Personality Disorders in the Elderly Personality and Aging Module 2

1. Personality Disorders in the Elderly Personality and AgingModule 2 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 stop

3. Objectives Upon completion the learner will be able to: • List the prevalence of personality disorders • List the diagnostic difficulties in evaluation of personality disorders. • Describe the affect of aging on personality disorders

4. Personality and Aging • Changes in the brain can lead to qualitative change • new introversion due to vascular depression • And quantitative change • new frontal lobe-related impulsiveness in a gregarious person • Change in social environment, life event make qualitative changes • new paranoia and anxiety after an assault • And quantitative changes • schizoid loner now forced into a NH by needs • Experience and reflection can induce change • Hopefully, this is wisdom

5. Personality Disorders and Aging • Little research done so far • Reverse cohort effect • Little old ladies don’t have personality disorders • They don’t have sex, commit crimes or use drugs either… • “They just burn out” • Is it a real change or is our means of diagnosing not relevant to older persons

6. Prevalence rates • More stressful the environment, the more people psychologically regress • In hospitals and NHs stress may make an individual look more like a personality disorder • Primary care clinics…20% • Community dwelling should be least stressed • Older persons…….5-10% • Younger people…..10-18% • Less reported or recorded, but still present • Persons over 50…...10% (Abrams, Horowitz) • All ages 9% …….…0.5% over 65 Samuels (2002)

7. Diagnostic Difficulties • How to diagnose • PDs are diagnoses of history • Consistently chaotic or pathologic • Pattern of dysfunction over time • When these patients come to see us it is because of depression, anxiety, psychotic symptoms • Rigid, non-adaptable to new environments, needs, roles • Creates distress which develops into symptoms • They do not come to see us for the personality disorder, but because of it

8. Diagnostic Difficulties • Not everyone with a personality disorder in life gets in to see us • Egosyntonic • Borderlines and antisocials • Present because of suicide attempts, drug use and jail/court • Some live in supportive environments • Dependent spouse with controlling partner • Some have dysfunctional traits which make them avoid mental health settings • Suspiciousness, avoidance, fearful of others

9. Diagnostic Difficulties • Aging brings them to us • More positive defense mechanisms may weaken • Less adaptable then they used to be • As they age, these patients are forced by change to leave supportive or more comfortable environments • Spouse, family and friends die or become disabled • Children move or refuse to take them in • Hospital visits increase, health declines • Nursing homes, assisted living placement a reality

10. Diagnostic Difficulties • Think of this as a continuum • Everyone has a “seizure threshold” • Some people are so florid even under the best circumstances they display a personality disorder • With other people, in certain circumstances, they may lean toward a personality disorder-picture, but only under stress does it manifest • Most others retain their personalities, even with stress • If every physician’s personality were determined by the first month of medical school we’d all be personality disorders

11. Clinical Clues • Recurrent depressive episodes • Usually precipitated by ongoing stressors • Poor compliance with treatment • Multiple examples of past discontinuation of treatment • Many medications, many physicians, many diagnoses, many side effects • More difficulty adjusting to age-associated stressors • Deaths, loss of function, health decline, move to NH or ALF • Changes in social role (now the caregiver, e.g.)

12. Clinical Clues • Chronic interpersonal stress • “I really don’t know why my daughter won’t talk to me…” • Chaotic lives • Multiple marriages, jobs, moves • Abrasive interpersonal style • Your afternoon is made because they cancelled • Labor intensive • Office staff gives you “the look.”

13. Symptoms and Aging • Cluster A “Odd and Eccentric” • Social isolation is problematic if they have functional impairments or medical conditions that need personal care • Institutional life may lead to agitation, aggression, delusions • Home care agencies rejected by mistrust or fear of contact

14. Symptoms and Aging • Cluster B “Dramatic and emotional” • Vulnerable to bereavement problems, loss of social network, retirement and income loss problems • Splits physicians and caregivers • Impulsive with medication management • Relationship with new social network at the NH resembles all past relationships

15. Symptoms and Aging • Cluster C“Anxious and fearful” • Overuse of medical and social support networks by dependent patient • Inability to make decisions interferes with with medical and placement issues • Rigidity with schedules leads to problems with nursing staff • Fear of rejection causes “nursing home depression” because of isolation in their room

16. Who Do We Diagnose? • Most common personality disorder diagnoses after 65 • Obsessive-compulsive personality disorder • Dependent personality disorder • Mixed personality disorder • Most common diagnosis among younger patients as well

17. The End of Module Two on Personality Disorders in the Elderly

18. Post-test • A 70-year-old woman is persuaded by her husband to present for evaluation. He reports that his wife has become irritable, argumentative, and demanding. She no longer is interested in the social activities she once enjoyed, such as golf and volunteering at a local community theater. He describes her as helpless and critical of him if he spends any time away from home pursuing his own hobbies and interests. These symptoms have been present for about 6 months and have been getting worse. Prior to this episode, she was described as optimistic, outgoing, and gregarious. • The patient’s score on Mini–Mental State Examination is 27/30. Her physical examination is unremarkable. Laboratory findings for serum thyroxine (T4) and thyroid-stimulating hormone are within normal limits. • What 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.

19. What is the most likely diagnosis? A. Passive-aggressive personality disorder B. Borderline personality disorder C. Histrionic personality disorder D. Major depressive episode E. Dysthymic disorder

20. Answer; D. Major depressive episode • It is most likely that the patient is suffering from a major depressive episode, which is characterized by the presence of either a depressed mood or loss of pleasure in one’s usual activities. Although no information is offered about other depressive symptoms, it would be desirable for the physician to inquire about them to corroborate the diagnosis. Often, depressed older adults will not complain of a depressed mood per se but instead will experience personality changes such as those of the patient in this case.

21. Passive-aggressive, borderline, and histrionic personality disorders can be excluded on the basis of the history of good psychosocial functioning prior to the onset of the patient’s current symptoms 6 months ago. Personality disorders are pervasive, lifelong patterns of dysfunctional behavior that do not arise de novo in late life. Dysthymic disorder, similarly, can be excluded, since this diagnosis requires a 2-year duration of illness. End

22. Which of the following describes the most likely effect of normal aging on basic personality? A.More rigid B.More irritable C.More mellow D.More childlike E.No change

23. Answer;  E.  No change • Personality is an enduring pattern of inner experience and behavior. Although various stereotypes about personality and aging exist and empirical studies are limited, most authors agree that basic personality remains relatively unchanged throughout life, including the geriatric period. Personality may have somewhat different manifestations as the capabilities of the person change, but significant changes in personality most often herald an unrecognized psychiatric illness (eg, depression or dementia) or the onset of a medical illness. This is particularly evident in the new onset of carelessness, lack of discretion, or apathy that often accompanies frontal lobe disease.

24. The idea that aging persons become more mellow or more irritable reflects ageism and cultural stereotyping. Such observations commonly are the result of countertransference reactions of professionals or the lack of adequate longitudinal data or corroborating information from outside sources. The impression that older persons become more childlike most often reflects the reemergence of longstanding basic personality traits that were suppressed in midlife by social or other constraints. Studies have shown that birth cohorts may differ in degree of personal rigidity, but this trait also does not change within individuals over time. However, an obsessional personality may become more apparent as an individual becomes more dependent and involved with the health care system. End