Personality Disorders and Aging


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Personality Disorders and Aging

  1. 1. 4/24/2014 Copyright 2014, Lindsey Slaughter 1 Personality Disorders and Aging Lindsey K. Slaughter, Psy.D. Licensed Clinical Psychologist April 24, 2014 ABBREVIATIONS • PD = Personality Disorders • OA = Older Adults • YA = Younger Adults • DSM = Diagnostic Statistical Manual of Mental Disorders
  2. 2. 4/24/2014 Copyright 2014, Lindsey Slaughter 2 Goals and Objectives To define personality and the “Big Five” traits To identify trends in personality and aging To learn general criteria of personality disorders (PD) To discuss challenges in diagnosis and assessment with PD and OA To identify trends in prevalence of PD’s and aging To discover how PD may manifest in older adults (OA) To glean some tricks-of-the-trade for treatment and management of PD in OA What is Personality, Its Purpose and Origins? 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 an individual’s pattern of psychological processes, including his or her motives, feelings, thoughts, behavioral patterns, and other major areas of psychological functioning. Think of your and others personalities. What are their purposes?
  3. 3. 4/24/2014 Copyright 2014, Lindsey Slaughter 3 “Big Five” Dimensions of Personality (O.C.E.A.N.) (originally Goldberg, 1960’s) EXTRAVERSION excitability, sociability, talkativeness, assertiveness, high amounts of emotional expressiveness AGREEABLENESS trust, altruism, kindness, affection, and other prosocial behaviors CONSCIENTIOUSNESS high levels of thoughtfulness, good impulse control, goal- directed behavior, organized, mindful of details, planful NEUROTICISM emotional instability, anxiety, moodiness, irritability, sadness OPENNESS TO EXPERIENCE imagination and insight, broad range of interests Personality Traits and Aging Trends (Donnellan and Lucas, 2009) Levels of Agreeableness and Conscientiousness are positively associated with age (may decline after 70) Extraversion and Openness are negatively associated with age (starts to decline around age 50) Average levels of Neuroticism are generally negatively associated with age, although trait may increase from age 80 and beyond Both per observers and per self report
  4. 4. 4/24/2014 Copyright 2014, Lindsey Slaughter 4 Healthy Personality Trends in Aging • “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 for losses (i.e., loved ones, functional), with better emotional regulation and decrease in physiological arousal levels. Maybe even better than younger adults! (Alea, Diehl, & Bluck, 2004) Maladaptive Personality . What happens when an individual’s personality creates ongoing interpersonal problems between him/her and their world (i.e., relationships with others at home, at work)? When he or she has trouble maintaining a stable sense of self? When he or she struggles in tolerating strong emotions? When might these problems meet the threshold for a PD?
  5. 5. 4/24/2014 Copyright 2014, Lindsey Slaughter 5 Personality Disorders Classifications • ICD-10 (International Statistical Classification of Diseases and Related health Problems) • DSM-IV-TR and V Diagnostic Statistical Manual of Mental Disorders Personality Disorder per DSM-V PERSONALITY DISORDER per DSM-V “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” Affects 2 or more areas of functioning - cognition - affectivity - interpersonal functioning - impulse control Leads to problems in social, occupational, or other important areas of functioning Is NOT due to medical conditions
  6. 6. 4/24/2014 Copyright 2014, Lindsey Slaughter 6 Cluster A: Odd, Eccentric Paranoid • Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent Schizoid • Pervasive pattern of detachment from social relationships and a restricted range of emotions in interpersonal settings Schizotypal • Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior Cluster B: Dramatic, Emotional, Erratic Antisocial • Pervasive pattern of disregard for, and violation of, the rights of others Borderline • Pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity Histrionic • Pervasive and excessive emotionality and attention- seeking behavior Narcissistic • Pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy
  7. 7. 4/24/2014 Copyright 2014, Lindsey Slaughter 7 Cluster C: Fearful, Avoidant Avoidant • Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation Dependent • Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation Obsessive- Compulsive • Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency Limitations of Diagnostic Criteria of PD in OA Assessments for PDs and classification criteria neglect the LATER LIFE CONTEXT RETIRED: “occupational impairment” FINANCIAL: “miserly attitude” ELDER ABUSE: “paranoid” Assessments for PDs and classification criteria neglect the LATER LIFE CHANGES POSSIBLE SENSORY DECLINE: “paranoid” POSSIBLE PHYSICAL DECLINE: “parasuicidal behavior,” “fights”; “avoidant” POSSIBLE INCREASE IN LOSS OF PARTNER(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)
  8. 8. 4/24/2014 Copyright 2014, Lindsey Slaughter 8 Limitations of Diagnostic Criteria of PD in OA What if PD doesn’t “show” until later adulthood? What if PD symptoms manifest differently in later adulthood? Maybe not mellowing, just showing itself differently than younger adults? If so (likely!), then our data may be systematically flawed We need more research on PD and OA! • 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) Barriers to PD Diagnosis in Older Adults
  9. 9. 4/24/2014 Copyright 2014, Lindsey Slaughter 9 Prevalence Rates of PD 10-14% across ages 10% of OA’s in the community (Abrams & Horowitz, 1996) About 11% of nursing home residents have PD Rates go up if OA has another 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 and depressive symptoms occur in up to 26% of OA’s in the community and 35% in nursing homes Anxiety often accompanies depressive symptoms
  10. 10. 4/24/2014 Copyright 2014, Lindsey Slaughter 10 Trends of PD in Older Adults 11.40% 12.30% 7.40% 1 6 -34 35-54 55-7 4 PREVALENCE RATES FOR ANY PD SEEMS TO DECREASE 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) Assessing for PD in OA 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)
  11. 11. 4/24/2014 Copyright 2014, Lindsey Slaughter 11 Formal Treatments for PD in OA Treat Axis I (i.e., other mental disorders such as depression, dementia, anxiety) simultaneously Consider psychotherapy before medications •Cognitive behavioral •Short-term psychodynamic •Interpersonal •Dialectical behavioral •Family If medications are warranted, consider anti-addictive agents with minimal side effects, especially for OA (i.e., anti- depressants like SSRI’s) Tips for Working with OA with PD Ask yourself how resident makes you feel? Angry? Hurt? Disempowered? Incompetent? Special? Remind yourself it’s likely not about you. Consult liberally with co- workers and supervisors. It prevents blindspots and protects you. Know thyself: reflect on who you are, get feedback from others, and know your “hot buttons.” This prevents countertransference and power struggles. E.g., BPD: Staff feels less able to manage resident, responds with less empathy, and believes resident is at fault for behavior (Marley & Fung, 2013)
  12. 12. 4/24/2014 Copyright 2014, Lindsey Slaughter 12 How PD Can Manifest in Older Adults • 74-year-old never-married white male who owns house in 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 use it against me.” • At times became hostile with team “because you’re part of the system, always up to something! I just wanna stay in my home!” Cluster A Case Vignette: Treatment and Management Tips Cluster A Strategies: Don’t be so warm and fuzzy! Be goal-directed and focused on what the OA’s motivation is Be matter-of-fact, direct Focus on the facts and appeal to logic Understand that OA may have only one person as a support, and may prefer it that way Understand that OA may not “get you,” e.g., humor. If daily ADL care/hygiene is an issue, set clear expectations with contingencies in place if possible Tailor environment as much as possible to meet preferences •Single room, indiv. treatment rather than group, sit alone in dining areas
  13. 13. 4/24/2014 Copyright 2014, Lindsey Slaughter 13 How PD Can Manifest in Older Adults • 80-year-old divorced African American female who was referred from ALF to nursing home for skilled rehab. • Very complimentary of staff, then later verbally abusive if her needs were not met when she wanted. • Demanded pain meds for unclear conditions. • When angry, picked at healing wounds, sunk to floor intentionally during PT, etc. • Made accusations towards staff about “neglectful care and mistreatment.” Cluster B Case Vignette: Treatment and Management Tips Cluster B Strategies: Balance, balance, balance! Balance warmth/concer n with professional boundaries Balance professional competence with acknowledging minor errors Balance consistency with flexibility Be matter-of- fact and genuine Provide structure while preventing power struggles Validate feelings while clearly stating behavioral expectations Consider brief, frequent scheduled meetings Be careful recommending medications, especially addictive ones Be alert to the risk of suicide, even if it doesn’t manifest like YA Have low threshold for seeking consultation Perform physical/other exams with witness/chaper one present, regardless of gender of professional
  14. 14. 4/24/2014 Copyright 2014, Lindsey Slaughter 14 How PD Can Manifest in Older Adults • 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: Treatment and Management Tips Cluster C Strategies: Empathic empowering! Provide verbal reassurance while encouraging OA to do for him/herself as independently as possible Publicly recognize (to the OA’s comfort level) small successes leading to bigger changes Be patient- during ADLs, ambulating, etc. Do with rather than for Consider break- down interventions with verbal and visual prompts, role modeling, hand-over-hand, etc.
  15. 15. 4/24/2014 Copyright 2014, Lindsey Slaughter 15 Summary Tips for Managing PD in OA Cluster A: • Don’t be so warm and fuzzy! Cluster B: • Balance, balance, balance! Cluster C: • Empathic empowering! Discussion and Questions