Debate: Are we overlooking personality disorder in older people?

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1 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. 1

2 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 ICD- 10 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. 2

3 Table 1. Diagnostic categories of personality disorders ICD-10 DSM-IV Characteristics Paranoid Paranoid Suspiciousness, misinterpreting neutral stimuli as hostile and marked selfreference Cluster A Schizoid 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 Cluster B Borderline Impulsivity, emotional outbursts, anger, interpersonal conflict, self-harm/suicidal attempts Histrionic Histrionic Labile affect, dramatic and attentionseeking behaviour and egocentricity Anakastic Narcissistic Obsessive Compulsive Self importance, grandiosity, need for admiration Perfectionism, rigidity and checking behavior Anxious Avoidant Sensitivity to rejection, seeking approval Cluster by others and avoidance of misperceived C risk Dependent Dependent Depending on others for important decisions, fear of abandonment and a sense of helplessness. 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 3

4 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. 4

5 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. 5

6 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. 6

7 Table 2 Summary of arguments Pros Diagnostic Clinically recognized Multiaxial diagnoses help understanding Cons Limited research evidence Length of time since formative life events Need for assessment tools for older group Controversies about diagnoses, changing in DSM-V Clinical Inform management plans Literature on treatment available Stigmatization, denial of access to service Comorbidity may be missed Commissioning service and research References 1. Abrams RC. Theoretical and management issues In: Principles and Practice of Geriatric Psychiatry, 2 nd edition, ed. Copeland JR, Abou-Saleh MT, Blazer DG. John Wiley & Sons, Ltd Mordekar A, Spence S. in older people: how common is it and what can be done? Advances in Psychiatric Treatment Abrams RC. s in the elderly: a flagging field of inquiry. International Journal of Geriatric Psychiatry. 21: Gutiérrez F. et al. features through the life course. Journal of Personality Disorders. 26(5) NICE. Antisocial Personality Disorder. CG Van den Broeck J. et al. Validation of the FFM count technique for screening personality pathology in later middle-aged and older adults. Aging and Mental Health (Epub ahead of print) 7. Charland LC. Moral nature of the DSM-IV Cluster B personality disorders. Journal of Personality Disorders. 20(2) Stone MH. Disorder in the domain of the personality disorders. Psychodynamic Psychiatry. 40(1)

8 9. Skodol AE. s in DSM-5. Annual Review of Clinical Psychology. 8: Deans C, Meocevic E. Attitudes of registered psychiatric nurses towards patients diagnosed with borderline personality disorder. Contemporary Nurse. 21(1) Fraser K, Gallop R. Nurses' confirming/disconfirming responses to patients diagnosed with borderline personality disorder. Archives of Psychiatric Nursing. 7(6) Markham D, Trower P. The effects of the psychiatric label 'borderline personality disorder' on nursing staff's perceptions and causal attributions for challenging behaviour. British Journal of Clinical Psychology. 42(3)