personality disorders and aging
DESCRIPTION
Presentation made by Dr. Lindsey Slaughter April 24, 2014. All rights reservedTRANSCRIPT
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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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