Old Age Psychiatrist: Issue 55: January 2013
Personality disorder
Debate: Are we overlooking personality disorder in older people?
Dr. Justin Marley
Consultant in Older Adult Psychiatry, Clacton Hospital, Clacton-on-Sea,
Essex
Dr. Robert Fung
Specialty Doctor in Neuropsychiatry, St. George’s Hospital, South West
London and St. George’s Mental Health NHS Trust
Case vignette 1:
Dr Fung wrote
A 68-year old woman presented with increasing anxiety and depressive
symptoms despite antidepressant medication following her husband
moving into a residential home due to a stroke a few months previously.
She was admitted to a psychiatric ward following an intentional overdose
of medication. On the ward, she improved quickly with emotional support
with no need to change her antidepressant. She was self-caring, with good
mobility and no physical disability, scored 28/30 in the MMSE and
performed well in the occupational therapy assessment. She continued to
complain of insomnia, poor appetite and anxiety which contradicted with
observations of good sleep, appetite and enjoyment of socializing on the
ward.
She was reluctant to return home as she was anxious about having to care
for herself. She eventually agreed to trial periods of increasing home
leave. As the leave progressed, she started phoning her daughter
repeatedly in relation to anxious ruminations as happened previously. She
returned to the ward after expressing suicidal thoughts. The team
explained to her that she was dependent on the ward environment which
was unhelpful for further recovery and a discharge date was set. She then
refused to eat with a flavour of ‘hunger strike’. The daughter recalled that
her mother had always been a worrier, feeling insecure and timid
throughout her life, with lack of confidence in daily activities, for
example, avoiding going out on her own. She had never lived alone. ‘Her
glass is always half empty’ according to her daughter. She was pleasant
in the company of others but she had a controlling and manipulative side
as well. Over the years, her family accepted her as ‘high maintenance’,
dependent and anxious, with few friends or hobbies, 'attention seeking',
and self-pitying. Despite trials of antidepressants in the past from her
general practitioner, she never felt better.
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Personality disorder
When the discharge date was cancelled, her mood, behaviour and appetite
improved quickly. It was agreed with her social worker that she could
have funding for a package of care to help her cope at home because of
mental health needs from enduring personality difficulties. Meanwhile
our psychologist had explored the issue of carer stress with her children
who agreed to ring the patient regularly rather than respond to her helpseeking phone-calls which reinforced her behaviour. Following further
attempts of trial leave, she was discharged successfully from the ward,
with support from home carers, community mental health nurse (CMHN)
and a day hospital one day a week.
Discussion
This example may be a case of cluster C personality disorder (a mixed
anxious and dependent type, see table 1).
Despite controversies over the application of diagnostic criteria in ICD10 or DSM-IV for diagnosing personality disorder in older people, it is
acknowledged that some patients have relatively mild personality
dysfunction in young and middle adulthood, but develop a marked and
persistent worsening in old age. This late onset or emergent personality
disorder is recognized in the clinical setting (1). Other older people are
‘graduates’ who have always had personality disorder (2). It is important
to establish a local agreement between the General Adult and Old Age
services on how best to manage this subgroup based on their needs.
Recent research findings showed a prevalence of personality disorder of
about 31% among the older people with major depression or dysthymia
(3). Cluster C personality disorder predominates.
DSM-IV Axis II disorders including personality disorder and learning
disabilities should be addressed to complete our understanding of our
patients to facilitate a comprehensive management plan.
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Personality disorder
Table 1. Diagnostic categories of personality disorders
ICD-10
DSM-IV
Paranoid
Characteristics
Paranoid
Suspiciousness, misinterpreting neutral
stimuli as hostile and marked selfreference
Schizoid
Preoccupation with fantasy and social
withdrawal
Schizotypal
Odd affect, thinking and behaviour
Dissocial
Antisocial
Lack of concern for feelings of others,
disregard for social obligations and
aggression.
Emotionally
Unstable
Borderline
Impulsivity, emotional outbursts, anger,
interpersonal conflict, self-harm/suicidal
attempts
Histrionic
Labile affect, dramatic and attentionseeking behaviour and egocentricity
Narcissistic
Self –importance, grandiosity, need for
admiration
Obsessive
Compulsive
Perfectionism,
behavior
Avoidant
Sensitivity to rejection, seeking approval
by others and avoidance of misperceived
risk
Dependent
Depending on others for important
decisions, fear of abandonment and a
sense of helplessness.
Cluster
A
Schizoid
Cluster
B
Histrionic
Anakastic
Anxious
Dependent
Cluster
C
rigidity
and
checking
The importance of recognizing personality disorder
Recognizing the diagnosis is the first stage in moving towards effective
interventions which will reduce suffering and distress. The case vignette
described how understanding the disorder helped communicate with other
professionals, for example, a social worker, about mental health needs
and resources required to meet them. Some recent literature has shed light
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Personality disorder
on the understanding and management of personality disorders of older
people (2)(3). The mainstay of treatment is to identify and treat comorbid Axis I disorders, such as depression, psychosis and dementia.
Pharmacotherapy has also been tried to target individual symptoms of
personality disorder. Psychotherapy mainly applies to individuals with
personality disorder with co-morbid depression, with the emphasis on
forming a therapeutic alliance with patient and carers, plus maintaining a
consistent approach (2).
Finally, identifying personality disorder and responding effectively is
important at the service level particularly when commissioning services.
This can only be achieved if we have a better grasp of the condition,
which in turn relies on more research and adequate recognition of it.
In summary, we have much to learn about personality disorder in the
older population. If old age psychiatrists choose to ignore it, we may be
losing a valuable opportunity for studying these conditions and gaining
insights into management strategies.
Case vignette 2: Dr. Marley wrote
A nurse-led older adult crisis response team assessed a 71-year old man
Mr Smith who had been increasingly verbally aggressive towards his wife
over several months and threatening, but not engaging in, physical
aggression. Two nurses visited the patient and identified his wife's
increasing difficulties with cooking and cleaning at home (due to
arthritis) as a precipitant. Mrs Smith mentioned a difficult marriage.
There was a history of alcohol misuse in early adulthood associated with
disorderly behavior in public for which Mr Smith was cautioned by the
police.
The GP had excluded acute medical conditions and Mr Smith reported no
difficulty with his mood or memory. The team visited for the next few
days and the case was then discussed at the weekly team meeting. Mr
Smith was discharged from the service without a diagnosis although
dysfunctional personality traits were mentioned. Mrs Smith was advised
to contact the police if the behaviour persisted. No follow-up was
arranged.
A few months later Mr Smith was admitted to a medical ward with
delirium secondary to a chest infection. A psychiatric liaison assessment
revealed cognitive impairment despite complete recovery of his chest
infection and delirium. He returned home and was referred into the
memory clinic where a diagnosis of early Alzheimer’s disease was made.
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Personality disorder
Following CMHN input and the use of a cholinesterase inhibitor, his
hostility improved to some extent.
In this vignette, the presenting complaint focused on relationship
difficulties with threats of physical violence. These difficulties may have
been secondary to the emergence of Alzheimer’s disease which was
identified when a subsequent presentation suggested the need for a
cognitive assessment (although a cognitive function screening tool should
be routinely used in all older adult assessments). In the above example a
formal diagnosis of personality disorder was not used but was implied by
‘personality traits’.
I argue that there are significant challenges associated with newly
diagnosing personality disorder in older people.
Discussion
Much of the clinical assessment relates to life events and coping
strategies and requires a detailed personal history. The assessment is
more challenging in older people where formative life events may have
occurred seven decades previously. Research suggests that there are
significant changes in the presentation of personality disorders over the
lifespan (4). The National Institute for Health and Clinical Excellence
(NICE) guidelines recommend a structured assessment tool to diagnose
antisocial personality disorder (5) although the lifespan changes suggest a
separate older adult assessment tool would be appropriate. In one recent
study when a five-factor model was applied to personality disorders in the
older adult population it was concluded that Antisocial Personality
Disorder was not a valid construct in contrast with the younger adult
population (6)
Both ICD-10 and DSM-IV personality disorder constructs are not without
controversy. For instance, the DSM-IV cluster B personality disorders
(Table 1) have been critiqued as being moral rather than clinical
conditions, (7) demarcating the limits of the medical model. There are
difficulties with the use of cluster C disorders in older adults as dependent
personality disorder criteria do not incorporate the effect of their multiple
losses and vulnerability. Additionally there is considerable diagnostic
overlap between many personality disorders (8). In DSM-V (draft) there
are significant changes in the approach to diagnosing personality
disorders (9) and along with other changes in the manual these have the
potential to modify clinical practice. One of the biggest of the proposed
changes will be the removal of five personality disorders leaving just the
Borderline, Antisocial, Avoidant, Obsessive-Compulsive and Schizotypal
Personality Disorders.
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Personality disorder
Once the diagnosis has been made, staff counter-transference can be
problematic. Studies have shown that nursing staff feel less able to
manage patients with borderline personality disorder (10), respond with
less empathy than to other patient groups (11) and believe that patients
have greater culpability for their actions (12). These studies support the
often implicit assumptions that people with personality disorders are in
control of their actions, bring events upon themselves and obstruct people
with 'real' problems from receiving services. Older people are vulnerable
and stigmatised as it is and those with dementia even more so. Adding
another layer of potential stigma should be done only with the greatest
caution and with the relevant infrastructure in place, including staff
training, monitoring the response of the services to this diagnosis and
providing additional services as necessary.
Patients may also have significant Axis I disorders which may get
overlooked in the focus on Axis II pathology. Using borderline
personality disorder as an example, the DSM-IV diagnostic criterion
would include suicidal behaviour, identity disturbance, impulsivity
(associated with binge-eating and substance misuse), disorders of affect
and dissociative experiences each of which may be sufficiently severe to
warrant intervention in its own right. Multiple psychiatric pathology may
be reduced to a single label. Under these circumstances the inappropriate
but common use of moral reductionism leading to therapeutic nihilism is
at best counterproductive and at worst discriminatory.
To summarise, personality disorder diagnoses in older adults have many
drawbacks. There are needs for further research to better characterise
clinical presentation and for assessment tools. There is potential for
discrimination if the diagnosis is misused and if services are insufficiently
prepared to manage personality disorders appropriately.
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Personality disorder
Table 2 – Summary of arguments
Pros
Diagnostic
Clinical
Cons
·
Clinically
recognized
·
Multiaxial diagnoses
help understanding
·
Limited research evidence
·
Length of time since formative
life events
·
Need for assessment tools for
older group
·
Controversies about diagnoses,
changing in DSM-V
·
Inform management
plans
·
Stigmatization, denial of access
to service
·
Literature
on
treatment available
·
Comorbidity may be missed
·
Commissioning
service and research
References
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2012. (Epub ahead of print)
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