Personality Disorders in the ElderlyModule 1

Thomas Magnuson, M.D.Assistant Professor

Division of Geriatric PsychiatryUNMC

PROCESS

A series of modules and questionsStep #1: Power point module with voice

overlayStep #2: Case-based question and answerStep # 3: Proceed to additional modules or

take a break

Case• 72-year old white male

– Former “school superintendent” in a large city in a nearby state

• Lost job because of spouse’s “drinking”• Series of jobs selling textbooks

– At lower socio-economic Omaha NH– Two children

• Little contact with son in town• Daughter is estranged (“I don’t know…”)• No contact with grandchildren

– Two ex-wives• Reasons for divorce are vague

Case

• In NH due to neuro-degenerative disorder– Cognitively intact

• Mad he was sent here to “the shrink”– Over-familiarity from the get-go– Looks at my diplomas, licenses– Angry outburst at CNA, nurse over when, how he

would go to dinner• Rage • Upset they did not recognize his status

Case

• Called doctor himself, went the DON, NH Director with his complaint– “nonprofessional treatment”

• Denies mood, anxiety, mood lability, psychosis now

• Notes his cognition is “slower”• Calls the incident a misunderstanding

– All “blown out of proportion”

ObjectivesFor all three modules

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

ObjectivesModule One

Upon completion the learner will be able to:• List the elements that make up personality• List the definition of personality disorder• Describe the characteristics of each type of

personality disorders

What is Personality?

• A totality of behavioral and emotional traits• Characterize a person in day-to-day living,

under normal circumstances• Mainly formed by adulthood• Stable• Predictable• What people feel makes you “you”

What is a Personality Disorder?

• An enduring pattern of culturally deviant inner experience and behavior– Cognition

• distorted perceptions/misinterpretations– Affectivity

• inappropriate intensity or range of emotions– Interpersonal functioning– Impulse control

What is a Personality Disorder?

• A pattern of long duration• Present by early adulthood

– Some evidence in childhood (Conduct Disorder)• Maladaptive and rigid

– Invariant across situations, clinical states• Associated with significant emotional distress or

disturbed functioning– When their personality cannot adapt

What are the Types of Personality Disorders?

• Cluster A“Odd and Eccentric”– Paranoid– Schizoid– Schizotypal

Cluster A

• Paranoid Personality Disorder– Long-standing suspiciousness of people in

general– Assign responsibility for feelings to others– Hostile, irritable, angry– Bigots, injustice collectors, conspiracy theorist,

jealous spouse, litiginous crank

Cluster A

• Schizoid Personality Disorder– Lifelong social withdrawal– Uncomfortable with human interaction– Introverted; bland, constricted affect– Eccentric, isolated lonely– Night shift workers, hidden neighbors, stamp

collectors

Cluster A

• Schizotypal Personality Disorder– Strikingly odd, even to laypersons– Magical-thinking, peculiar ideas, ideas of

reference, illusions and derealization are part of the schizotypal patient’s everyday world

– Bizarre dress, speech, mannerisms– Poor interpersonal relationships

What are the Types of Personality Disorders?

• Cluster B“Dramatic and emotional”– Antisocial– Borderline– Narcissistic– Histrionic

Cluster B

• Antisocial Personality Disorder– Continual antisocial or criminal acts– Unable to conform to social norms in

development– Lack a conscience– “do unto others before they do unto you” – Criminals, con men, addicts

• State penitentiary is a big clinic

Cluster B

• Borderline Personality Disorder– On the border between neurosis and psychosis– Unstable mood, relationships, behavior and

self-image– Emotional chameleons– Multiple marriages, danger seekers, roller

coasters of emotion, near-constant crisis– Bane of the psychiatrist’s existence

Cluster B

• Histrionic Personality Disorder– Colorful, dramatic, extroverted behavior– Excitable emotional persons– Unable to maintain deep, long-lasting, mature

relationships– Physical appearance is paramount

• Aging leads to plastic surgery– Rapidly-shifting, shallow emotions

Cluster B

• Narcissistic Personality Disorder– Heightened sense of self-importance– Grandiose feelings– Unique in some way– Unempathic, feels the need to associate with

other “high status persons”– Entitled

What are the Types of Personality Disorders?

• Cluster C“Anxious and fearful”– Avoidant– Dependent– Obsessive-compulsive

Cluster C

• Avoidant Personality Disorder– The flip side of social phobia– Great fear of personal rejection– Seek human relationships, but fearful they will be

embarrassed or not wanted– Need guarantees of acceptance

• Family usually only trusted

– Sees self as inferior to others• Opposite of narcissism

Cluster C

• Dependent Personality Disorder– Subordinate their own needs for others– Get others to assume responsibility for their

decisions– Lack self-confidence– Intense discomfort with being alone– Exaggerated fears of being helpless when by

themselves

Cluster C

• Obsessive-compulsive Personality Disorder– Emotional constriction

• No little white lies– Orderliness, perseverance– Stubborn. Indecisive

• 9-year engagements– Perfection and inflexibility to the point where

they cannot complete projects

The End of Module One on

Personality Disorders

in the Elderly

Post-test• An 82-year-old man who lives in a nursing home

has gradual onset of socially inappropriate actions characterized by loud, intrusive, and exhibitionistic behavior. He has no history of psychiatric illness or substance use. His family says he had always been introverted and considerate. The nursing staff have become angry with him because of his behavior and his lack of concern for their requests. On examination, he is alert, has clear speech, and has a steady gait. Which of the following is the most likely diagnosis?

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.

Which of the following is the most likely diagnosis?

A. Antisocial personality disorderB. Bipolar disorderC. Dementia with frontal lobe signsD. Major depressive disorder with mixed

personality disorderE. Histrionic personality disorder

Answer; C. Dementia with frontal lobe signs• Personality is relatively stable throughout life, although

behavioral expressions may change to some degree. The change in this patient is not consistent with his former pattern as validated by his family. The irritation of the staff suggests that they are responding to his behavior, and the recent onset makes it likely that this has an organic cause.

• This patient most likely has dementia with frontal lobe signs. Cognitive impairment accompanied by frontal lobe cortical or subcortical pathology often presents with personality change involving disinhibition and other manic-like symptoms in addition to lack of attention to appropriate social behavior.

• Bipolar disorder may present with these symptoms but would be extremely unlikely to develop in an 82-year-old patient with no history of psychiatric illness or treatment.

• Personality disorders are generally lifelong and are unlikely to develop at age 82 years. Persons with antisocial personality disorder have a longstanding pattern of inability to conform to social norms, rules, or laws. Histrionic personality also begins in early adulthood and is characterized by self-dramatization, excessive emotional display, and use of physical appearance to draw attention to the self. Mixed personality disorder refers to a mixture of the traits of personality disorder subtypes. This patient exhibits neither depressive symptoms nor a mixture of personality disorder subtypes. End