Transcript Personality Disorder and Older People

Personality Disorder and
Older People
Sandy McAfee
Consultant Clinical Psychologist
St John’s Hospital, West Lothian
[email protected]
Prevalence studies
Community Dwelling Older People
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Large variability between studies
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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)
Opinions vary however…
I work with
older people
So what do
you do?
So, what are you
doing at this
conference?
Things I’ve heard said…
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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
Change with Age
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Some PDs may become exacerbated with age:
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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)
Other considerations
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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)
There undoubtedly are some differences about
the way older people present to services…
Issues to do with working with older
people
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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”
Issues to do with working with older
people
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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
Diagnostic Issues and Older People
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Problems with labelling
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Cultural bias affecting choice of diagnostic labels
applied to different groups
Attribution and preconception issues (Kroessler,
1990)
Problems with ageism
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See symptoms as normal for old age
‘Invisibility’ of older people and their problems
Hopelessness double whammy
Diagnostic Issues and Older People
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Problems with validity of the diagnosis
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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?
Diagnostic Issues and Older People
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Problems with reliability of the diagnosis
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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
Diagnostic Issues and Older People
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Problems with reliability of the diagnosis
(cont.)
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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
But the issues are real no matter what
we choose to call them…
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Older people can present with multiple
chronic problems:
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Coping
Interpersonal functioning
Cognitive functioning e.g. cognitive flexibility,
problem solving
Rapid arousal, emotional intensity
Insight/self-awareness
Recurrent affective disorder
A useful model for working with older
peoples’ PD issues
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Schema Therapy
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Comprehensive model
Valid
Reliable
Applies well across the age range
Offers an explanation and treatment modality
rather than purely focus on categorisation and
diagnosis
Schema Therapy
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Early Maladaptive Schemas
Life-traps
Filters
Early Maladaptive Schemas
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Young’s model is that EMSs result from
unmet core emotional needs in childhood
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Secure attachment to others
Autonomy, competence & sense of identity
Freedom to express valid needs & emotions
Spontaneity & play
Realistic limits and self-control
What are the EMSs?
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Disconnection & Rejection
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Abandonment/Instability
Mistrust/Abuse
Emotional Deprivation
Defectiveness/Shame
Social isolation/Alienation
What are the EMSs?
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Impaired Autonomy & Performance
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Dependence/Incompetence
Vulnerability to harm, illness or random events
Enmeshment/Undeveloped self
Failure
What are the EMSs?
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Impaired Limits
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Entitlement/Grandiosity
Insufficient self-control/Self-discipline
What are the EMSs?
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Other-directedness
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Subjugation
Self-sacrifice
Approval-seeking/Recognition-seeking
What are the EMSs?
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Overvigilance & Inhibition
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Negativity/Pessimism
Emotional Inhibition
Unrelenting standards/Hypercriticalness
Punitiveness
Mr X, 74 year old man
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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’
Mr X, 74 year old man
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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
Presenting Problems
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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
Psychiatric history
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Suicide attempt (OD) aged mid twenties
Self harm (cutting) same time
Catastrophic reaction to loss of relationship mid
forties
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inpatient briefly
two years of unspecified psychotherapy (helpful)
diagnosis of personality disorder
Private counselling aged late sixties – prematurely
terminated
Diagnostic Issues
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Meets diagnostic criteria for Borderline PD
(Cluster B)
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Efforts to avoid real or imagined abandonment
Unstable + intense interpersonal relationships +
idealization/devaluation
Identity disturbance
Sexual impulsivity
Affective instability
Inappropriate intense anger
Diagnostic Issues
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Features of Histrionic PD (Cluster B)
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Physical appearance draws attention to self
Excessively impressionistic style of speech
Theatricality
Diagnostic Issues
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Features of Dependent PD (Cluster C)
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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?
YSQ – L2
1/4
100
90
80
70
60
50
40
30
20
10
0
Emotional Deprivation
Abandonment
M istrust/Abuse
Social Isolation
YSQ – L2
2/4
100
90
80
70
60
50
40
30
20
10
0
D efectiveness/ Shame
So cial Undesirability
F ailure to A chieve
F unctio nal
D ependence
YSQ – L2
3/4
100
90
80
70
60
50
40
30
20
10
0
Vulnerability to H arm
Enmeshment
Subjugatio n
Self Sacrifice
YSQ – L2
4/4
100
90
80
70
60
50
40
30
20
10
0
Emo tio nal Inhibitio n
Unrelenting
Standards
Entitlement
Insufficient SelfC o ntro l