FINANCIAL ANALYSIS REPORT .docx

FINANCIAL ANALYSIS REPORT
2
Decision Tree: Personality Disorders
Frank Jones
Sam’s University
Nurs 3333: PMHNP Role IV
Dr. Joe Mark
October 20 , 2010
Running head: DECISION TREE
1
DECISION TREE
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Decision Tree: Personality Disorders
As described by the American Psychiatric Association (APA)
(2013), ‘‘personality disorder is an enduring pattern of inner
experience and behavior that deviates markedly from the

expectations of the individual’s culture, is pervasive and
inflexible, has an onset in adolescence or early adulthood, is
stable over time, and leads to distress or impairment’’. There
are different types of personality disorders classified into three
clusters. Cluster A individuals are described as the odd or
eccentric, cluster B as the dramatic, emotional, or erratic and
cluster C as the anxious or fearful. The purpose of this paper is
to discuss the case study of a young woman with personality
disorder. This paper will explore threes decisions relating to
differential diagnosis, psychotherapy and psychopharmacology
based on the presented clinical manifestations.
Decision One
The clinical manifestation presented in the case study are
indicative of more than one personality disorder, specifically
borderline personality disorder (BPD) and antisocial personality
disorder (ASPD). Patients exhibits a fear of abandonment which
aligns with BPD. The patient mentioned an interpersonal
relationship involvement which she exhibited idolization for the
man of her interest, and now is devaluing the man. This is also
evident in BPD as outlined by diagnostic criteria set forth by
the APA (2013).
My diagnosis for this patient is ASPD, because the client
exhibits clinical manifestations of ASPD than BPD. One of the
reasons that led me to the diagnosis of ASPD is the client’s lack
of remorse. The client stole from a friend, instead of being
sorry, client’s blames friend instead. Client exhibits lack of
respect for social norm and failure to comply with the law as
evidenced by more than one record of arrest. The client fails to
upholding financial obligation and is deceitful. Client shows
irresponsibility evidenced by inability to keep a job. These
presentations are evident in clients with ASPD as outlined in
the DSM-5.
The two personality disorders which are classified as cluster B
personality disorders by the APA (2013) have clinical
manifestations which overlap, thus needs to be ruled out as
differential diagnoses for each other. As described on the DSM-

5 diagnostic criteria, BPD and ASD have similar features of
impulsivity, aggression and manipulative behaviors, which
client exhibits in the case study. The differing manifestation
between the two is that in BPD, clients seek out interpersonal
relationship, while ASPD client is unable to form any
attachment to relationship. Clients with BPD exhibit self-
mutilating behaviors and self-aggression, while in ASPD,
aggression is directed on others. In ASPD clients are egocentric
(also seen in narcisstic personality disorder), while BPD clients
have a poor image of self.
Decision Two
Since the client exhibits symptoms which are synonymous with
one more than personality disorder, specifically borderline and
antisocial; the best decision is to opt to conduct a psychological
testing. This will to further help the practitioner to decipher
between the two diagnoses or conclude that patient indeed has
the two personality disorders which is a possible occurrence.
Psychological testing can be in the form of rating scales which
includes questionnaires, checklists e.t c. According to Sadock,
Sadock and Ruiz (2014), these scales are useful for monitoring
patient overtime or to provide a comprehensive assessment
information that was not obtained during a routine clinical
interview.
There is limited evidence from existing literatures on the
effectiveness of medications to target the core symptoms of
ASPD. Khalifa et al. (2010) mentions that pharmacological
interventions are not to be considered as monotherapy but as
adjunctive intervention to target associated symptoms of ASPD
such as depression, aggression etc. The option of Haldol, an
antipsychotic medication can be used to address aggression but
does not treat the core features of the disorder such as lack of
remorse, deceitfulness. Furthermore, the plethora of side effects
known to be caused by the medication can increase
noncompliance. Psychotherapy can be beneficial, but
psychodynamic is not appropriate for this patient because it may
require patient to address emotional states. According to Hesse

(2010), probing about 'feeling states' is unhelpful because the
ASPD client may have difficulty accessing such state and may
become aggressive when made to confront personal
shortcoming.
Decision Three
In decision three, the recommendation is for a group-based
cognitive therapy. Latuda an antipsychotic can be used to treat
aggression but not the core symptoms of ASPD. Dialectical
behavioral therapy will be more appropriate in the client with
BPD than in ASPD. The most cited effective psychotherapeutic
approach used in ASPD is cognitive behavioral therapy (CBT).
This approach helps the client address distorted beliefs about
self, others and the world. CBT can be used to enhance social
and intrapersonal functioning.
A group setting may be beneficial for these clients as they may
be able to learn from others experience or information shared
about self. Psychotherapy for ASPD should be met with
skepticism, but Hesse (2010) suggested that approaches that
includes employing moral reasoning, cognitive behavioral
approach, applying a social information processing approach,
and planning for relapse prevention should be used.
Additionally, the clients need a high level of external structure
that includes supervision of the patient and reinforcement of
positive social behaviors to yield increased outcomes for ASPD
clients (Hesse, 2010).
Ethical and Legal Considerations
Due to the clinical manifestation of ASPD, some clinicians
believe that it is hopeless to treat ASPD clients due to their
clinical manifestation of aggression, deceitfulness and
manipulation. Clients tends to be noncompliant, fueling the
clinician’s pessimism. Existence of pessimism can hinder
practitioners from upholding the ethical principles to do no
harm and to do the best for the patient to full capacity. Hatchet
(2015), implores clinicians to turn to published studies to
become more aware of treatment options and to avoid expert

opinions or clinical myths in regards to treating clients with
ASPD. For these clients, autonomy may be purposely
compromised to prevent harm to the patient and to others. This
is seen in cases where patient refuse to comply with treatment
plan or ordered into treatment and remain in treatment until
deemed fit to come out of treatment.
Conclusion
It is essential for the practitioner to be knowledgeable about
personality s disorder to effectively care for the patient. The
practitioner should explore various options of medication, used
to target accompanied symptoms. Psychotherapy, even though
some might argue of its effectiveness, should not be ruled out.
Assessment tools should be used to guide the clinicians, in
diagnosing, especially with disorders that have overlapping
symptoms.
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Khalifa, N., Duggan, C., Stoffers, J., Huband, N., Völlm, B. A.,
Ferriter, M., & Lieb, K. (2010). Pharmacological interventions
for antisocial personality disorder. The cochrane database of
systematic Reviews, (8). Doi:
10.1002/14651858.CD007667.pub2
Hatchett, G. T. (2015). Treatment guidelines for clients with
antisocial personality disorder. Journal of mental health
counseling, 37(1). Retrieved from Walden University Database
Hesse, M. (2010). What should be done with antisocial
personality disorder in the new edition of the diagnostic and
statistical manual of mental disorders (DSM-V)? Biomed central

medicine, 8(66). DOI: 10.1186/1741-7015-8-66
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan &
Sadock’s synopsis of psychiatry: Behavioral sciences/clinical
psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Assignment: Decision Tree
For this Assignment, as you examine the client case study in
this week’s Learning Resources, consider how you might assess
and treat pediatric clients presenting symptoms of a mental
health disorder.
The Assignment:
Examine Case 2: You will be asked to make three decisions
concerning the diagnosis and treatment for this client. Be sure
to consider co-morbid physical as well as mental factors that
might impact the client’s diagnosis and treatment.
At each Decision Point, stop to complete the following:
· Decision #1: Differential Diagnosis
· Which Decision did you select?
· Why did you select this Decision? Support your response with
evidence and references to the Learning Resources.
· What were you hoping to achieve by making this Decision?
Support your response with evidence and references to the
Learning Resources.
· Explain any difference between what you expected to achieve
with Decision #1 and the results of the Decision. Why were they
different?
· Decision #2: Treatment Plan for Psychotherapy
Learning Resources.
with Decision #2 and the results of the Decision. Why were they
different?

· Decision #3: Treatment Plan for Psychopharmacology
Learning Resources.
with Decision #3 and the results of the decision. Why were they
different?
· Also include how ethical considerations might impact your
treatment plan and communication with clients and their
families.
Note: Support your rationale with a minimum of three academic
resources. While you may use the course text to support your
rationale, it will not count toward the resource requirement.
Case #2
Anxiety disorder, OCD, or something else?
BACKGROUND
Tyrel is an 8-year-old black male who is brought in by his
mother for a variety of psychiatric complaints. Shaquana,
Tyrel’s mother, reports that Tyrel has been exhibiting a lot of
worry and “nervousness” over the past 2 months. She states that
she notices that he has been quite “keyed up” and spends a great
deal of time worrying about “germs.” She states that he is
constantly washing his hands because he feels as though he is
going to get sick like he did a few weeks ago, which kept him
both out of school and off the playground. He was also not able
to see his father for two weekends because of being sick.
Shaquana explains that although she and her ex-husband
Desmond divorced about 2 years ago, their divorce was
amicable and they both endeavor to see that Tyrel is well cared
for.
Shaquana reports that Tyrel is irritable at times and has also had
some sleep disturbances (which she reports as “trouble staying

asleep”). She reports that he has been more and more difficult
to get to school as he has become nervous around his
classmates. He has missed about 8 days over the course of the
last 3 weeks. He has also stopped playing with his best friend
from across the street.
His mother reports that she feels “responsible” for his current
symptoms. She explains that after he was sick with strep throat
a few weeks ago, she encouraged him to be more careful about
washing his hands after playing with other children, handling
things that did not belong to him, and especially before eating.
She continues by saying “maybe if I didn’t make such a big deal
about it, he would not be obsessed with germs.”
Per Shaquana, her pregnancy with Tyrel was uncomplicated, and
Tyrel has met all developmental milestones on time. He has had
an uneventful medical history and is current on all
immunizations.
OBJECTIVE
During your assessment of Tyrel, he seems cautious being
around you. He warms a bit as you discuss school, his friends at
school, and what he likes to do. He admits that he has been
feeling “nervous” lately, but when you question him as to why,
he simply shrugs his shoulders.
When you discuss his handwashing with him, he tells you that
“handwashing is the best way to keep from getting sick.” When
you question him how many times a day he washes his hands, he
again shrugs his shoulders. You can see that his bilateral hands
are dry. Throughout your assessment, Tyrel reveals that he has
been thinking of how dirty his hands are; and no matter how
hard he tries to stop thinking about his “dirty” hands, he is
unable to do so. He reports that he gets “really nervous” and
“scared” that he will get sick, and that the only way to make
himself feel better is to wash his hands. He reports that it does
work for a while and that he feels “better” after he washes his
hands, but then a little while later, he will begin thinking “did I
wash my hands well enough? What if I missed an area?” He

reports that he can feel himself getting more and more “scared”
until he washes his hands again.
MENTAL STATUS EXAM
Tyrel is alert and oriented to all spheres. Eye contact varies
throughout the clinical interview. He reports his mood as
“good,” admits to anxiety. Affect consistent to self-reported
mood. He denies visual/auditory hallucinations. No overt
delusional or paranoid thought processes were apparent. He
denies suicidal ideation.
Lab studies obtained from Tyrel’s pediatric nurse practitioner
were all within normal parameters. An antistreptolysin O
antibody titer was obtained for reasons you are unclear of, and
this titer was shown to be above normal parameters.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE
SCENARIO ABOVE, WHICH OF THE FOLLOWING
DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?
In your write-up of this case, be certain to link specific
symptoms presented in the case to DSM–5 criteria to support
your diagnosis.
Generalized Anxiety Disorder (GAD)
Obsessive Compulsive Disorder
Pediatric Autoimmune Neuropsychiatric Disorders Associated
with Streptococcal Infections (“PANDAS”)
ANSWER CHOOSEN: Obsessive Compulsive Disorder
Decision Point Two
BASED ON THE ABOVE INFORMATION, SELECT YOUR

NEXT ACTION. BE CERTAIN TO DISCUSS THE
RATIONALE FOR YOUR DECISION.
Begin Zoloft 50 mg orally daily
Begin Fluvoxamine immediate release 25 mg orally at bedtime
Begin Fluvoxamine controlled release 100 mg orally in the
morning
Discontinue Zoloft and begin Fluvoxamine controlled release
100 mg orally every morning In terms of an actual diagnosis,
the child’s main symptoms are most consistent with obsessive-
compulsive disorder. There may also be an element of social
phobia developing, but at this point, the PMHNP has not
assessed the nature of the school avoidance—that is, why is the
child avoiding school. Notice that nothing in the scenario tells
us that the PMHNP has assessed this. Zoloft is FDA-approved
to treat OCD in children. However, between ages 6 and 12, it
should be started at 25 mg orally daily. If starting doses are too
high, the child may experience side effects that he associates
with the medication and as such, may refuse to take the
medication. Starting at too high a dose can result in unfavorable
side effects (gastrointestinal side effects are notable in this
drug), and we can see that Tyrel is experiencing nausea and
decreased appetite. In this case, it is recommended to wait to
see if the side effects dissipate. Decreasing the dose to 12.5 mg
orally daily for about 3 or 4 days, then going back to 25 mg
orally daily may help to overcome the unfavorable side effects.
If side effects persist, the PMHNP may need to consider
switching to a different medication.Fluvoxamine controlled
release is not FDA-approved for use in children with OCD (see
“Special Populations: Children and Adolescents” in the
Fluvoxamine monograph of Stahl’s Prescriber’s Guide for
further details). Fluvoxamine 100 mg orally daily may not be

tolerated in the morning secondary to the drug’s sigma-1
antagonist properties, which can cause sedation. Dosing of
Fluvoxamine should be such that the larger dose is given in the
evening to minimize daytime sedation. It is also worth noting
that nothing in the scenario tells us that the Zoloft will not be
effective.
ANSWER CHOOSEN:Begin Fluvoxamine immediate release 25
mg orally at bedtime
· Client returns to clinic in four weeks
· Upon return to the clinic, Tyrel’s mother reported that he has
had some decrease in his symptoms. She states that the
frequency of the handwashing has decreased, and Tyrel seems a
bit more “relaxed” overall.
· She also reports that Tyrel has not fully embraced returning to
school, but that his attendance has improved. She reported that
over this past weekend, Tyrel went outside to play with his
friend from across the street, which he has not done in a while.
RESULTS OF DECISION POINT TWO
· She also reports that Tyrel has not fully embraced returning
to school, but that his attendance has improved. She reported
that over this past weekend, Tyrel went outside to play with his
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR
NEXT ACTION. BE CERTAIN TO DISCUSS THE
RATIONALE FOR YOUR DECISION.

Increase Fluvoxamine to 50 mg orally at bedtime
Augment with an atypical antipsychotic such as Abilify
Augment treatment with cognitive behavioral therapy
ANSWER CHOOSEN:Increase Fluvoxamine to 50 mg orally at
bedtime
Guidance to Student
In terms of an actual diagnosis, the child’s main symptoms are
most consistent with obsessive-compulsive disorder. There may
also be an element of social phobia developing, but at this
point, the PMHNP has not assessed the nature of the school
avoidance—that is, why is the child avoiding school. Notice
that nothing in the scenario tells us that the PMHNP has
assessed this.
Fluvoxamine immediate release is FDA-approved for the
treatment of OCD in children aged 8 years and older.
Fluvoxamine’s sigma-1 antagonist properties may cause
sedation and as such, it should be dosed in the evening/bedtime.
At this point, it would be appropriate to consider increasing the
bedtime dose, especially since the child is responding to the
medication and there are no negative side effects.
Atypical antipsychotics are typically not used in the treatment
of OCD. There is also nothing to tell us that an atypical
antipsychotic would be necessary (e.g., no psychotic
symptoms). Additionally, the child seems to be responding to
the medication, so there is no rationale as to why an atypical
antipsychotic would be added to the current regimen.
Cognitive behavioral therapy is the psychotherapy of choice for
treating OCD. The PMHNP should augment medication therapy
with CBT. If further assessment determines that Tyrel has social
anxiety disorder, CBT is effective in treating this condition as

well.
Learning Resources
Required Readings
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan &
Sadock’s synopsis of psychiatry: Behavioral sciences/clinical
psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
· Chapter 31, “Child Psychiatry” (pp. 1253–1268)
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington,
DC: Author.
· “Anxiety Disorders”
American Academy of Child & Adolescent Psychiatry
(AACAP). (2012a). Practice parameter for the assessment and
treatment of children and adolescents with obsessive-
compulsive disorder. Journal of the American Academy of Child
& Adolescent Psychiatry, 51(1), 98–113. Retrieved
from http://www.jaacap.com/article/S0890-8567(11)00882-3/pdf
McClelland, M., Crombez, M-M., Crombez, C., Wenz, C.,
Lisius, M., Mattia, A., & Marku, S. (2015). Implications for
advanced practice nurses when pediatric autoimmune
neuropsychiatric disorders associated with streptococcal
infections (PANDAS) is suspected: A qualitative study. Journal
of Pediatric Health Care, 29(5), 442–452.
doi:10.1016/j.pedhc.2015.03.005
Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential
Psychopharmacology (5th ed.). New York, NY: Cambridge
University Press.
To access information on the following medications, click on
The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website
and select the appropriate medication.

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