Presentation made by Dr. Lindsey Slaughter April 24, 2014. All rights reserved

1. 4/24/2014
Copyright 2014, Lindsey Slaughter 1
Personality
Disorders
and Aging
Lindsey K. Slaughter, Psy.D.
Licensed Clinical Psychologist
April 24, 2014
ABBREVIATIONS
• PD = Personality Disorders
• OA = Older Adults
• YA = Younger Adults
• DSM = Diagnostic Statistical Manual of Mental Disorders

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Goals and Objectives
To define
personality and the
“Big Five” traits
To identify trends in
personality and
aging
To learn general
criteria of
personality
disorders (PD)
To discuss
challenges in
diagnosis and
assessment with PD
and OA
To identify trends in
prevalence of PD’s
and aging
To discover how PD
may manifest in
older adults (OA)
To glean some
tricks-of-the-trade
for treatment and
management of PD
in OA
What is Personality, Its
Purpose and Origins?
How about where they come from?
Nature (i.e., trait)? Nurture (i.e., context)?
Both (i.e., developmental/life-span)?
PERSONALITY
can be defined as an
individual’s pattern of psychological processes,
including his or her
motives,
feelings,
thoughts,
behavioral patterns, and
other major areas of psychological functioning.
Think of your and others personalities.
What are their purposes?

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“Big Five” Dimensions of Personality (O.C.E.A.N.)
(originally Goldberg, 1960’s)
EXTRAVERSION
excitability, sociability, talkativeness, assertiveness,
high amounts of emotional expressiveness
AGREEABLENESS
trust, altruism, kindness, affection,
and other prosocial behaviors
CONSCIENTIOUSNESS
high levels of thoughtfulness,
good impulse control, goal-
directed behavior, organized,
mindful of details, planful
NEUROTICISM
emotional instability,
anxiety, moodiness,
irritability, sadness
OPENNESS TO
EXPERIENCE
imagination and insight,
broad range of interests
Personality Traits and
Aging Trends
(Donnellan and Lucas, 2009)
Levels of
Agreeableness
and
Conscientiousness
are positively
associated with
age (may decline
after 70)
Extraversion and
Openness are
negatively
associated with
age (starts to decline
around age 50)
Average levels of
Neuroticism are
generally
negatively
associated with
age, although trait
may increase from
age 80 and beyond
Both per
observers and per
self report

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Healthy Personality
Trends in Aging
• “Successful aging” components (Rowe & Kahn, 1998)
• Avoiding disease
• Maintaining high cognitive and physical function
• Engagement with life
• About 80% heritability with personality
• Most OA have psychological resources to compensate for
losses (i.e., loved ones, functional), with better emotional
regulation and decrease in physiological arousal levels. Maybe
even better than younger adults! (Alea, Diehl, & Bluck, 2004)
Maladaptive Personality
.
What happens when an
individual’s personality
creates ongoing
interpersonal problems
between him/her and
their world (i.e.,
relationships with others
at home, at work)?
When he or she has
trouble maintaining a
stable sense of self?
When he or she struggles
in tolerating strong
emotions?
When might these
problems meet the
threshold for a PD?

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Personality Disorders
Classifications
• ICD-10
(International Statistical Classification of Diseases and Related health Problems)
• DSM-IV-TR and V
Diagnostic Statistical Manual of Mental Disorders
Personality Disorder per DSM-V
PERSONALITY DISORDER
per DSM-V
“An enduring pattern of inner
experience and behavior that
deviates markedly from the
expectations of the individual’s
culture, is pervasive and
inflexible, has an onset in
adolescence or early adulthood, is
stable over time, and leads to
distress or impairment”
Affects 2 or more areas of
functioning
- cognition
- affectivity
- interpersonal functioning
- impulse control
Leads to problems in
social, occupational, or
other important areas of
functioning
Is NOT due to medical
conditions

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Cluster A:
Odd, Eccentric
Paranoid
• Pervasive distrust
and suspiciousness
of others such that
their motives are
interpreted as
malevolent
Schizoid
• Pervasive pattern of
detachment from
social relationships
and a restricted
range of emotions
in interpersonal
settings
Schizotypal
• Pervasive pattern of
social and
interpersonal
deficits marked by
acute discomfort
with, and reduced
capacity for, close
relationships as
well as by cognitive
or perceptual
distortions and
eccentricities of
behavior
Cluster B:
Dramatic, Emotional, Erratic
Antisocial
• Pervasive
pattern of
disregard for,
and violation
of, the rights
of others
Borderline
• Pervasive
pattern of
instability of
interpersonal
relationships,
self-image,
and affects,
and marked
impulsivity
Histrionic
• Pervasive and
excessive
emotionality
and
attention-
seeking
behavior
Narcissistic
• Pervasive
pattern of
grandiosity
(in fantasy or
behavior),
need for
admiration,
and lack of
empathy

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Cluster C:
Fearful, Avoidant
Avoidant
• Pervasive pattern
of social
inhibition,
feelings of
inadequacy, and
hypersensitivity
to negative
evaluation
Dependent
• Pervasive and
excessive need to
be taken care of
that leads to
submissive and
clinging behavior
and fears of
separation
Obsessive-
Compulsive
• Pervasive pattern
of preoccupation
with orderliness,
perfectionism,
and mental and
interpersonal
control, at the
expense of
flexibility,
openness, and
efficiency
Limitations of
Diagnostic Criteria
of PD in OA
Assessments for PDs
and classification
criteria neglect the
LATER LIFE
CONTEXT
RETIRED:
“occupational impairment”
FINANCIAL:
“miserly attitude”
ELDER ABUSE:
“paranoid”
Assessments for
PDs and
classification
criteria neglect the
LATER LIFE
CHANGES
POSSIBLE SENSORY DECLINE:
“paranoid”
POSSIBLE PHYSICAL DECLINE:
“parasuicidal behavior,” “fights”; “avoidant”
POSSIBLE INCREASE IN LOSS OF
PARTNER(S), FAMILY, FRIENDS:
“abandonment”
POSSIBLE DECREASE IN LIBIDO;
EMOTIONAL EXPRESSION:
“schizoid”
Indeed, “the presentation of a PD is intimately tied to contexts, contexts that can help to bring about the presentation of the features”
(Oltmanns & Balsis, 2011)
(Segal, Coolidge, &
Rosowsky, 2006)

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Limitations of Diagnostic
Criteria of PD in OA
What if PD doesn’t
“show” until later
adulthood?
What if PD symptoms
manifest differently
in later adulthood?
Maybe not
mellowing, just
showing itself
differently than
younger adults?
If so (likely!), then our
data may be systematically
flawed
We need more research on
PD and OA!
• Lack of co-informant
• Co-informant has little knowledge of OA’s early life
• Unreliable OA and/or co-informant
• Cognitive impairment of OA and/or co-informant
• Co-informant’s characteristics (e.g., shame, guilt, minimization)
affect account
• Severe physical illness in OA
• Axis I and II similarities (e.g., PD versus personality changes
related to dementia) (Mordekar & Spence, 2008)
Barriers to PD
Diagnosis in
Older Adults

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Prevalence
Rates of
PD
10-14% across ages
10% of OA’s in the
community
(Abrams & Horowitz, 1996)
About 11% of nursing
home residents have
PD
Rates go up if OA has
another psychiatric
disorder
Major depression and dysthymia
31%
(mainly Obsessive-Compulsive and
Avoidant subtypes)
Anxiety disorder
up to 13%
(mainly Avoidant, Obsessive-
Compulsive, and Dependent subtypes)
Alcohol dependence and depression
(mainly related to Cluster B and C)
Depression and
depressive symptoms
occur in up to 26% of
OA’s in the community
and 35% in nursing
homes
Anxiety often
accompanies
depressive symptoms

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Trends of PD in Older
Adults
11.40%
12.30%
7.40%
1 6 -34 35-54 55-7 4
PREVALENCE RATES FOR ANY PD SEEMS TO
DECREASE ACROSS AGES
Possible decline of Cluster B PDs in OA (i.e., Borderline, Antisocial)
(Samuels et al, 2002)
Possible increase in Cluster A and C (i.e., Paranoid, Schizoid, Obsessive-Compulsive)
(Abrams & Horowitz, 1999)
Assessing for PD in
OA
Always consider and manage medical issues first
Listen to your gut/instincts:
PDs reveal themselves whether the resident likes it or not
Obtain as much collateral information as you can
(e.g., from family, peers, other professionals)
Formal assessment/consult, if possible
Try at least to identify what PD Cluster resident may have
(i.e., A, B, C)

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Formal
Treatments
for PD in
OA
Treat Axis I
(i.e., other mental
disorders such as
depression,
dementia, anxiety)
simultaneously
Consider
psychotherapy
before medications
•Cognitive behavioral
•Short-term
psychodynamic
•Interpersonal
•Dialectical behavioral
•Family
If medications are
warranted, consider
anti-addictive
agents with minimal
side effects,
especially for OA
(i.e., anti-
depressants like
SSRI’s)
Tips for Working with OA with PD
Ask yourself how resident
makes you feel?
Angry? Hurt? Disempowered?
Incompetent? Special?
Remind yourself it’s likely not
about you.
Consult liberally with co-
workers and supervisors. It
prevents blindspots and
protects you.
Know thyself:
reflect on who you are, get
feedback from others, and
know your “hot buttons.” This
prevents countertransference
and power struggles.
E.g., BPD: Staff feels less able to manage
resident, responds with less empathy, and
believes resident is at fault for behavior
(Marley & Fung, 2013)

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How PD Can Manifest in
Older Adults
• 74-year-old never-married white male who owns house
in rural area and was enrolled (reluctantly) in PACE.
• Didn’t want to lose home.
• Presented as suspicious of peers and staff in groups:
“What do you wanna know about me for? You’ll just use
it against me.”
• At times became hostile with team “because you’re part
of the system, always up to something! I just wanna
stay in my home!”
Cluster A Case Vignette:
Treatment and Management Tips
Cluster A
Strategies:
Don’t be so
warm and
fuzzy!
Be goal-directed
and focused on
what the OA’s
motivation is
Be matter-of-fact,
direct
Focus on the facts
and appeal to logic
Understand that
OA may have only
one person as a
support, and may
prefer it that way
Understand that
OA may not “get
you,” e.g., humor.
If daily ADL
care/hygiene is an
issue, set clear
expectations with
contingencies in
place if possible
Tailor
environment as
much as possible
to meet
preferences
•Single room, indiv.
treatment rather
than group, sit alone
in dining areas

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How PD Can Manifest in
Older Adults
• 80-year-old divorced African American female who
was referred from ALF to nursing home for skilled
rehab.
• Very complimentary of staff, then later verbally
abusive if her needs were not met when she wanted.
• Demanded pain meds for unclear conditions.
• When angry, picked at healing wounds, sunk to floor
intentionally during PT, etc.
• Made accusations towards staff about “neglectful
care and mistreatment.”
Cluster B Case Vignette:
Treatment and Management Tips
Cluster B
Strategies:
Balance,
balance,
balance!
Balance
warmth/concer
n with
professional
boundaries
Balance
professional
competence
with
acknowledging
minor errors
Balance
consistency
with flexibility
Be matter-of-
fact and
genuine
Provide
structure while
preventing
power
struggles
Validate
feelings while
clearly stating
behavioral
expectations
Consider brief,
frequent
scheduled
meetings
Be careful
recommending
medications,
especially
addictive ones
Be alert to the
risk of suicide,
even if it
doesn’t
manifest like
YA
Have low
threshold for
seeking
consultation
Perform
physical/other
exams with
witness/chaper
one present,
regardless of
gender of
professional

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How PD Can Manifest in
Older Adults
• 68-year-old married Indian American female whose daughter
asked PCP for help.
• Lived in home together. Didn’t like to make decisions, relied on
husband and daughter.
• Had mild arthritis but otherwise fair health.
• Often hollered to have someone else walk with her, get her
medicine.
• Others cooked and cleaned.
• Had general anxiety with panic/crying episodes, clinginess if
daughter went out or discussed moving out.
• Often wanted to call/go to ER if in distress.
Cluster C Case Vignette:
Treatment and Management Tips
Cluster C
Strategies:
Empathic
empowering!
Provide verbal
reassurance while
encouraging OA to
do for him/herself
as independently as
possible
Publicly recognize
(to the OA’s
comfort level) small
successes leading to
bigger changes
Be patient- during
ADLs, ambulating,
etc.
Do with rather than
for
Consider break-
down interventions
with verbal and
visual prompts,
role modeling,
hand-over-hand,
etc.

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Summary Tips for
Managing PD in OA
Cluster A:
• Don’t be so
warm and
fuzzy!
Cluster B:
• Balance,
balance,
balance!
Cluster C:
• Empathic
empowering!
Discussion
and
Questions