Assessment is a key component of any psychotherapeutic undertaking. Without an accurate and thorough understanding of the nature of the patient's problems, it may be difficult for the clinician to conceptualize the case, select targets for treatment (done collaboratively with the patient if possible), and develop a treatment plan. We view assessment as part of the treatment process, not as a separate clinical task to be completed as a precursor to treatment. Assessment should be considered an ongoing process in which hypotheses are continually being developed, tested, and refined as treatment progresses.
Identification and assessment of personality disorders is critical because they exert significant clinical impact and need to be incorporated into the treatment planning (Dougherty, 1999; Millon & Davis, 2000;Paris, 2003;Rosowsky & Dougherty, 1998; Rosowsky, Dougherty, Johnson, & Gurian, 1997). We concur with Paris who concluded that "early diagnosis of a personality disorder has a great clinical advantage. If you know this much about a patient, you will not be surprised when he or she presents treatment difficulties or fails to respond to methods that are effective for others. You can also adjust your expectations to chronicity" (p. x).
Compared to Axis I clinical disorders, the assessment of personality disorders is known to be particularly challenging and fraught with difficulty. Clinicians and researchers alike have struggled with their ability to accurately diagnose personality disorders and distinguish one personality disorder from another (Coolidge & Segal, 1998; Westen & Shedler, 2000; Widiger, 2005). Unfortunately, this process tends to be even more complicated among older individuals (Dougherty, 1999; Sadavoy, 1996; Sadavoy & Fogel, 1992). The criteria sets for the personality disorders simply do not fit older adults as well as younger adults (Agronin & Maletta, 2000; Rosowsky & Gurian, 1991). As we described earlier, some clinicians may not think to diagnose personality disorders in their older patients, despite evidence of having "difficult" patients on their caseloads.
Another important issue concerns the reliability of personality disorder diagnoses. In general, reliability of measurement refers to consistency, replicability, or stability (Segal & Coolidge, 2006). In psychiatric diagnosis, reliability refers to the extent of agreement between clinicians concerning the presence or absence of particular disorders, which is often called inter-rater reliability. Reliability is highly important because if different clinicians cannot agree on specific diagnoses, those diagnostic categories are, at best, of limited value and, at worst, virtually meaningless (Segal & Coolidge, 2003).
Notably, inter-rater reliability has historically been poor for the personality disorders (see Mellsop, Varghese, Joshua, & Hicks, 1982; Spitzer, Forman, & Nee, 1979) although diagnostic practices have improved in recent years. Nonetheless, research has documented lower reliability rates for the personality disorders compared to almost all of the major Axis I disorders such as Major Depression, Panic Disorder, and Schizophrenia (Grove, 1987). Poor reliability of diagnosis for the personality disorders is a problem across the life span. An important contributing factor to unreliability has to do with the actual diagnostic criteria for the personality disorders because many of the criteria lack behavioral anchors (thus requiring some level of judgment on the part of the clinician), the criteria sets lack a mechanism for specifying severity in diagnostic categories, and some criteria overlap among different personality disorders (Zweig & Hillman, 1999). Another source of unreliability is that patients rarely present with the classic homogenous signs of one particular personality disorder; rather, it is common for them to have some signs and features of several personality disorders (Oldham et al., 1992; Paris, 2005). This is also true across the life span, which makes accurate diagnosis of personality disorder difficult at any age.
An important point to emphasize about the assessment of personality disorders is that it cannot be conducted "in a vacuum." A full evaluation of episodic clinical disorders and the patient's current mental state should be a part of the comprehensive assessment. Given that the report or description of enduring personality characteristics can be seriously compromised in a patient who is experiencing acute psychopathology or distress, this is not surprising. And the presence of some clinical disorders can exacerbate the patient's typical personality. Indeed, the aim of all personality assessment measures is to rate the respondent's typical, habitual, and lifelong personal functioning rather than acute, temporary, or ephemeral states. Making the distinction between "state" versus "trait" is an important part of the diagnostic process, one which has significant implications for case formulation and intervention.
Thorough and careful assessment has long been a hallmark of geropsychological practice (Qualls & Segal, 2003; Segal, Coolidge, & Hersen, 1998), a development which was necessitated by the types of complex cases commonly seen in clinical practice. Older adults presenting for mental health treatment are much more likely than younger adults to have significant comorbid health issues, real catastrophic losses (e.g., death of a spouse), complicated histories, and numerous other psychosocial stressors. Older adults are also less familiar with psychological testing and assessment, which can make them anxious and fearful about the process and perhaps unmotivated to cooperate. All of these issues complicate the assessment of personality problems among older adults. In this chapter, we discuss five primary elements that should be considered pieces of a thorough assessment of personality disorders among older patients: (1) chart/records review, (2) clinical interview of the patient, (3) interview with informants, (4) self-report objective personality inventories, and (5) semi-structured interviews. For each approach, we identify and discuss issues and challenges in evaluating older adults. Before proceeding, we want to emphasize that an understanding of the patient's normal and maladaptive personality traits is critical to the therapeutic process. Mental health clinicians do not treat disorders or problems; rather, we treat people with disorders and problems and, thus, an understanding of the person we are treating is essential.
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This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.