Week 7: Personality and Paraphilic Disorders

Personality disorders represent perhaps the most challenging disorders that psychiatric-mental health nurse practitioners will have to address in their professional careers. Personality disorders can co-occur in every mental health disorder and, in some cases, can mask other disorders. Although difficult to treat, the PMHNP must be able to identify personality disorders and endeavor to work with the patient to not only recognize the disorder but also treat a disorder that patients often do not believe exist.

Although there is tremendous variety in what is considered normal sexual interests, paraphilic disorders occur when a persistent behavior or fantasy causes distress, harm, or risk of harm to oneself or others. Some paraphilic disorders include pedophilia, exhibitionism, fetishism, and voyeurism.

This week, you will explore controversies related to personality and paraphilic disorders, as well as clinical, ethical, and legal issues that should be considered when working with patients with such diagnoses.
Learning Objectives

Students will:

Analyze controversies related to the diagnosis and treatment of personality and paraphilic disorders
Analyze professional beliefs about personality and paraphilic disorders
Apply strategies for maintaining a therapeutic relationship with patients with personality and paraphilic disorders
Analyze legal and ethical considerations related to personality and paraphilic disorders

Learning Resources

Required Readings (click to expand/reduce)

National Institute for Health and Care Excellence: NICE Guidelines. (2010). Antisocial personality disorder: Prevention and management.

https://www.nice.org.uk/guidance/cg77

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)

Chapter 22, “Personality Disorders”

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.

Chapter 67, “Disorders of Personality”
Chapter 68, “Developmental Risk for Psychopathy”
Chapter 69, “Gender Dysphoria and Paraphilic Sexual Disorders” (pp. 988–993 only)

Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.

Chapter 14, “Personality Disorders”

Required Media (click to expand/reduce)

Buchanan, N. T. (2020, April 13). Lecture 14 part 3: Paraphilic disorders [Video]. YouTube. https://www.youtube.com/watch?v=ykkMo9t0bxs

MDedge. (2020, January 22). Personality disorders with Dr. Frank Yeomans [Video]. YouTube. https://www.youtube.com/watch?v=ESQIDslCX_s

Assignment: Controversy Associated with Personality and Paraphilic Disorders

Between 10% and 20% of the population experience personality disorders. They are difficult to treat as individuals with personality disorders are less likely to seek help than individuals with other mental health disorders. Treatment can be challenging as they do not see their symptoms as painful to themselves or others.

Photo Credit: Joe Houghton – www.joehoughtonphotography.ie / Moment / Getty Images

Paraphilic disorders are far more common in men than in women, and generally quite chronic, lasting at least two years. Treatment of these disorders usually involves both psychotherapeutic and pharmacologic treatments.

In this Assignment, you will explore personality and paraphilic disorders in greater detail. You will research potentially controversial elements of the diagnosis and/or treatment and explain ethical and legal considerations when working with these disorders.
To Prepare

Review this week’s Learning Resources and consider the insights they provide on assessing, diagnosing, and treating personality and paraphilic disorders.
Select a specific personality or paraphilic disorder from the DSM-5 to use for this Assignment.
Use the Walden Library to investigate your chosen disorder further, including controversial aspects of the disorder, maintaining the therapeutic relationship, and ethical and legal considerations.

The Assignment

In 2–3 pages:

Explain the controversy that surrounds your selected disorder.
Explain your professional beliefs about this disorder, supporting your rationale with at least three scholarly references from the literature.
Explain strategies for maintaining the therapeutic relationship with a patient that may present with this disorder.
Finally, explain ethical and legal considerations related to this disorder that you need to bring to your practice and why they are important.

By Day 7 of Week 7

Submit your Assignment.

Personality Disorder: Narcissistic Personality Disorder (NPD)

Narcissistic Personality Disorder (NPD) is a personality disorder that is characterized by a pervasive pattern of grandiosity, a lack of empathy, and a need for admiration. Individuals with NPD often exhibit a sense of entitlement, a preoccupation with fantasies of success and power, and a tendency to exploit and manipulate others to achieve their own goals. They also have a fragile self-esteem that is vulnerable to criticism or failure (American Psychiatric Association, 2013).

Controversies surrounding Narcissistic Personality Disorder

One of the controversies surrounding NPD is the high comorbidity rates with other mental health disorders. Individuals with NPD are more likely to have co-occurring mood, anxiety, and substance use disorders, making it difficult to diagnose and treat NPD alone (Pincus et al., 2014).

Another controversy surrounding NPD is the potential overdiagnosis of the disorder, particularly in the media and popular culture. The term “narcissist” is often used to describe individuals who exhibit self-centered or selfish behavior, which can lead to a misunderstanding of the disorder and stigmatization of those who are diagnosed with NPD (Pincus et al., 2014).

Professional Beliefs about NPD

As a mental health practitioner, it is my professional belief that individuals with NPD can benefit from therapy, even though the disorder is challenging to treat. Cognitive-behavioral therapy, psychodynamic therapy, and group therapy have shown some efficacy in treating NPD symptoms (Levy et al., 2019). Additionally, it is essential to consider comorbid disorders, as treating them can indirectly improve NPD symptoms (Levy et al., 2019).

Strategies for Maintaining the Therapeutic Relationship

One strategy for maintaining the therapeutic relationship with individuals with NPD is to establish clear boundaries and expectations at the beginning of treatment. NPD individuals may have difficulty with boundaries and can become manipulative or aggressive when they feel challenged or criticized (Baskin-Sommers & Krusemark, 2019). Therefore, it is essential to establish therapeutic goals, rules, and boundaries in a non-confrontational manner to foster a safe and collaborative therapeutic environment.

Another strategy is to provide feedback and validation when appropriate. NPD individuals often struggle with a fragile self-esteem and may react negatively to criticism or negative feedback. It is essential to provide feedback and validation in a way that is non-judgmental, empathic, and focused on the individual’s strengths rather than their weaknesses (Baskin-Sommers & Krusemark, 2019).

Ethical and Legal Considerations

As a mental health practitioner, it is important to consider ethical and legal considerations when working with individuals with NPD. One ethical consideration is the need to maintain confidentiality and privacy, as individuals with NPD may fear judgment or exposure (Baskin-Sommers & Krusemark, 2019). It is also important to consider informed consent and the individual’s autonomy, ensuring they understand the risks, benefits, and alternatives to treatment (American Psychological Association, 2017).

In conclusion, NPD is a personality disorder that is challenging to treat, but individuals with NPD can benefit from therapy. Maintaining the therapeutic relationship with individuals with NPD requires establishing clear boundaries and expectations, providing feedback and validation when appropriate, and considering ethical and legal considerations related to confidentiality, informed consent, and autonomy.

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