Personality Disorder and Older People

1. Personality Disorder and Older People Sandy McAfee Consultant Clinical Psychologist St John’s Hospital, West Lothian sandy.mcafee@wlt.scot.nhs.uk

2. 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)

3. Opinions vary however… I work with older people So what do you do? So, what are you doing at this conference?

4. 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

5. 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)

6. 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)

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

8. 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”

9. 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

10. 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

11. 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?

12. 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

13. 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

14. 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

15. 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

16. Schema Therapy • Early Maladaptive Schemas • Life-traps • Filters

17. 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

18. What are the EMSs? • Disconnection & Rejection • Abandonment/Instability • Mistrust/Abuse • Emotional Deprivation • Defectiveness/Shame • Social isolation/Alienation

19. What are the EMSs? • Impaired Autonomy & Performance • Dependence/Incompetence • Vulnerability to harm, illness or random events • Enmeshment/Undeveloped self • Failure

20. What are the EMSs? • Impaired Limits • Entitlement/Grandiosity • Insufficient self-control/Self-discipline

21. What are the EMSs? • Other-directedness • Subjugation • Self-sacrifice • Approval-seeking/Recognition-seeking

22. What are the EMSs? • Overvigilance & Inhibition • Negativity/Pessimism • Emotional Inhibition • Unrelenting standards/Hypercriticalness • Punitiveness

23. 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’

24. 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

25. 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

26. 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

27. 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

28. Diagnostic Issues • Features of Histrionic PD (Cluster B) • Physical appearance draws attention to self • Excessively impressionistic style of speech • Theatricality

29. 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?

30. YSQ – L2 1/4

31. YSQ – L2 2/4

32. YSQ – L2 3/4

33. YSQ – L2 4/4