1. Personality Disorder and Older People
Sandy McAfee
Consultant Clinical Psychologist
St John’s Hospital, West Lothian

2. Prevalence studies Community 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