Personality Disorders in Long Term Care Thomas Magnuson, M.D. Department of Psychiatry Division of...

Personality Personality Disorders in Long Disorders in Long

Term CareTerm CareThomas Magnuson, M.D.Thomas Magnuson, M.D.Department of PsychiatryDepartment of Psychiatry

Division of Geriatric PsychiatryDivision of Geriatric PsychiatryUNMCUNMC

WebsitesWebsites

• www.unmc.edu/nebgecwww.unmc.edu/nebgec– Information on:Information on:

• Long-term Care Mental Health Series, 2-hour Long-term Care Mental Health Series, 2-hour evening conferences, Annual conferences, evening conferences, Annual conferences, Geriatric Minifellowship, Online Educational Geriatric Minifellowship, Online Educational ModulesModules

• http://ltcmentalhealth.forumcircle.comhttp://ltcmentalhealth.forumcircle.com– Long-Term Care Mental Health ForumLong-Term Care Mental Health Forum

• www.unmc.edu/cce/gec_moduleswww.unmc.edu/cce/gec_modules– 40 online modules for free continuing 40 online modules for free continuing

education credit (for most disciplines)education credit (for most disciplines)

To Obtain Your Nursing To Obtain Your Nursing Continuing Education Continuing Education

CreditCredit• After the program, go to After the program, go to

www.unmc.edu/nursing/mkwww.unmc.edu/nursing/mk• If paying by credit card, you will be If paying by credit card, you will be

able to print your certificate onlineable to print your certificate online• If paying by check, download & print If paying by check, download & print

form and send with check via snail mailform and send with check via snail mail• All CNE credit questions should be All CNE credit questions should be

directed to Lisa Anzai at 402-559-6270 directed to Lisa Anzai at 402-559-6270 or at [email protected] at [email protected]

ObjectivesObjectives

• Discuss how to recognize a personality Discuss how to recognize a personality disorderdisorder

• Note the how the manifestations of Note the how the manifestations of personality disorders are effected by personality disorders are effected by agingaging

• Delineate current treatment strategiesDelineate current treatment strategies

The Difficult LadyThe Difficult Lady

• 75 year old white female moves in to the NH75 year old white female moves in to the NH– Living at home with daughter, granddaughterLiving at home with daughter, granddaughter

• Moved here by another childMoved here by another child• APS evaluation about financial abuseAPS evaluation about financial abuse• Long, convoluted personal and psychiatric historyLong, convoluted personal and psychiatric history

• Many medications, especially psychiatric Many medications, especially psychiatric and painand pain– Real disease exists, but…Real disease exists, but…

• ““Does she really need all this?”Does she really need all this?”

– Refuses medications, treatmentsRefuses medications, treatments• Commonly phones assigned providerCommonly phones assigned provider• Generates dissention among nursing staffGenerates dissention among nursing staff


• Makes accusations about workersMakes accusations about workers– Most unfounded or hard to verifyMost unfounded or hard to verify

• Family interferes with treatmentFamily interferes with treatment– To multiple specialists, appointmentsTo multiple specialists, appointments– Opinions coming out of the woodworkOpinions coming out of the woodwork

• Feel like you are in the middleFeel like you are in the middle

• Has hopes of returning home to ramshackle home Has hopes of returning home to ramshackle home – With chemically-dependent, unemployed daughter and With chemically-dependent, unemployed daughter and

granddaughter granddaughter – Denies any abuse going on thereDenies any abuse going on there

• Commonly agitates other residentsCommonly agitates other residents– Stories of mistreatmentStories of mistreatment– You know the state surveyors are going to interview herYou know the state surveyors are going to interview her

What is Personality?What is Personality?

• A totality of behavioral and A totality of behavioral and emotional traitsemotional traits– Formed by the end of childhoodFormed by the end of childhood– StableStable– PredictablePredictable– Characterize how a person carries out Characterize how a person carries out

day to day livingday to day living– What makes you…youWhat makes you…you

What is a Personality What is a Personality Disorder?Disorder?

• A pattern of enduring thoughts and A pattern of enduring thoughts and behaviorsbehaviors– Culturally deviantCulturally deviant– Often distort or misinterpret Often distort or misinterpret

informationinformation

• Display an unusual intensity or Display an unusual intensity or range of emotionrange of emotion– Poor interpersonal skillsPoor interpersonal skills– Trouble controlling impulsesTrouble controlling impulses

What is a Personality What is a Personality Disorder?Disorder?

• We display various aspects of our We display various aspects of our personalitypersonality– Pieces of a pie that vary in sizePieces of a pie that vary in size– Some more vain, some less vainSome more vain, some less vain

• Personality disorders are a distortionPersonality disorders are a distortion– Their entirety of personality is composed of Their entirety of personality is composed of

one trait or aspectone trait or aspect• Narcissistic, dependent, paranoid, e.g.Narcissistic, dependent, paranoid, e.g.

– Often, that trait alone cannot solve problems Often, that trait alone cannot solve problems or deal with stressor deal with stress• Leads to heightened anxiety, depression even Leads to heightened anxiety, depression even

psychosis in order to try and copepsychosis in order to try and cope

History History

• Usually chaotic livesUsually chaotic lives– Broken professional and personal Broken professional and personal

relationshipsrelationships– Interrupted schooling, multiple jobsInterrupted schooling, multiple jobs

• Live on the fringes of societyLive on the fringes of society– Jail, homeless, still with parents Jail, homeless, still with parents

• Reluctant to make changesReluctant to make changes– Lack flexibilityLack flexibility– Problem is with everyone elseProblem is with everyone else

Types of Personality Types of Personality DisordersDisorders

• Divided into clustersDivided into clusters– Odd and eccentricOdd and eccentric

• Schizoid, schizotypal, paranoidSchizoid, schizotypal, paranoid

– Dramatic and emotionalDramatic and emotional• Narcissistic, histrionic, antisocial, Narcissistic, histrionic, antisocial,

borderlineborderline

– Anxious and fearfulAnxious and fearful• Dependent, avoidant, OCPDDependent, avoidant, OCPD

Odd and EccentricOdd and Eccentric

• Paranoid Personality DisorderParanoid Personality Disorder– Long history of being suspicious in Long history of being suspicious in

generalgeneral• Hostile, angry, easily irritableHostile, angry, easily irritable

– Think everyone is trying to take Think everyone is trying to take advantage of themadvantage of them• Government, businesses, neighborsGovernment, businesses, neighbors

– See a conspiracy behind every turnSee a conspiracy behind every turn• Interesting views expressedInteresting views expressed

– Readily sue other peopleReadily sue other people

Schizoid Personality Schizoid Personality DisorderDisorder

• Socially withdrawnSocially withdrawn– Do not want interpersonal relationships Do not want interpersonal relationships

so they do not seek them outso they do not seek them out– Work history reveal jobs that require Work history reveal jobs that require

little human interactionlittle human interaction– Seen by others as eccentric, isolated, Seen by others as eccentric, isolated,

lonelylonely– Commonly present as hidden neighbors, Commonly present as hidden neighbors,

quiet co-workersquiet co-workers• Pass through life unnoticed Pass through life unnoticed

Schizotypal Personality Schizotypal Personality DisorderDisorder

• Strikingly odd, even to lay personsStrikingly odd, even to lay persons– ““Hey, look at that!”Hey, look at that!”

• Magical thinkersMagical thinkers– Tarot, astrology, UFOsTarot, astrology, UFOs

• Embrace fantasy worldsEmbrace fantasy worlds– Star Wars, Dungeons and DragonsStar Wars, Dungeons and Dragons

• Bizarre in dress, mannerisms, speechBizarre in dress, mannerisms, speech– Dress up like movie charactersDress up like movie characters

• Poor interpersonal skillsPoor interpersonal skills– ““Oh, grow up!”Oh, grow up!”

Dramatic and EmotionalDramatic and Emotional

• Antisocial Personality DisorderAntisocial Personality Disorder– Usually has history of repeated Usually has history of repeated

criminality or antisocial actionscriminality or antisocial actions• Con men, career criminals, addictsCon men, career criminals, addicts

– Never conforms to social normsNever conforms to social norms• Early history of violence or criminality Early history of violence or criminality

– Lack a conscienceLack a conscience• ““Do unto others before they do unto you”Do unto others before they do unto you”

– World is full of suckersWorld is full of suckers• Manipulative, even charming at first glanceManipulative, even charming at first glance


• Histrionic Personality DisorderHistrionic Personality Disorder– Colorful, dramatic, extremely extrovertedColorful, dramatic, extremely extroverted

• Excitable, but shallow emotionallyExcitable, but shallow emotionally

– Everyone must see themEveryone must see them• Like a peacockLike a peacock

– Cannot develop deep, long-lasting Cannot develop deep, long-lasting relationshipsrelationships• Everything is skin deepEverything is skin deep

– Respond only to external success measuresRespond only to external success measures• Money, physical beautyMoney, physical beauty• Spend time with plastic surgeonsSpend time with plastic surgeons


• Narcissistic Personality DisorderNarcissistic Personality Disorder– Heightened sense of self importanceHeightened sense of self importance

• For absolutely no reasonFor absolutely no reason

– Grandiose about abilities, attractivenessGrandiose about abilities, attractiveness• Feel unique in somewayFeel unique in someway• Need to associate with other high status Need to associate with other high status

personspersons

– UnempathicUnempathic• Step over anyone, anytimeStep over anyone, anytime


• Borderline Personality DisorderBorderline Personality Disorder– Unstable mood, relationships, emotionsUnstable mood, relationships, emotions

• Emotional chameleonEmotional chameleon– Feel empty insideFeel empty inside

• Cutters, multiple suicide attempts/gesturesCutters, multiple suicide attempts/gestures

– Engender chaosEngender chaos• Reduces their anxietyReduces their anxiety• Splitting Splitting

– Watch everyone around them get angryWatch everyone around them get angry

– Multiple marriages, adventure seekers, poor Multiple marriages, adventure seekers, poor decisions about people, situationsdecisions about people, situations

Anxious and FearfulAnxious and Fearful

• Avoidant Personality DisorderAvoidant Personality Disorder– Similar to social phobiaSimilar to social phobia– Lifestyle similar to schizoid personalityLifestyle similar to schizoid personality

• Extreme fear of rejectionExtreme fear of rejection– Desire human relationshipsDesire human relationships

• Opposite of NarcissismOpposite of Narcissism– Need guarantees of acceptanceNeed guarantees of acceptance

• Family only people trustedFamily only people trusted


• Dependent Personality DisorderDependent Personality Disorder– Get others to assume responsibilityGet others to assume responsibility

• ““My husband does all that…”My husband does all that…”

– Subordinate their own needs for those of Subordinate their own needs for those of othersothers• No one asks their opinionNo one asks their opinion• Lack self-confidenceLack self-confidence

– Intensely anxious about being aloneIntensely anxious about being alone• No personal reflectionNo personal reflection

– Exaggerated feelings of being helplessExaggerated feelings of being helpless• ““Just do it”Just do it”


• Obsessive Compulsive Personality Obsessive Compulsive Personality DisorderDisorder– Not OCDNot OCD

• Morally rigid, inflexibleMorally rigid, inflexible– No little white liesNo little white lies

• Seek orderlinessSeek orderliness– Stubborn, indecisiveStubborn, indecisive

• Worry intensely about making a mistakeWorry intensely about making a mistake– Nothing ever finishedNothing ever finished– Ten-year engagements, e.g.Ten-year engagements, e.g.

Personality and AgingPersonality and Aging

• Can be changed by changes in the brainCan be changed by changes in the brain– Newly introverted, avoidant due to a stroke, Newly introverted, avoidant due to a stroke,

e.g.e.g.– Disinhibited by frontal lobe symptoms of Disinhibited by frontal lobe symptoms of

dementiadementia

• Can be changed by changes in life Can be changed by changes in life situationssituations– More paranoid due to assaultMore paranoid due to assault– Increase in social withdrawal by moving into Increase in social withdrawal by moving into

community livingcommunity living

Personality Disorders Personality Disorders and Agingand Aging

• Not much known so farNot much known so far– Don’t see older people negativelyDon’t see older people negatively– Wears away, calms downWears away, calms down

• Prevalence rates varyPrevalence rates vary– 0.5% to 10% of older people0.5% to 10% of older people– Can vary depending on where they are Can vary depending on where they are

studiedstudied– Means we have more research to doMeans we have more research to do

DiagnosisDiagnosis

• Need a good life historyNeed a good life history– Come to see us because they cannot copeCome to see us because they cannot cope

• Commonly to treat anxiety, depression, Commonly to treat anxiety, depression, psychosispsychosis

• Changes with aging create more to Changes with aging create more to cope withcope with– Continuum theoryContinuum theory

• Stress can move one along the continuumStress can move one along the continuum• Need life historyNeed life history

Clues to DiagnosisClues to Diagnosis

• Recurrent depressive episodesRecurrent depressive episodes– Driven by ongoing stressDriven by ongoing stress

• Poor compliancePoor compliance– Multiple breaks in treatmentMultiple breaks in treatment

• More difficulty with age associated stressMore difficulty with age associated stress– Little social supportLittle social support

• Chaotic livesChaotic lives– Many changes in jobs, relationships, responsibilitiesMany changes in jobs, relationships, responsibilities

• You feel relieved when they cannot meet with You feel relieved when they cannot meet with youyou

Problems in LTCProblems in LTC

• Odd and EccentricOdd and Eccentric– Become more and more socially isolatedBecome more and more socially isolated

• Highly anxious with roommateHighly anxious with roommate

– Others avoid themOthers avoid them• Too eccentric or constant suspiciousnessToo eccentric or constant suspiciousness

– Reject care by facility providersReject care by facility providers• Lack of trustLack of trust

– Suspicious of good willSuspicious of good will• ““Trying to lure me in…”Trying to lure me in…”

– Report perceived abuse to the stateReport perceived abuse to the state• Paranoia about costs, medicines, what staff does to Paranoia about costs, medicines, what staff does to

other residentsother residents


• Dramatic and EmotionalDramatic and Emotional– Take advantage of others, causes chaosTake advantage of others, causes chaos

• Peers relegated to servants, take money for “favors”Peers relegated to servants, take money for “favors”• Splitting caused among workers, family, providersSplitting caused among workers, family, providers

• Dramatic emotional displaysDramatic emotional displays– Disrupts existing peer relationshipsDisrupts existing peer relationships

• Anger, depression about lack of statusAnger, depression about lack of status– Not treated uniquelyNot treated uniquely

• NoncomplianceNoncompliance– No meds, refuses to eat or batheNo meds, refuses to eat or bathe


• Anxious and FearfulAnxious and Fearful– Overuse of medical and facility staffOveruse of medical and facility staff

• Want everything done for themWant everything done for them

– Inability to make decisions leads to delays, Inability to make decisions leads to delays, frustrationfrustration• Simple decisions, tooSimple decisions, too

– Rigidity with schedules leads to problems with busy Rigidity with schedules leads to problems with busy staffstaff• Refuses bath at 9:01Refuses bath at 9:01

– Fear of rejection leads to “nursing home depression”Fear of rejection leads to “nursing home depression”• Planted in their roomPlanted in their room• Attempts by facility to socialize increase anxiety and Attempts by facility to socialize increase anxiety and

depressed mooddepressed mood

Treatment Treatment

• InformalInformal– Difficult residents engender negative Difficult residents engender negative

thoughts by staff, providersthoughts by staff, providers• Use as a barometerUse as a barometer

– Avoid anger, confrontationAvoid anger, confrontation• Pulling away reinforces abandonment fearsPulling away reinforces abandonment fears

– Will engage in more behavior to stay attachedWill engage in more behavior to stay attached– Regular scheduled meetings with trusted staffRegular scheduled meetings with trusted staff

• Social services directorSocial services director

• Behavioral modification planBehavioral modification plan– Reward absence of disruptive behaviorsReward absence of disruptive behaviors

Treatment Treatment

• Informal Informal – Consistency is the keyConsistency is the key

• Everyone needs to be on the same pageEveryone needs to be on the same page

– Care plans need to be known by all Care plans need to be known by all caregiverscaregivers• Especially CNAsEspecially CNAs

– Emotionally limited in responseEmotionally limited in response• Calm, firm approach the bestCalm, firm approach the best• Know where to draw lines in the sandKnow where to draw lines in the sand

– Good nurse, bad nurseGood nurse, bad nurse

TreatmentTreatment

• The main treatment is psychotherapyThe main treatment is psychotherapy– However psychotherapy does not work unless However psychotherapy does not work unless

you want to be thereyou want to be there– Personality disorders see nothing wrongPersonality disorders see nothing wrong

• Aging poses problemsAging poses problems– CognitionCognition– Physical healthPhysical health– Sensory problemsSensory problems– Therapists without geriatric experienceTherapists without geriatric experience– Therapists do not visit LTCTherapists do not visit LTC

Treatment Treatment

• Personality disorders commonly Personality disorders commonly develop other psychiatric symptomsdevelop other psychiatric symptoms– MoodMood– AnxietyAnxiety– PsychosisPsychosis

• Treat with appropriate medical Treat with appropriate medical treatmenttreatment– MedicationsMedications– ECTECT


• DiagnosisDiagnosis– Borderline personality disorderBorderline personality disorder

• Treatment planTreatment plan– StructureStructure– Behavioral treatment planBehavioral treatment plan– Appropriate medication managementAppropriate medication management– Anxiety logAnxiety log– Appointed one formal decision makerAppointed one formal decision maker– Refused psychotherapyRefused psychotherapy

Personality Disorders in Personality Disorders in LTCLTC

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