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Personality Disorders in the Elderly Module 1

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Personality Disorders in the Elderly Module 1 Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC PROCESS A series of modules and ... – PowerPoint PPT presentation

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Title: Personality Disorders in the Elderly Module 1


1
Personality Disorders in the ElderlyModule 1
  • Thomas Magnuson, M.D.
  • Assistant Professor
  • Division of Geriatric Psychiatry
  • UNMC

2
PROCESS
  • A series of modules and questions
  • Step 1 Power point module with voice overlay
  • Step 2 Case-based question and answer
  • Step 3 Proceed to additional modules or take a
    break

3
Case
  • 72-year old white male
  • Former school superintendent in a large city in
    a nearby state
  • Lost job because of spouses drinking
  • Series of jobs selling textbooks
  • At lower socio-economic Omaha NH
  • Two children
  • Little contact with son in town
  • Daughter is estranged (I dont know)
  • No contact with grandchildren
  • Two ex-wives
  • Reasons for divorce are vague

4
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

5
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

6
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

7
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

8
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

9
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

10
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

11
What are the Types of Personality Disorders?
  • Cluster A
  • Odd and Eccentric
  • Paranoid
  • Schizoid
  • Schizotypal

12
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

13
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

14
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 patients everyday world
  • Bizarre dress, speech, mannerisms
  • Poor interpersonal relationships

15
What are the Types of Personality Disorders?
  • Cluster B
  • Dramatic and emotional
  • Antisocial
  • Borderline
  • Narcissistic
  • Histrionic

16
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

17
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 psychiatrists existence

18
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

19
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

20
What are the Types of Personality Disorders?
  • Cluster C
  • Anxious and fearful
  • Avoidant
  • Dependent
  • Obsessive-compulsive

21
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

22
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

23
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

24
  • The End of Module One on
  • Personality Disorders
  • in the Elderly

25
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.
26
Which of the following is the most likely
diagnosis?
  • Antisocial personality disorder
  • B. Bipolar disorder
  • C. Dementia with frontal lobe signs
  • D. Major depressive disorder with mixed
    personality disorder
  • E. Histrionic personality disorder

27
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.

28
  • 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
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