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Personality Disorders in the
Elderly
Personality and Aging
Module 2
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
stop
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
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
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
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)
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
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
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
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
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.)
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.”
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
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
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
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
The End of Module Two
on
Personality Disorders
in the Elderly
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 thyroidstimulating 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.
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
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.
• 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
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
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.
• 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
•