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Personality Disorders in the
Elderly
Diagnosis & Treatment
Module 3
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
Objectives
Upon completion the learner will be able to:
• Describe the affect of aging on personality
disorders
• Discuss treatment modalities for
personality disorders
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
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
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
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
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”
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
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
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
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
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
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
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!”
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”
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.
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
The End of the Modules
on
Personality Disorders in the Elderly
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.
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
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.
• 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.
• 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
• 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 countertherapeutic. 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