Personality Disorder

Diagnosis and Treatment
Axis II of the DSM covers personality disorders extensively, illuminating the criteria by which personality disorders can be diagnosed, and allowing clinicians to effectively distinguish between them in order to provide the most accurate diagnosis and treatment plan for the client. As a multi-model model, the DSM also allows clients like Mary to be treated for additional clinical conditions and accounts for comorbidity. Alternative models of personality disorder assessment and diagnosis can also be used alone or in conjunction with the DSM (Oldham, 2015). Using any model of assessment, the clinician is advised to take into account the client’s health history with a long range view of behavioral and other presenting symptoms. Clinicians can also take into account what prior treatments Mary has received and the assessments given by her former therapists.
In Mary’s case, personality disorder symptoms are diverse, including self-harm behaviors, suicidal ideation, substance abuse, and troubles maintaining interpersonal relationships. In fact, a superficial overview of Mary’s symptoms would indicate the possibility of paranoid, antisocial, or avoidant personality disorders. A closer look at Mary’s presentation would indicate that borderline personality disorder would also be likely given Mary’s impulsivity, her self-harming behaviors, her difficulties trusting others, outbursts of anger, and her pattern of “intense and unstable relationships with family, friends, and loved ones, often swinging from extreme closeness and love (idealization) to extreme dislike or anger (devaluation),” (National Institute of Mental Health, 2017, p. 1). The latter symptom, Mary’s relationship issues and her inability to form the social connections that would improve her sense of self as well as her coping mechanisms, is central to the diagnosis. Mary’s overall symptom picture includes potential red herrings for clinicians who have not spent as much time with the client, including her history with truancy and her most recent expressions of paranoia related to her coworkers. Feeling “vibrations” from others and feeling persecuted or disliked in the office is not necessarily indicative of a psychotic disorder or paranoid personality disorder, particularly given these are recent, rather than consistent, symptom manifestations. Furthermore, it is possible that Mary’s coworkers indeed do not like her given that Mary might be consciously or unconsciously putting up barriers that prevent her from achieving intimacy.
Treatment approaches for Mary would depend on the recent evidence on borderline personality disorder, which is notoriously “difficult to treat,” (National Institute of Mental Health, 2017, p. 1). Being difficult to treat does not make borderline personality disorder impossible to address or manage, though. As Dingfelder (2004) points out, the central focus of therapy should be on mindfulness and emotion self-regulation. Mindfulness practices “allows clients to observe their emotions without reacting to them or seeking instant relief through self-harm,” (Dingfelder, 2004, p. 1). A combination of therapeutic interventions, including talk therapy, group therapy, and if necessary, pharmacological therapies, might also help Mary to manage her symptoms over time.
Legal and Ethical Issues
Mary is of age, and there are no immediately apparent legal or ethical issues. Although she has exhibited some self-harming behaviors, she does not seem to be in any immediate danger to herself or others in any way that would warrant a civil commitment. Mary has not committed any serious crime and certainly not any violent one, which would be the main parameter against which to base a decision to commit Mary to an inpatient setting against her will. In fact, doing so would reinforce Mary’s already fragile sense of trust in other people. Outside agents could only legally intervene if Mary did act violently against others, or perhaps if she carried out a suicide attempt. In the unlikely event that Mary commits a crime, she would be deemed legally capable of standing trial because borderline personality disorder does not preclude someone from having clear judgments—unlike some other disorders like those of the schizoid cluster. Ethically, Mary needs to be treated with respect and empowered to make decisions about her own mental health. She has sought help on her own, voluntarily, and thus demonstrates a commitment to healing.
References
Dingfelder, S.F. (2004). Treatment for the ‘untreatable.’” APA Monitor 35(3):http://www.apa.org/monitor/mar04/treatment.aspx
National Institute of Mental Health (2017). Borderline personality disorder. https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
Oldham, J.M. (2015). The alternative DSM-V model for personality disorders. World Psychiatry 14(2): 234-236. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471981/