Personality Disorders in the Elderly Diagnosis & Treatment Module 3

1. Personality Disorders in the Elderly Diagnosis & TreatmentModule 3 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. Objectives Upon completion the learner will be able to: • Describe the affect of aging on personality disorders • Discuss treatment modalities for personality disorders

4. Role of Aging on Personality Disorders • Burn out or not? • Risk-taking PDs (Fishbain, 1991) • Antisocial and Borderline • Reckless, suicidal, impulsive, substance abuse • Lessen in intensity after after 65 • Antisocial Personality Disorder • Only personality disorder in long-term studies • Tends to remit, yet some actively antisocial in old age • Borderline Personality Disorder • Lessens in middle age; little data after 65

5. Role of Aging on Personality Disorders • Solomon, 2000 • Differences between two groupings • Emotionally and behaviorally labile • Antisocial, Borderline, Histrionic, Narcissistic, Avoidant and Dependent • Lessen aggression, impulsivity as they age • Tend to improve in late life • Depression and somatization common end points • Overcontrol of emotions • Paranoid, Schizotypal, Schizoid, Obsessive-Compulsive • Remain the same or worsen

6. Role of Aging in Personality Disorders • Aging can promote • The personality disorder patient to remain rigid in their behavior and suspicious of others • Maladaptive traits to emerge in new surroundings or circumstances • Borderline patient in the NH refuses to eat, take meds rather than cut herself • Depression, anxiety, psychosis, and even personality disorder traits can bring out or worsen cognitive problems • Especially as aging leads to life changes

7. Role of Aging in Personality Disorders • Depression in Elders with Personality Disorders • More likely then depression alone: • To be admitted as an inpatient • 15-50% • To have more problems with ADL, IADL after treatment • To be less amenable to psychotherapy • To have a greater risk of relapse • To have a greater risk of suicide

8. Treatment • Difficult patients engender negative thoughts and feelings about them in providers • This is counter transference • Reflexive acts rarely help • Avoidance or angry confrontation • Reinforces fears of abandonment, rejection • Lead to increased efforts to remain attached • More phone calls, ER visits • Noncompliant to “stay sick”

9. Treatment • Consistency is the key • Whether in clinic, hospital or long-term settings • Everyone needs to be on the same page • Care plans, behavioral modification plans, need to be known by all caregivers • Borderlines thrive on conflict • Avoid splitting over safety issues • Know where to “draw a line in the sand” • Good nurse, bad nurse scenario may limit bigger problems

10. Treatment • Treat all anxiety, depression and psychosis with appropriate medical treatments • Personality disorders are at risk for depression, mood lability, anxiety, psychosis • No one antidepressant, mood stabilizer, anxiolytic or antipsychotic works better than another for the symptom under treatment in personality disorders • Similar to treating cold symptoms • Axis I disorders • A “barometer” of stress

11. Treatment • The main treatment modality is psychotherapy • May be difficult in the aged • Cognitive impairment • Sensory problems • Therapists without geriatric experience • Therapists do not visit ALF, NH

12. Treatment • Little research on psychotherapy in elderly personality disorder patients • Case studies point to multiple modalities that are effective • CBT, couples, DBT, psychodynamic • Slow process to change these life-long patterns • Long haul to make minimal changes

13. Treatment • In the acute-care hospital • Usually have motivator of going home • Unless Dependent • Willingness to go to outpatient treatment • All care providers present a unified front • Introduce the idea of a therapist • Begin medication for depression, anxiety • Assess willingness, ability to engage in therapy • Delirium, dementia

14. Treatment • In the Assisted Living Facilities (ALF) & NHs • Education of staff paramount • As unified as you can • In-house therapy helpful • Develop behavioral modification plans • Always positive and therapeutic • Five-page journal v. risperidone prn

15. Treatment • If somatic symptoms are plentiful • Real disease happens • These patients do get tumors • “Pressure cooker” scenario • Displaced anxiety, depression…treat it! • Did not learn to emote normally • Brief, frequent visits to their HCP • Sending them to me reinforces their view you don’t believe them • Only with time can the mind/body argument be addressed • Symptoms are REAL, source is non-organic • Always stress as a positive…”It’s not cancer!”

16. Need a Stable Doctor-Patient Relationship • Cluster A“Odd and Eccentric” • Be cool and professional, but caring • Paranoid patients are suspicious of engagement • Cluster B“Dramatic and emotional” • Weather the storms of transference and counter transference, but provide a stable ego • Consistent questioning and elaboration of choices • Cluster C “Anxious and fearful” • Be supportive, but provide firm expectations • “Yes, you do have to make a decision”

17. Case • Diagnosis: • Narcissistic Personality Disorder • Plan • Monitor mood and anxiety symptoms • May require medication in the future • Approach with many choices • Provide status to ease caretaking • Ask HCP to see first, etc.

18. Objectives 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

19. The End of the Modules on Personality Disorders in the Elderly

20. Post-test • A 68-year-old woman presents to your office for an initial evaluation. She was dissatisfied with her previous physician because she would not prescribe propoxyphene for her chronic back pain. She also complains of frequent frontal headaches, dysphagia, amnesia, abdominal pain, and dysuria. The patient relates that she has had exhaustive work-ups by numerous physicians in the past and that these have failed to reveal the cause of her complaints. Her Mini–Mental State Examination score is 30/30. • After a baseline history and physical examination, what would be the most appropriate next step? 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.

21. After a baseline history and physical examination, what would be the most appropriate next step? A. Computed tomography scan of the head B. Measurement of thyroid function C. Measurement of erythrocyte sedimentation rate D. Referral to a neurologist E. Schedule a return visit for next week

22. Answer; E. Schedule a return visit for next week • The most appropriate next step is to schedule a return visit for this patient in the near future. This is based on the diagnosis of somatization disorder. The patient’s clinical picture, consisting of multiple complaints in multiple organ systems, coupled with negative work-ups, is typical of patients with somatization disorder. Often such patients present not with a long list of symptoms but one or two at a time, making diagnosis that is based on a single interview challenging. Obtaining collateral information from significant others as well as past medical records can be illuminating, as is watchful waiting over time to establish a pattern of transient symptoms. Patients with somatization disorder, who are nearly always female, usually develop their symptoms in early adulthood. “Doctor shopping” and requests for analgesics are also consistent with this diagnosis.

23. The single most effective treatment plan for patients with somatization disorder is regular, scheduled contact with one caring physician. During each visit, the physician should inquire about the current active symptom(s) and psychosocial stressors and conduct a limited physical examination. Temporizing, rather than automatically trying to treat each new symptom, is the proper therapeutic stance to take. At the end of each visit, another is scheduled, with the frequency being determined by the intensity of the patient’s symptoms and distress at that time. Allowing “as-needed” office visits instead of scheduling each visit tends to reinforce somatic complaints, as these complaints represent the ticket of admission to the doctor’s office.

24. Additionally, patients with somatization disorder may at some point ask what is wrong with them. This is an opportunity to discuss the disorder, using either somatization disorder or its other name, Briquet’s syndrome, to give it a name and to educate patients about the illness. For example, one might explain that patients with Briquet’s syndrome have an unusual sensitivity to bodily sensations and thus may misinterpret normal somatic stimuli. Education and reassurance about the non–life-threatening nature of the disorder are helpful for patients (and their families). The physician should also provide information about the treatment plan, namely, frequent office visits to monitor symptoms as well as eventual work in stress management. In some cases, the physician-patient relationship may develop over time to a point where gentle probing about psychosocial triggers for somatic symptoms may be done, and the patient may be educated about the connection between life events and exacerbation of the illness

25. At this point further testing, such as thyroid function tests, antinuclear antibody level, or erythrocyte sedimentation rate, is probably not warranted until old medical records can be reviewed to see what tests have already been done. Furthermore, doing more tests tends to reinforce illness behavior and can be counter-therapeutic. On the other hand, patients with somatization disorder do certainly develop physical maladies as well. The best advice for dealing with these is to base tests, especially invasive ones, on objective physical findings rather than purely subjective complaints (ie, using signs rather than symptoms). Referral to a neurologist should be excluded on the basis of the same rationale for not ordering unnecessary tests and on the principle that it is preferable for a single physician to take an interest in the patient. Patients with somatization disorder tend to promote a sense of helplessness and frustration in their physicians and frequently get referred to other physicians. Often they are told to find a new primary physician when their care becomes particularly stressful. Although this provides relief for the physician who is now “off the case,” it is ultimately detrimental to the patient’s best interests End