Introduction
Though personality disorders are described by researchers as being widespread and incapacitating, there have been developments in the field, and they have focused on understanding this disorder with intent to treat (Lenzenweger, 2008). Settling on a comprehensive definition, assessment approaches and the management of these disorders has been problematic because of the varying dimensions and impacts to individuals and the general society (Clarkin, Lenzenweger & Meehan, 2015). According to Widiger (2003), individuals often have self-distinguishing approaches to creating and developing relationships, expressing their feelings and thinking. On the same, while some people are outgoing, others have been described as being reclusive and as such have isolated themselves from the rest of the society. Moreover, there is another group that has been described by psychologists as being extremely thorough and thus, approach issues systematically while its opposites are carefree and, as a result, cheerful because nothing troubles them.
While these adaptive behaviors might be considered normal, psychologists have been of the view that such personalities can be challenging because they are maladaptive. They add that this could be a form of escape from various distresses in life. While psychologists have been able to pinpoint such behaviors as being indicative of personality disorders, it has been hard to assess and thus diagnose these traits. Some of the issues that have led to this dilemma include; distinguishing between personality disorders and mental illness and the prevalent gender bias. To this end, this paper will discuss current issues in the assessment of personality disorders.
Background
American Psychiatric Association (2000), personality disorder has been defined as an eternal inner system that characterizes an individual’s thought processes, actions and behaviors thus resulting in nonconformity to socially and culturally acceptable norms. This behavior system is usually prevalent and thus obstinate. Further, personality disorders have been found to be very prevalent in the adolescents: majorly because of their flexible and ever-changing nature; and in young adult. According to the American Psychiatric Association (2013a), personality disorders have been presented as being related to individuals’ thought processes and the esteem with which they hold themselves(Association, 2013). As a result of this, their relationships and approach to life are usually shaped. The American Psychiatric Association has also asserted that personality disorders can remain classified into ten different groups: paranoid, schizoid, schizotypal, antisocial, histrionic, borderline, avoidant, narcissistic, dependent and obsessive personality disorders(Association, 2013).. Oltmanns et al. (2004), notes that these disorders assessed in individuals based on various factors: self-reporting, behavioral observations and reports based on other people's observations of the subject under study.
The Diagnostic and Statistical Manual of Mental Disorders(Association, 2013)., which is usually regarded by psychologists and psychiatrists as the foundation of the study of personality and mental disorders, has been essential in providing guidelines on how these illnesses achieve diagnosis. While there has been issues regarding whether personality disorders should ultimately be considered as mental illness, the assessment and diagnosis of personality disorders has challenging because of the thin line that exists between common personality functionalities and mental illness. According to Nelson-Gray et al. (2007), while personality disorders have proven difficult to identify and thus effectively develop assessment mechanisms, it has been even harder to devise effective approaches to treatment. He notes that although there are various attempts at finding treatment to this disorder, a few methods adopted into practice are supported by research.
According to Nelson-Gray et al. (2007), one of the major problems that are currently affecting the assessment of personality disorders is the existing limitation in available assessment and treatment approaches that are backed by research work. As a result of this outcome, it has been challenging to develop effective decision-making strategies that can inform the treatment of personality disorders. To successfully develop frameworks that used in the diagnosis, assessment and treatment of this disorder, there is a need for empirically supported data that can assure the application of best practices in the industry. Although there are various ways of assessing personality disorders: for example the use of semi-structured interviews and self-reports; research has shown that they are not foolproof. Semi-structured interviews and self-reports have evidence of being widely practiced in the fourth edition of American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (Association, 2013). When using the semi-structured interviews, the issue of consistency from both the psychotherapist and the patient haveissue of consistency from both the psychotherapist and the patient has been raised, and thus, there is still need for empirically supported assessment methodologies (Nelson-Gray et al., 2007).
The other issue has been the evaluation of personality disorders in adolescents. Psychologists and other clinicians have been reluctant to assess mental disorders in adolescent because of the overriding belief that this is a group of individuals that is under transition and as such is bound to be transient. Moreover, since this group is easily stigmatized, it has been challenging to come up with effective strategies that will take this into consideration. Moreover, while there are assessments that have been carried out on the adolescents in the past, psychologists have been of the view that some of the traits that have previously described as being personality disorders have been found to be normal behaviors at this stage of growth and development. Thus, such issues brought into question the validity of some of the assessments conducted on this group. Although this group is still being viewed as being transient, there have been breakthroughs in the diagnosis and evaluation of particular personality disorders in the adolescents, for example, borderline personality disorder. This disorder, which is usually characterized by unstable moods and relationships, is prevalent amongst this group. The developments in addressing this disorder have been timely because if it is not assessed and treated, it can easily affect adolescents in their adulthood (Laurenssen et al., 2013).
In the current practice, Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) has ensured that cultural understanding is an essential part of the personality disorder assessment process(Association, 2013). In this development, DSM-V advises psychologists to make sure that they have a clearer understanding of their patients' racial, ethnic or culture because personality disorders are understood and hence perceived differently in these settings. In some cultural backgrounds, when a community member has headaches or is experiencing certain pains, it is usually understood to be symptoms of something else; and thus as a psychologist, it is important to gain an understanding of these cultural implications successfully so as to effectively assess and hence treat personality disorders. For instance, when dealing with antisocial personality disorder within the Japanese culture, it is important for the psychologist to understand that this culture values social harmony whereby individuals go to greater lengths to avoid upsetting others. When a psychologist gets the understanding that individuals would rather hurt themselves that upset others, they can easily structure intervention approaches to assess and hence address the issue (American Psychiatric Association, 2013b).
Avoidant personality disorders are often comorbid with the anxiety disorder Selective Mutism (SM)(Skinstad, 2011). Among those with antisocial personality disorder 17.5% were also diagnosed with selective mutism, (Skinstad, 2011). The case of Sarah will illustrate a patients struggle with this comorbid disorder. Sarah is school aged and has been diagnosed by her psychiatrist with SM causes children to felt like they are unable to speak to freely(Lang, Regester, Mulloy, Rispoli, & Botout, 2011; Oerbeck, Stein, Wentzel‐Larsen, Langsrud, & Kristensen, 2014). Sarah’s other was aware of the diagnosis but given their current socioeconomic status was unable to afford treatment and was at a loss for how to help her daughter.
The Selective Mutism Resource Manual by Wintgens and Johnson has been a widely used protocol to help younger individuals struggling with SM(Harwood & Bork, 2011; Wintgens & Johnson, 2012). This protocol highlights and emphasizes the unique characteristics of this form of anxiety as it relates to the voice, and techniques that contribute to a life free of such crippling anxiety(Harwood & Bork, 2011; Lang et al., 2011; Wintgens & Johnson, 2012). According to Johnson's manual, Sarah’s condition was classified as severe. Sarah spoke to just eight people in her immediate family, and solely in the context of her home. She had otherwise been completely silent for three years. Sarah's primary source of communication was gesturing.
For example, if Sarah approached a teacher, pointed to herself and then looked in a direction outside the classroom, the teacher might ask, “Do you have to go to the bathroom?” Sarah would then nod, and the teacher would reply, “Go ahead.” Sarah classmates also had their ways of trying to help Sarah communicate. For instance, they might watch Sarah approach an adult and rub her hands together, and then chime in to reveal, “Sarah is saying that she wants to wash her hands.” Sarah had begun to talk only when feeling safe; she underwent behavioral treatment for nine months. Behavioral interventions have shown to be effective in improving lives of school-aged children who are diagnosed with selective mutism (SM)(Lang et al., 2011).
This condition has led to impairments in both educational achievement and socialization (Harwood & Bork, 2011). Compulsive behaviors and speech are also impacted. Early intervention has shown to have long last positive effects (Lang et al., 2011; Oerbeck et al., 2014).Specifically there is an active therapeutic association with participating in Integrated Behavior Therapy sessions with school-aged children who are diagnosed with SM(Bergman, Gonzalez, Piacentini, & Keller, 2013). During her treatment, she receives twenty 60-minute sessions which included the technique of integrated behavior therapy, such as exposure to new situations to try to sound out words, which has also shown to impact anti-social personality(Bergman et al., 2013).
Exercises include not practicing speaking in a clinical setting but also at school and home. Reinforcement for attempts to speak is vital to the success of this treatment. Therapists created a circumstance in which Sarah felt less pressured to speak. Consequently, this relaxed her enough to elicit boisterous laughter, and also led us to play around with silly, unvoiced sounds (i.e. "t-t-t-t" or "sss"). Moving forward, therapists encouraged Sarah to employ writing as an additional tool to communicate. The goal was to have Sarah to have the experience of expressing herself in a more accurate way than gesturing, but without pressuring her to speak(Bergman et al., 2013; Wintgens & Johnson, 2012). As a kindergartener, her writing skills were limited, her spelling was far below her reading level. Clinicians also utilized a visual anxiety rating scale to learn more about Sarah’s feelings, thoughts and thresholds. SM children have very clear cut-offs regarding when they are comfortable speaking, and when they are no(Bergman et al., 2013; Wintgens & Johnson, 2012).
During treatment, at six weeks, she began speaking to the therapist also began speaking to her entire family for the first time in three years. About three weeks later, she was ready to start practicing brave talking with her classmates and teachers. Sarah met clinical goal within the first two months of the school year, and she is currently speaking fully on voice to her classmates and educators. Such effectiveness of this treatment in the case of Sarah is echoed in the current body of literature. Research has shown that those who participate in this form of therapy show significant improvements of words spoken at school and well exhibiting fewer symptoms of antisocial personality disorder(Bergman et al., 2013; Wintgens & Johnson, 2012).
Treatment: Cognitive Behavioral Therapy
Other psychological informed treatments associated with addresses personality disorders or intellective disorders. Treatments attempts to change attitudes and behaviors, borderline personality disorder, as well as antisocial personality disorder, are the most prevalent and thus have been researched at a higher rate(Bateman, 2012). It is important to discuss effective treatments as many of those with either antisocial or borderline have a high rate of suicide, homicide and overall have a higher rate of early mortality(Bateman, 2012).DSM-IV definition of such disorders states that ‘it must currently be pondered a manifestation of a behavioral, psychological or biological dysfunction.' (Sperry, 2013)Thus, a treatment that targets each area are the most effective(Ciccarelli & White, 2015; Shafran et al., 2009).
Cognitive therapies are useful when patients demonstrate impulsiveness and severe anxiety that impacts internal issues(Gill, Bennett-Penn, & Bernstein, 2015; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Sperry, 2013). Systematic reviews have shown this treatment to be effective for several personality and mental disorders. Such analysis included 269 meta-analytic studies efficacy of CBT for : "substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions". (Hofmann et al., 2012). Cognitive therapy refers to psychotherapy that is based on the cognitive approach(Beck, 2005). Treatment was developed by Aaron T. Beck, and has been used for quite some time (Wells, 2013). The essential features of the cognitive approach have nevertheless remained notably the influence that distorted thinking, and unrealistic cognitive appraisal of experiences have on individuals’ behavior and feelings (Mathews, 2013; Knapp & Beck, 2008).
Cognitive Behavioral Therapy (CBT), which includes Cognitive Processing Therapy (CPT), is first line treatment for anyone stuffing with anxiety-related personality disorders(Hofmann et al., 2012; Shafran et al., 2009). CPT provides patients with skills to handle distressing and intrusive thoughts related to the trauma. Through meetings with a therapist patients complete practice exercises that aim at changing what these thoughts and the anxiety induced event mean to the patient as a way of creating an integrated, yet positive outlook on life (Baer, 2015).In cognitive therapy, the subject's therapist is there to help patients understand the relationship between thoughts and symptoms. Symptoms that are associated with certain thoughts about the trauma and patient will practice gaining more awareness of these ideas to be able to see how one influences the other ((Baer, 2015). In regards to feelings of guilt and anger, CBT will help guide patients through the process of healing which eventually will lead to the realization that the disorder is not a personal flaw, and patients can live a fulfilling life(Hofmann et al., 2012; Shafran et al., 2009).
For the physical effects tied to the emotionally charged symptoms, CBT offers patients instructions on coping techniques to change the physiology of the body and reduce anxiety (Baer, 2015). Breathing, muscle relaxation and positive self-talk are all forms of coping that have shown to help the physical and emotional effects of symptoms. All techniques impact the parasympathetic nervous system responsible for restoring balance after stress and thus
result in a decrease of anxiety (Ciccarelli & White, 2015). Patients with personality disorders have reported that CBT skills that they have acquired through therapy have helped them live with their symptoms. Their relationships both personal and professional have been improved during and after CBT (Şalcıoğlu & Başoğlu, 2013; Shafran et al., 2009). Overall, the review included strong evidence base of the success of CBT to reduce symptoms. However, more reach is needed for subgroup particular to cultural and minority populations(Shafran et al., 2009).
Conclusion
In conclusion, while the discussion of whether personality disorders should be considered as mental illnesses continues, it is essential to note that there have been numerous developments within the psychiatric sector; especially regarding mental health care. The publishing of the fifth edition of DSM has considerably improved approaches being undertaken to ensure that the mental health of individuals is well understood by psychologists, thus enabling them to effectively assess, diagnose and hence treat mental disorders(Gill et al., 2015; Sperry, 2013). Some researchers have been of the view that personality disorders should not be considered as mental disorders but rather as risk features that can lead to the latter. In sum, although there are issues that need addressing, further empirical researches into personality disorders will present effective approaches towards the diagnosis and treatment of these disorders.
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