Download Personality Disorders in the Elderly

Personality Disorders in the
Elderly
Module 1
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
UNMC
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
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
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
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”
Objectives
For 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
Objectives
Module 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
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”
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
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
What are the Types of
Personality Disorders?
• Cluster A
“Odd and Eccentric”
– Paranoid
– Schizoid
– Schizotypal
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
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
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
What are the Types of
Personality Disorders?
• Cluster B
“Dramatic and emotional”
– Antisocial
– Borderline
– Narcissistic
– Histrionic
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
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
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
Cluster B
• Narcissistic Personality Disorder
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–
–
–
Heightened sense of self-importance
Grandiose feelings
Unique in some way
Unempathic, feels the need to associate with
other “high status persons”
– Entitled
What are the Types of
Personality Disorders?
• Cluster C
“Anxious and fearful”
– Avoidant
– Dependent
– Obsessive-compulsive
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
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
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
The End of Module One
on
Personality Disorders
in the Elderly
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.
Which of the following is the most likely
diagnosis?
A. Antisocial personality disorder
B. Bipolar disorder
C. Dementia with frontal lobe signs
D. Major depressive disorder with mixed
personality disorder
E. Histrionic personality disorder
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.
• 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 selfdramatization, 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