Personality Disorders in the Elderly Module 1

1. Personality Disorders in the ElderlyModule 1 Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC

2. PROCESS A series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Case • 72-year old white male • Former “school superintendent” in a large city in a nearby state • Lost job because of spouse’s “drinking” • Series of jobs selling textbooks • At lower socio-economic Omaha NH • Two children • Little contact with son in town • Daughter is estranged (“I don’t know…”) • No contact with grandchildren • Two ex-wives • Reasons for divorce are vague

4. Case • In NH due to neuro-degenerative disorder • Cognitively intact • Mad he was sent here to “the shrink” • Over-familiarity from the get-go • Looks at my diplomas, licenses • Angry outburst at CNA, nurse over when, how he would go to dinner • Rage • Upset they did not recognize his status

5. Case • Called doctor himself, went the DON, NH Director with his complaint • “nonprofessional treatment” • Denies mood, anxiety, mood lability, psychosis now • Notes his cognition is “slower” • Calls the incident a misunderstanding • All “blown out of proportion”

6. ObjectivesFor all three modules Upon completion the learner will be able to: • List the elements that make up personality • Describe the types of personality disorders • Delineate issues for these patients and their providers as they age • List the treatment modalities for personality disorders

7. ObjectivesModule One Upon completion the learner will be able to: • List the elements that make up personality • List the definition of personality disorder • Describe the characteristics of each type of personality disorders

8. What is Personality? • A totality of behavioral and emotional traits • Characterize a person in day-to-day living, under normal circumstances • Mainly formed by adulthood • Stable • Predictable • What people feel makes you “you”

9. What is a Personality Disorder? • An enduring pattern of culturally deviant inner experience and behavior • Cognition • distorted perceptions/misinterpretations • Affectivity • inappropriate intensity or range of emotions • Interpersonal functioning • Impulse control

10. What is a Personality Disorder? • A pattern of long duration • Present by early adulthood • Some evidence in childhood (Conduct Disorder) • Maladaptive and rigid • Invariant across situations, clinical states • Associated with significant emotional distress or disturbed functioning • When their personality cannot adapt

11. What are the Types of Personality Disorders? • Cluster A “Odd and Eccentric” • Paranoid • Schizoid • Schizotypal

12. Cluster A • Paranoid Personality Disorder • Long-standing suspiciousness of people in general • Assign responsibility for feelings to others • Hostile, irritable, angry • Bigots, injustice collectors, conspiracy theorist, jealous spouse, litiginous crank

13. Cluster A • Schizoid Personality Disorder • Lifelong social withdrawal • Uncomfortable with human interaction • Introverted; bland, constricted affect • Eccentric, isolated lonely • Night shift workers, hidden neighbors, stamp collectors

14. Cluster A • Schizotypal Personality Disorder • Strikingly odd, even to laypersons • Magical-thinking, peculiar ideas, ideas of reference, illusions and derealization are part of the schizotypal patient’s everyday world • Bizarre dress, speech, mannerisms • Poor interpersonal relationships

15. What are the Types of Personality Disorders? • Cluster B “Dramatic and emotional” • Antisocial • Borderline • Narcissistic • Histrionic

16. Cluster B • Antisocial Personality Disorder • Continual antisocial or criminal acts • Unable to conform to social norms in development • Lack a conscience • “do unto others before they do unto you” • Criminals, con men, addicts • State penitentiary is a big clinic

17. Cluster B • Borderline Personality Disorder • On the border between neurosis and psychosis • Unstable mood, relationships, behavior and self-image • Emotional chameleons • Multiple marriages, danger seekers, roller coasters of emotion, near-constant crisis • Bane of the psychiatrist’s existence

18. Cluster B • Histrionic Personality Disorder • Colorful, dramatic, extroverted behavior • Excitable emotional persons • Unable to maintain deep, long-lasting, mature relationships • Physical appearance is paramount • Aging leads to plastic surgery • Rapidly-shifting, shallow emotions

19. Cluster B • Narcissistic Personality Disorder • Heightened sense of self-importance • Grandiose feelings • Unique in some way • Unempathic, feels the need to associate with other “high status persons” • Entitled

20. What are the Types of Personality Disorders? • Cluster C “Anxious and fearful” • Avoidant • Dependent • Obsessive-compulsive

21. Cluster C • Avoidant Personality Disorder • The flip side of social phobia • Great fear of personal rejection • Seek human relationships, but fearful they will be embarrassed or not wanted • Need guarantees of acceptance • Family usually only trusted • Sees self as inferior to others • Opposite of narcissism

22. Cluster C • Dependent Personality Disorder • Subordinate their own needs for others • Get others to assume responsibility for their decisions • Lack self-confidence • Intense discomfort with being alone • Exaggerated fears of being helpless when by themselves

23. Cluster C • Obsessive-compulsive Personality Disorder • Emotional constriction • No little white lies • Orderliness, perseverance • Stubborn. Indecisive • 9-year engagements • Perfection and inflexibility to the point where they cannot complete projects

24. The End of Module One on Personality Disorders in the Elderly

25. Post-test • An 82-year-old man who lives in a nursing home has gradual onset of socially inappropriate actions characterized by loud, intrusive, and exhibitionistic behavior. He has no history of psychiatric illness or substance use. His family says he had always been introverted and considerate. The nursing staff have become angry with him because of his behavior and his lack of concern for their requests. On examination, he is alert, has clear speech, and has a steady gait. Which of the following is the most likely diagnosis? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

26. Which of the following is the most likely diagnosis? • Antisocial personality disorder B. Bipolar disorder C. Dementia with frontal lobe signs D. Major depressive disorder with mixed personality disorder E. Histrionic personality disorder

27. Answer; C. Dementia with frontal lobe signs • Personality is relatively stable throughout life, although behavioral expressions may change to some degree. The change in this patient is not consistent with his former pattern as validated by his family. The irritation of the staff suggests that they are responding to his behavior, and the recent onset makes it likely that this has an organic cause. • This patient most likely has dementia with frontal lobe signs. Cognitive impairment accompanied by frontal lobe cortical or subcortical pathology often presents with personality change involving disinhibition and other manic-like symptoms in addition to lack of attention to appropriate social behavior.

28. Bipolar disorder may present with these symptoms but would be extremely unlikely to develop in an 82-year-old patient with no history of psychiatric illness or treatment. • Personality disorders are generally lifelong and are unlikely to develop at age 82 years. Persons with antisocial personality disorder have a longstanding pattern of inability to conform to social norms, rules, or laws. Histrionic personality also begins in early adulthood and is characterized by self-dramatization, excessive emotional display, and use of physical appearance to draw attention to the self. Mixed personality disorder refers to a mixture of the traits of personality disorder subtypes. This patient exhibits neither depressive symptoms nor a mixture of personality disorder subtypes. End