Personality Disorder and Older PeopleSandy McAfee

Consultant Clinical Psychologist

St John’s Hospital, West Lothian

sandy.mcafee@wlt.scot.nhs.uk

Prevalence studiesCommunity Dwelling Older People Large variability between studies

Measures used Samples studied

13% in older adults vs 17.9% younger adults (Ames and Molinari, 1994)

10.5% older adults vs 6.6% younger adults (Cohen et al, 1994) + fewer Antisocial and Histrionic PD

11 % older adults vs 20% younger adults (Coolidge et al, 2006)

Opinions vary however…

So what do you do?

I work with older people

So, what are you doing at this conference?

Things I’ve heard said… Clinicians’ impressions are that problems associated

with PD (particularly ‘cluster B’) ‘burn out’ – people get more mellow as they get older

Perhaps people with PD have learned useful coping strategies by the time they get to old age, so don’t need to use services

Perhaps people with severe PD don’t make it to old age

Perhaps it’s a life stage issue – different problems apply to older peoples’ life stage

Change with Age Some PDs may become exacerbated with age:

Schizoid and Obsessive-Compulsive (Coolidge & Merwin, 1992; Segal et al, 2001)

Obsessive-Compulsive and Dependent (Molinari et al, 1999)

Narcissistic (Kenan et al, 2000) 12 year follow up in adult age group shows

reduction in cluster B traits but increase in cluster A and C traits (Seivewright et al, 2002)

Other considerations Inadequate PD in older people difficult

to distinguish from executive dysfunction (Segal et al, 2006)

“Reverse J curve” (Seivewright et al, 2002)

Social functioning improves (in cluster B PDs) compared with impairment in earlier years (Segal et al, 2006)

There undoubtedly are some differences about the way older people present to services…

Issues to do with working with older people May only present to services following crisis

of later life, e.g. death of spouse, family moves away – may be more likely to reveal Dependent PD

May have used psychiatric services decades earlier, in a different era when different formulations and treatment applied

May be living with a label, e.g. “I’m depressed”

Issues to do with working with older people May be no one else in the family available

who can assist with giving a history May have suspected cognitive problems, so

presenting problems are attributed to these, e.g. behavioural difficulties

Diagnostic Issues and Older People Problems with labelling

Cultural bias affecting choice of diagnostic labels applied to different groups

Attribution and preconception issues (Kroessler, 1990)

Problems with ageism See symptoms as normal for old age ‘Invisibility’ of older people and their problems Hopelessness double whammy

Diagnostic Issues and Older People Problems with validity of the diagnosis

Lots of debate about the construct validity of DSM system (and other psychiatric classification systems – see Bentall, Madness Explained)

Criteria, categories and labels have changed a lot over time

Developed with younger people in mind (e.g. references to functioning in the workplace)

If you become immersed in the language of DSM does it constrain your thinking?

Diagnostic Issues and Older People Problems with reliability of the diagnosis

Where older people don’t meet the full range of symptoms may fall short of being given the diagnosis

Interpretation of symptoms, e.g. ‘geriatric variants’ of self-harm such as treatment refusal (Rosowsky and Gurian, 1992)

Lack of research on the assessment of PD in older people compared to younger people

Diagnostic Issues and Older People Problems with reliability of the diagnosis

(cont.) Where physical or explanations for behaviour are

possible psychiatric explanations are less likely to be used

Lack of training of the assessment (and treatment) of PD in older people

Also be aware of possibility of Disordered Personality vs Personality Disorder

But the issues are real no matter what we choose to call them… Older people can present with multiple

chronic problems: Coping Interpersonal functioning Cognitive functioning e.g. cognitive flexibility,

problem solving Rapid arousal, emotional intensity Insight/self-awareness Recurrent affective disorder

A useful model for working with older peoples’ PD issues Schema Therapy

Comprehensive model Valid Reliable Applies well across the age range Offers an explanation and treatment modality

rather than purely focus on categorisation and diagnosis

Schema Therapy Early Maladaptive Schemas Life-traps Filters

Early Maladaptive Schemas Young’s model is that EMSs result from

unmet core emotional needs in childhood Secure attachment to others Autonomy, competence & sense of identity Freedom to express valid needs & emotions Spontaneity & play Realistic limits and self-control

What are the EMSs? Disconnection & Rejection

Abandonment/Instability Mistrust/Abuse Emotional Deprivation Defectiveness/Shame Social isolation/Alienation

What are the EMSs? Impaired Autonomy & Performance

Dependence/Incompetence Vulnerability to harm, illness or random events Enmeshment/Undeveloped self Failure

What are the EMSs? Impaired Limits

Entitlement/Grandiosity Insufficient self-control/Self-discipline

What are the EMSs? Other-directedness

Subjugation Self-sacrifice Approval-seeking/Recognition-seeking

What are the EMSs? Overvigilance & Inhibition

Negativity/Pessimism Emotional Inhibition Unrelenting standards/Hypercriticalness Punitiveness

Mr X, 74 year old man Unmarried Fourth of five siblings Both parents deceased Three siblings deceased Worked as a waiter in ‘top hotel’ Worked as a cinema manager in ‘top cinema’ Worked as a sales assistant for a ‘prestigious

male clothing company’

Mr X, 74 year old man Homosexual Lives with partner of >40 years but has had

numerous other partners Sexually promiscuous Falls in love very quickly, idealises then

rejects partners Numerous health problems

Presenting Problems Chronic severe anxiety Chronic fluctuating low mood Chronic anger Chronic interpersonal problems Preoccupied with maternal relationship Preoccupied with social status Preoccupied with prosocial behaviour Psychosomatic rashes and bowel disorder

Psychiatric history Suicide attempt (OD) aged mid twenties Self harm (cutting) same time Catastrophic reaction to loss of relationship mid

forties inpatient briefly two years of unspecified psychotherapy (helpful) diagnosis of personality disorder

Private counselling aged late sixties – prematurely terminated

Diagnostic Issues Meets diagnostic criteria for Borderline PD

(Cluster B) Efforts to avoid real or imagined abandonment Unstable + intense interpersonal relationships +

idealization/devaluation Identity disturbance Sexual impulsivity Affective instability Inappropriate intense anger

Diagnostic Issues Features of Histrionic PD (Cluster B)

Physical appearance draws attention to self Excessively impressionistic style of speech Theatricality

Diagnostic Issues Features of Dependent PD (Cluster C)

Difficulty making everyday decisions Difficulty expressing disagreement with others Urgently seeks another relationship as a source of

care and support when a close relationship ends Preoccupied with fears of being left to take care

of himself – unrealistic?

YSQ – L2 1/4

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8090

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Emotional Deprivation Abandonment Mistrust/Abuse Social Isolation

YSQ – L2 2/4

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100

Defectiveness/ Shame Social Undesirability Failure to Achieve FunctionalDependence

YSQ – L2 3/4

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Vulnerability to Harm Enmeshment Subjugation Self Sacrifice

YSQ – L2 4/4

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100

Emotional Inhibition UnrelentingStandards

Entitlement Insufficient Self-Control