PERSONALITY DISORDERS IN THE ELDERLY

1. PERSONALITY DISORDERS IN THE ELDERLY OR………..”WORKING IN A SALT MINE IN SIBERIA HAS TO BE EASIER THAN THIS”, OR ……..“HOW DOES ONE BECOME A MONK IN THE HIMALAYAS”

2. WHAT IS “PERSONALITY”? • Personality refers to a distinctive set of traits, behavior styles, and patterns that make up our character or individuality. How we perceive the world, our attitudes, thoughts and feelings are all part of our personality. People with healthy personalities are able to cope with normal stresses and have no trouble forming relationships with family, friends, and co-workers.

3. WHAT IS A PERSONALITY DISORDER? • Those who struggle with a personality disorder have great difficulty dealing with other people. They tend to be inflexible, rigid, and unable to respond to the changes and demands of life. Although they feel that their behavior patterns are “normal” or “right”, people with personality disorders tend to have a narrow view of the world and find it difficult to participate in social activities.

4. RECOGNIZING A PERSONALITY DISORDER • Must fulfill several criteria • A deeply ingrained, inflexible pattern of relating, perceiving, and thinking serious enough to cause distress or impaired functioning is a personality disorder • Usually recognizable by adolescence or earlier, continue throughout adulthood, and become less obvious throughout middle age DSM-IV

5. PERSONALITY DISORDER CRITERIA AN ENDURING PATTERN OF INNER EXPERIENCE AND BEHAVIOR THAT DEVIATES MARKEDLY FROM THE EXPECTATIONS OF THE INDIVIDUALS CULTURE. THIS PATTERN IS MANIFESTED IN TWO OR MORE OF THE FOLLOWING AREAS:

6. PERSONALITY DISORDER/CRITERIA • COGNITION, I.E., WAYS OF PERCEIVING AND INTERPRETING SELF, OTHER PEOPLE, AND EVENTS • AFFECTIVITY, THEIR RANGE, INTENSITY, LABILITY, AND APPROPRIATENESS OF EMOTIONAL RESPONSE • INTERPERSONAL FUNCTIONING • IMPULSE CONTROL DSM-IV

7. CRITERIA/ CONT’D • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning • Not better accounted for as a manifestation or consequence of another mental disorder • Not due to direct physiological effects of a substance or a general medical condition • Is stable and long duration, onset can be traced back at least to adolescence or early adulthood DSM-IV

8. CAUSES OF PERSONALITY DISORDERS • Some experts believe that events occurring in early childhood exert a powerful influence upon behavior later in life. • Others indicate that people are genetically predisposed to personality disorders • Environmental facts may cause a person who is already genetically vulnerable to develop a personality disorder

9. TYPES OF PERSONALITY DISORDERS/FALL INTO THREE DIFFERENT CATEGORIES OR CLUSTERS • CLUSTSER A: ODD OR ECCENTRIC BEHAVIOR • CLUSTER B: DRAMATIC, EMOTIONAL OR ERRATIC BEHAVIOR • CLUSTER C: ANXIOUS FEARFUL BEHAVIOR

10. CLUSTER A • SCHIZOID PERSONALITY DISORDER • Neither desires nor enjoys close relationships, including being a part of a family • Almost always chooses solitary activities • Has little, if any, interest in having sexual experiences with another person • Takes pleasure in few, if any, activities • Lacks close friends or confidants other than first-degree relatives DSM-IV

11. SCHIZOID CONT’D • Shows emotional coldness, detachment, or flattened affectivity • Appears indifferent to the praise or criticism of others • Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder, not due to the direct physiological effects of a general medical condition DSM-IV DSM-IV

12. PARANOID DISORDER (PERVASIVE DISTRUST AND SUSPICIOUSNESS OF OTHERS SUCH THAT THEIR MOTIVES ARE INTERPRETED AS MALEVOLENT, BEGINNING BY EARLY ADULTHOOD ) • Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her • Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends and associates • Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack DSM-IV PARANOID PERSONALIT

13. PARANOID, CONT’D • Reluctant to confide in others because of unwarranted fear that information will be used maliciously against him/her • Reads hidden demeaning or threatening meanings into benign remarks or events • Persistently bears grudges, i.e., is unforgiving of insult, injuries, or slights • Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner • DSM-IV

14. Schizotypal Personality Disorder (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 • Odd beliefs or magical thinking that influences behavior is inconsistent with sub cultural norms (e.g., superstiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations) • Ideas of reference (including delusions of reference) • Unusual perceptual experiences, including bodily illusions DSM-IV At

15. SCHIZOTYPAL , CONT’D • Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self • Odd thinking and speech • Suspiciousness or paranoid ideation • Inappropriate or constricted affect • Behavior or appearance that is odd, eccentric, or peculiar • DSM-IV

16. CLUSTER B/ DRAMATIC, EMOTIONAL OR ERRATIC BEHAVIORANTISOCIAL PERSONALITY • Failure to reform to conform to social norms with respect to lawful behaviors, repeatedly performing acts that are grounds for arrest • Deceitfulness, repeated lying, use of aliases, conning others for personal profit or pleasure • At least 18 years of age DSM-IV

17. ANTISOCIAL, CONT’D • Impulsivity, failure to plan ahead • Irritability or aggressiveness, repeated physical fights or assaults • Reckless disregard for safety of self or others • Consistent irresponsibility, repeated failure to sustain consistent work or honor financial obligations • Lack of remorse DSM-IV

18. Borderline Personality Disorder • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, marked impulsivity beginning in early adulthood, must have 5 of the following: • Frantic efforts to avoid real or imagined abandonment • Pattern of unstable and intense interpersonal relationships characterized by idealization and devaluation • Identity disturbance, markedly and persistently unstable image of self or sense of self DSM-IV

20. BORDERLINE, CONT’D • Impulsivity in at least two areas that are self-damaging (e.g. spending, sex, substance abuse, binge eating, reckless driving • Recurrent suicidal behavior, gesturing, threats, self-injury • Affective instability, marked reactivity of mood, intense dysphoria, anxiety, irritability • Chronic feelings of emptiness • Inappropriate intense anger, or difficulty controlling anger, physical fights, constant anger • Transient , stress-related paranoid ideation or severe dissociative symptoms DSM-IV

21. HISTRIONIC PERSONALITY(5 OR MORE OF THE FOLLOWING) • Uncomfortable when not center of attention • Interactive with others sexually inappropriate, seductive • Displays rapidly shifting emotion, shallow • Consistently uses physical appearance to draw attention to self • Considers relationships to be more intimate than they really are • Suggestible, easily influenced by others or circumstances • Self-dramatization, theatricality, and exaggerated expression of emotion • Style of speech that is excessively impressionistic and lacking in detail DSM-IV

22. Pervasive pattern of grandiosity, need for admiration, lack of empathy Preoccupied with fantasies of power, brilliance, beauty, or ideal love Believes he/she special and unique and can only be understood by, or should associate with high-status people Requires excessive admiration Interpersonally exploitative, i.e. takes advantage of others to achieve his/her own ends Lacks empathy is unwilling to recognize or identify with the feelings and needs of others Is often envious of others or believes that others are envious of him/her Shows arrogant, haughty behaviors or attitudes Sense of entitlement DSM-IV Narcissistic Personality Disorder

23. CLUSTER C DISORDERS/Avoidant Personality Disorder • PERVASIVE PATTERN OF SOCIAL INHIBITION, FEELINGS OF INADEQUACY, AND HYPERSENSITIVITY TO NEGATIVE EVALUATION • Views self as socially inept, personally unappealing, or inferior to others • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection DSM-IV

24. AVOIDANT/CONT’D • Shows restraint within intimate relationships because of fear of being shamed or ridiculed • Preoccupation with being criticized or rejected in social situations • Inhibited in new relationships due to fear of inadequacy • Views self as socially inept, inferior, personally unappealing • Unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing DSM-IV

25. DEPENDENT PERSONALITY • PERVASIVE NEED TO BE TAKEN CARE OF, LEADING TO SUBMISSIVE AND CLINGING BEHAVIORS , FEAR OF SEPARATION, BEGINNING EARLY ADULTHOOD • Difficulty making everyday decisions without an excessive amount of assurance and advise from others • Difficulty expressing disagreement with others due to fear of loss of support or approval • Difficulty initiating projects or doing things on his/her own because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy DSM-IV

26. DEPENDENT, CONT’D • Excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant • Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for him/her self • Urgently seeks another relationship as a source of care and support when a close relationship ends • Is unrealistically preoccupied with fears of being left to take care of him/her self • Needs others to assume responsibility for most areas of his/her life DSM-IV

27. OBSESSIVE-COMPULSIVE DISORDER • A PERVASIVE PATTERN OF PREOCCUPATION WITH ORDERLINESS, PERFECTIONISM, AND MENTAL AND INTERPERSONAL CONTROL, AT THE EXPENSE OF FLEXIBILITY, OPENNESS, AND EFFICIENCY, BEGINNING EARLY ADULTHOOD AND BY FOUR OF FOLLOWING: • Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost • Perfectionism that interferes with task completion (unable to complete because of overly strict standards) • Rigidity and stubbornness DSM-IV

28. OCD DISORDER, CONT’D • Excessively devoted to work and productivity to the exclusion of leisure activities and friendships • Over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values ( not accounted for by cultural or religious identification) • Unable to discard worn-out /worthless objects even when they have no sentimental value • Reluctant to delegate tasks or to work with others unless they submit to exactly his/her way of doing things • Adopts a miserly spending style toward both self and others, money is viewed as something to be hoarded for future catastrophes DSM-IV

29. STAFF BEHAVIORS • BACKBITING • TEAM “SPLITTING” • “I CAN DO IT BETTER THAN YOU” • NEGATIVITY REGARDING PATIENT • INCREASED GOSSIPING, MISTRUST • ENERGY SPENT OFF HOURS TALKING ABOUT “YA-DA-YA-DA-YA-DA” • AWFULIZING, “AIN’T IT AWFUL” • TALKING AT DESK ,PT’S OVERHEARING

30. SO WHAT TO DO?????????? • SELF-AWARENESS (OBSERVE BODY REACTION, FEELING IN “GUT” • TIME OUT, DISTANCE • FREQUENT STAFF MEETINGS (INFORMAL, BRING FOOD, HUMOR) • SELF-CARE, TEAM-CARE • PRACTICE “V”S, VALIDATE, VENT, VOLUNTEER, VIGILANCE

31. WHAT TO DO, CONT’D • ASK FOR HELP!! • EMPATHY WHEN YOU FEEL LIKE, EXPLETIVE, EXPLETIVE, EXPLETIVE!!!!!!!!!!!!!! • NON-JUDGEMENTAL APPROACH, USE BUDDY SYSTEM • VALIDATE YOURSELF AND RESIDENT, PATIENT, FAMILY

32. WHAT TO DO CONT’D • SET LIMITS • AS OFTEN AS POSSIBLE, USE SAME PRIMARY • CHECK IT OUT • TELL CLIENT/RESIDENT WHEN YOU WILL RETURN • TIME OUT FOR SELF!

33. DON’T SHOULD ON YOURSELF!!!!

34. HOW DO YOU EAT AN ELEPHANT,ONE BITE AT A TIME!