personality disorders and aging

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PersonalityDisordersand Aging

Lindsey K. Slaughter, Psy.D.Psychology Director and Forensic

Coordinator Licensed Clinical Psychologist

Piedmont Geriatric Hospital

Burkeville, VA

April 24, 2014

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• PD = Personality Disorders

• OA = Older Adults

• YA = Younger Adults

• DSM = Diagnostic Statistical Manual of Mental Disorders

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To definepersonality and the

“Big Five” traits

To identify trends inpersonality and

aging

To learn generalcriteria of

personalitydisorders (PD)

To discusschallenges indiagnosis and

assessment with PDand OA

To identify trends inprevalence of PD’s

and aging

To discover how PDmay manifest in

older adults (OA)

To glean sometricks-of-the-tradefor treatment and

management of PDin OA

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How about where they come from?Nature (i.e., trait)? Nurture (i.e., context)?Both (i.e., developmental/life-span)?

PERSONALITY

can be defined as anindividual’s pattern of psychological processes,

including his or hermotives,feelings,

thoughts,behavioral patterns, and

other major areas of psychological functioning.

Think of your and others personalities.What are their purposes?

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“Big Five” Dimensions of Personality

(originally Goldberg, 1960’s)

EXTRAVERSIONexcitability, sociability,talkativeness,assertiveness, highamounts of emotionalexpressiveness

AGREEABLENESStrust, altruism, kindness, affection, andother prosocial behaviors

CONSCIENTIOUSNESShigh levels of thoughtfulness, good impulse control, goal-directedbehavior, organized, mindful of details, planful

NEUROTICISMemotional instability, anxiety,moodiness, irritability,sadness

OPENNESS TOEXPERIENCEimagination and insight,broad range of interests

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(Donnellan and Lucas, 2009)

Levels ofAgreeablenessandConscientiousnessare positivelyassociated withage (may declineafter 70)

Extraversion andOpenness arenegativelyassociated withage (starts to declinearound age 50)

Average levels ofNeuroticism aregenerallynegativelyassociated withage, although traitmay increase fromage 80 and beyond

Both perobservers and perself report

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• “Successful aging” components (Rowe & Kahn, 1998)

• Avoiding disease• Maintaining high cognitive and physical function• Engagement with life

• About 80% heritability with personality

• Most OA have psychological resources to compensate forlosses (i.e., loved ones, functional), with better emotionalregulation and decrease in physiological arousal levels. Maybeeven better than younger adults! (Alea, Diehl, & Bluck, 2004)

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What happens when anindividual’s personality

creates ongoinginterpersonal problemsbetween him/her and

their world (i.e.,relationships with others

at home, at work)?

When he or she hastrouble maintaining astable sense of self?

When he or she strugglesin tolerating strong

emotions?

When might theseproblems meet thethreshold for a PD?

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• ICD-10(International Statistical Classification of Diseases and Related health Problems)

• DSM-IV-TR and VDiagnostic Statistical Manual of Mental Disorders

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Personality Disorder per DSM-V

PERSONALITY DISORDER

per DSM-V

“An enduring pattern of innerexperience and behavior thatdeviates markedly from the

expectations of the individual’sculture, is pervasive andinflexible, has an onset in

adolescence or early adulthood, isstable over time, and leads to

distress or impairment”

Affects 2 or more areas offunctioning

- cognition

- affectivity

- interpersonal functioning

- impulse control

Leads to problems insocial, occupational, or

other important areas offunctioning

Is NOT due to medicalconditions

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Paranoid

• Pervasive distrustand suspiciousnessof others such thattheir motives areinterpreted asmalevolent

Schizoid

• Pervasive pattern ofdetachment fromsocial relationshipsand a restrictedrange of emotionsin interpersonalsettings

Schizotypal

• Pervasive pattern ofsocial andinterpersonaldeficits marked byacute discomfortwith, and reducedcapacity for, closerelationships aswell as by cognitiveor perceptualdistortions andeccentricities ofbehavior

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Antisocial

• Pervasivepattern ofdisregard for,and violationof, the rightsof others

Borderline

• Pervasivepattern ofinstability ofinterpersonalrelationships,self-image,and affects,and markedimpulsivity

Histrionic

• Pervasive andexcessiveemotionalityandattention-seekingbehavior

Narcissistic

• Pervasivepattern ofgrandiosity(in fantasy orbehavior),need foradmiration,and lack ofempathy

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Avoidant

• Pervasive patternof socialinhibition,feelings ofinadequacy, andhypersensitivityto negativeevaluation

Dependent

• Pervasive andexcessive need tobe taken care ofthat leads tosubmissive andclinging behaviorand fears ofseparation

Obsessive-Compulsive

• Pervasive patternof preoccupationwith orderliness,perfectionism,and mental andinterpersonalcontrol, at theexpense offlexibility,openness, andefficiency

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Limitations ofDiagnostic Criteria of

PD in OA

Assessments for PDsand classification

criteria neglect theLATER LIFE

CONTEXT

RETIRED:

“occupational impairment”

FINANCIAL:

“miserly attitude”

ELDER ABUSE:

“paranoid”

Assessments for PDsand classification

criteria neglect theLATER LIFE

CHANGES

POSSIBLE SENSORY DECLINE:

“paranoid”

POSSIBLE PHYSICAL DECLINE:

“parasuicidal behavior,” “fights”; “avoidant”

POSSIBLE INCREASE IN LOSS OFPARTNER(S), FAMILY, FRIENDS:

“abandonment”

POSSIBLE DECREASE IN LIBIDO;EMOTIONAL EXPRESSION:

“schizoid”

Indeed, “the presentation of a PD is intimately tied to contexts, contexts that can help to bring about the presentation of the features”(Oltmanns & Balsis, 2011)

(Segal, Coolidge, &Rosowsky, 2006)

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What if PD doesn’t“show” until later

adulthood?

What if PD symptomsmanifest differentlyin later adulthood?

Maybe notmellowing, justshowing itself

differently thanyounger adults?

If so (likely!), then ourdata may be systematically

flawed

We need more research onPD and OA!

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• Lack of co-informant• Co-informant has little knowledge of OA’s early life• Unreliable OA and/or co-informant• Cognitive impairment of OA and/or co-informant• Co-informant’s characteristics (e.g., shame, guilt, minimization)

affect account• Severe physical illness in OA• Axis I and II similarities (e.g., PD versus personality changes

related to dementia) (Mordekar & Spence, 2008)

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PrevalenceRates of

PD

10-14% across ages

10% of OA’s in thecommunity

(Abrams & Horowitz, 1996)

About 11% of nursinghome residents have

PD

Rates go up if OA hasanother psychiatric

disorder

Major depression and dysthymia- 31%(mainly Obsessive-Compulsive and

Avoidant subtypes)

Anxiety disorder- up to 13%(mainly Avoidant, Obsessive-Compulsive, and Dependent

subtypes)

Alcohol dependence and depression

(mainly related to Cluster B and C)

Depression anddepressive symptomsoccur in up to 26% of

OA’s in the communityand 35% in nursing

homes

Anxiety oftenaccompanies

depressive symptoms

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11.4

0%

12.3

0%

7.4

0%

1 6 - 3 4 3 5 - 5 4 5 5 - 7 4

PREVALENCE RATES FOR ANY PD SEEMS TODECREASE ACROSS AGES

Possible decline of Cluster B PDs in OA (i.e., Borderline, Antisocial) (Samuels et al, 2002)

Possible increase in Cluster A and C (i.e., Paranoid, Schizoid, Obsessive-Compulsive)(Abrams & Horowitz, 1999)

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Assessing for PD inOA

Always consider and manage medical issues first

Listen to your gut/instincts:

PDs reveal themselves whether the resident likes it or not

Obtain as much collateral information as you can

(e.g., from family, peers, other professionals)

Formal assessment/consult, if possible

Try at least to identify what PD Cluster resident may have(i.e., A, B, C)

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FormalTreatments

for PD inOA

Treat Axis I

(i.e., other mentaldisorders such as

depression,dementia, anxiety)

simultaneously

Considerpsychotherapybefore medications

•Cognitive behavioral•Short-termpsychodynamic

•Interpersonal•Dialectical behavioral•Family

If medications arewarranted, consideranti-addictiveagents with minimalside effects,especially for OA(i.e., anti-depressants likeSSRI’s)

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Tips for Working with OA with PDAsk yourself how resident

makes you feel?

Angry? Hurt? Disempowered?Incompetent? Special?

Remind yourself it’s likely notabout you.

Consult liberally with co-workers and supervisors. It

prevents blindspots andprotects you.

Know thyself:

reflect on who you are, getfeedback from others, and

know your “hot buttons.” Thisprevents countertransference

and power struggles.

E.g., BPD: Staff feels less able to manageresident, responds with less empathy, and

believes resident is at fault for behavior(Marley & Fung, 2013)

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• 74-year-old never-married white male who owns housein rural area and was enrolled (reluctantly) in PACE.

• Didn’t want to lose home.

• Presented as suspicious of peers and staff in groups:“What do you wanna know about me for? You’ll just useit against me.”

• At times became hostile with team “because you’re partof the system, always up to something! I just wannastay in my home!”

Cluster A Case Vignette:

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Treatment and Management Tips

Cluster AStrategies:Don’t be sowarm and

fuzzy!

Be goal-directedand focused onwhat the OA’smotivation is

Be matter-of-fact,direct

Focus on the factsand appeal to logic

Understand thatOA may have only

one person as asupport, and mayprefer it that way

Understand thatOA may not “get

you,” e.g., humor.

If daily ADLcare/hygiene is an

issue, set clearexpectations withcontingencies inplace if possible

Tailorenvironment asmuch as possibleto meetpreferences

•Single room, indiv.treatment ratherthan group, sit alonein dining areas

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• 80-year-old divorced African American female whowas referred from ALF to nursing home for skilledrehab.

• Very complimentary of staff, then later verballyabusive if her needs were not met when she wanted.

• Demanded pain meds for unclear conditions.

• When angry, picked at healing wounds, sunk to floorintentionally during PT, etc.

• Made accusations towards staff about “neglectfulcare and mistreatment.”

Cluster B Case Vignette:

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Treatment and Management Tips

Cluster BStrategies:Balance,balance,balance!

Balancewarmth/concer

n withprofessionalboundaries

Balanceprofessionalcompetence

withacknowledging

minor errors

Balanceconsistency

with flexibility

Be matter-of-fact andgenuine

Providestructure while

preventingpower

struggles

Validatefeelings whileclearly stating

behavioralexpectations

Consider brief,frequent

scheduledmeetings

Be carefulrecommending

medications,especially

addictive ones

Be alert to therisk of suicide,

even if itdoesn’t

manifest likeYA

Have lowthreshold for

seekingconsultation

Performphysical/other

exams withwitness/chaper

one present,regardless of

gender ofprofessional

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• 68-year-old married Indian American female whose daughter

asked PCP for help.

• Lived in home together. Didn’t like to make decisions, relied on

husband and daughter.

• Had mild arthritis but otherwise fair health.

• Often hollered to have someone else walk with her, get her

medicine.

• Others cooked and cleaned.

• Had general anxiety with panic/crying episodes, clinginess if

daughter went out or discussed moving out.

• Often wanted to call/go to ER if in distress.

Cluster C Case Vignette:

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Treatment and Management Tips

Cluster CStrategies:Empathic

empowering!

Provide verbalreassurance whileencouraging OA todo for him/herself

as independently aspossible

Publicly recognize(to the OA’s

comfort level) smallsuccesses leading to

bigger changes

Be patient- duringADLs, ambulating,

etc.

Do with rather thanfor

Consider break-down interventions

with verbal andvisual prompts,role modeling,

hand-over-hand,etc.

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Cluster A:

• Don’t be sowarm andfuzzy!

Cluster B:

• Balance,balance,balance!

Cluster C:

• Empathicempowering!

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