children were originally recruited from a random sample of government, independent and Catholic primary schools across metropolitan Melbourne. A large group of children (N=2453), between 10-12 years of age, were screened using the Early Adolescent Temperament Questionnaire (EATQ; see below) in order to: (a) select a smaller sample of children for more intensive assessment that represented the full range of temperament scores; and, (b) to maximize the inclusion of children with temperaments associated with both high and low risk of later affect-regulation problems, including PDs. Participants scoring at both extremes of each temperament dimension during the school-based screening were over-sampled for selection into the baseline cohort (N=415). Of the children selected and asked to participate in the more intensive assessments, 59% (N=245) consented to participate and completed the baseline assessments. At baseline, the participants were 11-13 (M=12.5, SD=0.5) years of age, with 121 (49%) male participants. At follow-up (approximately two years after baseline (M = 2.56 years, SD = 0.25 years, range = 1.74 - 3.39 years)), participants were 14-16 years of age (M = 14.57, SD = 0.53). Two hundred and fourteen participants (87%) consented to the followup assessment, but not all completed the assessment. The final sample consisted of 205 individuals who had usable follow-up data. Written informed consent was obtained in accordance with the guidelines of the Human Research Ethics Committee of the University of Melbourne, Australia. 222 Measures The Early Adolescent Temperament Questionnaire-Revised (EATQ-R: Ellis & Rothbart, 2001) was used to examine adolescent temperament child self-report forms. The EATQ-R consists of ten subscales (Activation Control, Affiliation, Attention, Fear, Frustration, High Intensity Pleasure, Inhibitory Control, Pleasure Sensitivity, Perceptual Sensitivity and Shyness) loading onto four higher-order temperamental dimensions: Negative Affect (NA), Surgency (SUR), Affiliation (AFL) and Effortful Control (EC). The EATQ-R has good internal consistency, test-retest reliability and validity data (Capaldi & Rothbart, 1992; Ellis & Rothbart, 2001). The BPD scale (26 items) and the ASPD scale (31 items) were utilized in the present study, and the subscales were used to dimensionally assess BPD and ASPD symptoms rather than for diagnostic purposes. The BPD and ASPD scores ranged from 1 to 3.92 (mean=1.72, SD=0.56) and 1.01 to 2.96 (mean=1.27, SD=0.27), respectively. This is comparable to the data reported in the CIC study for BPD (mean=1.7, SD=1.5); however, ASPD data was not collected until 1992 when participants were 22 years of age (Johnson, Smailes, Cohen, Brown, & Bernstein, 2000c). Both scales had excellent internal consistency (BPD Cronbach’s alpha = 0.94; ASPD Cronbach’s alpha = 0.86) and have appropriate convergence with other self-report instruments in the present sample. The Childhood Trauma Questionnaire (CTQ: Bernstein, Ahluvalia, Pogge, & Handelsman, 1997), a 28-item selfreport inventory suitable for use with adolescents, was used to screen for a history of abuse and/or neglect. The CTQ J Can Acad Child Adolesc Psychiatry, 22:3, August 2013 Temperament and Maltreatment in the Emergence of Borderline and Antisocial Personality Pathology during Early Adolescence Table 1. Summary statistics for temperament, maltreatment and personality disorder symptoms Minimum Maximum Mean SD EC (Baseline) 18 68 47.27 10.04 NA (Baseline) 8 35 23.10 6.46 SUR (Baseline) 22 70 46.93 11.10 AFL (Baseline) 22 64 44.25 8.60 Neglect (Baseline) 10 35 14.73 5.06 Abuse (Baseline) 15 43 18.38 4.92 ASPD (Baseline) 1 2.66 1.25 0.24 BPD (Baseline) 1 3.92 1.67 0.53 ASPD (Follow-up) 1 3.00 1.52 0.40 BPD (Follow-up) 1 2.19 1.30 0.26 SUR = surgency; AFL = affiliation; NA = negative affect; EC = effortful control; ASPD = antisocial personality disorder; BPD = borderline personality disorder consists of items measuring physical, sexual, and emotional abuse (‘Abuse’ scale), and items measuring physical and emotional neglect (‘Neglect’ scale). The CTQ is quick to administer, and has been shown to have acceptable psychometric properties for use in both clinical and community based samples (Bernstein et al., 1997; Scher, Stein, Asmundson, McCreary, & Forde, 2001). Procedure Interviewers met with the adolescent in their home for administration of baseline and follow-up assessments. Assessments were conducted as part of a larger Adolescent Development Study (Yap, Allen, & Ladouceur, 2008b). CIC-SR was administered at both baseline and follow-up. EATQ-R was also administered at both baseline and follow-up assessments, however; only baseline data was utilized, as it was closest to the baseline CIC-SR assessment. CTQ was completed at follow-up, and thus measures abuse and neglect that might have occurred between baseline and follow-up assessments. Data Analysis Data were analyzed using separate hierarchical regressions for each of the maltreatment (abuse and neglect) scores separately. The dependent variable in each regression model was follow-up PD score; with separate analyses conducted for BPD and ASPD scores. Baseline higher-order temperament scores and one of the maltreatment scores were entered into the second block of predictors, after first controlling for the effects of gender, baseline PD score, and SES (father’s highest level of education) in the first block. All two-way interactions involving second block predictors were entered into the third block. All continuous independent variables were mean-centred before forming any interaction terms (Aiken & West, 1991). Significant temperament by trauma interactions were probed using Stata J Can Acad Child Adolesc Psychiatry, 22:3, August 2013 Version 11 (StataCorp., 2009). An alpha level of 0.05 was used to classify findings as significant for all statistical tests. Two participants were missing temperament data and five were missing baseline CIC-SR data. All missing observations were imputed using the EM approach in the SPSS Missing Values procedure. In addition to the variables of interest, the imputation model contained all centered variables and two-way interactions. After imputation of missing data, all continuous independent variables were again mean-centered and interaction terms were re-calculated. Results Preliminary Analyses Summary statistics for temperament, maltreatment and PD symptoms are presented in Table 1. The pattern of stability and change of PD symptoms across the study period was examined. Paired samples t-tests revealed that mean ASPD symptoms significantly increased over the observed period (t(204) = -3.01, p =0.003) while mean BPD symptoms significantly decreased (t(204) = 4.48, p
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