Personality Disorders in
Long Term Care
Thomas Magnuson, M.D.
Department of Psychiatry
Division of Geriatric Psychiatry
– Information on:
• Long-term Care Mental Health Series, 2-hour evening
conferences, Annual conferences, Geriatric
Minifellowship, Online Educational Modules
– Long-Term Care Mental Health Forum
– 40 online modules for free continuing education
credit (for most disciplines)
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Continuing Education Credit
• After the program, go to
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send with check via snail mail
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Lisa Anzai at 402-559-6270 or at
[email protected]
• Discuss how to recognize a personality disorder
• Note the how the manifestations of personality
disorders are effected by aging
• Delineate current treatment strategies
The Difficult Lady
• 75 year old white female moves in to the NH
– Living at home with daughter, granddaughter
• Moved here by another child
• APS evaluation about financial abuse
• Long, convoluted personal and psychiatric history
• Many medications, especially psychiatric and pain
– Real disease exists, but…
• “Does she really need all this?”
– Refuses medications, treatments
• Commonly phones assigned provider
• Generates dissention among nursing staff
The Difficult Lady
• Makes accusations about workers
– Most unfounded or hard to verify
• Family interferes with treatment
– To multiple specialists, appointments
– Opinions coming out of the woodwork
• Feel like you are in the middle
• Has hopes of returning home to ramshackle home
– With chemically-dependent, unemployed daughter and granddaughter
– Denies any abuse going on there
• Commonly agitates other residents
– Stories of mistreatment
– You know the state surveyors are going to interview her
What is Personality?
• A totality of behavioral and emotional traits
Formed by the end of childhood
Characterize how a person carries out day to day
– What makes you…you
What is a Personality Disorder?
• A pattern of enduring thoughts and behaviors
– Culturally deviant
– Often distort or misinterpret information
• Display an unusual intensity or range of emotion
– Poor interpersonal skills
– Trouble controlling impulses
What is a Personality Disorder?
• We display various aspects of our personality
– Pieces of a pie that vary in size
– Some more vain, some less vain
• Personality disorders are a distortion
– Their entirety of personality is composed of one trait or
• Narcissistic, dependent, paranoid, e.g.
– Often, that trait alone cannot solve problems or deal with
• Leads to heightened anxiety, depression even psychosis in order to try
and cope
• Usually chaotic lives
– Broken professional and personal relationships
– Interrupted schooling, multiple jobs
• Live on the fringes of society
– Jail, homeless, still with parents
• Reluctant to make changes
– Lack flexibility
– Problem is with everyone else
Types of Personality Disorders
• Divided into clusters
– Odd and eccentric
• Schizoid, schizotypal, paranoid
– Dramatic and emotional
• Narcissistic, histrionic, antisocial, borderline
– Anxious and fearful
• Dependent, avoidant, OCPD
Odd and Eccentric
• Paranoid Personality Disorder
– Long history of being suspicious in general
• Hostile, angry, easily irritable
– Think everyone is trying to take advantage of them
• Government, businesses, neighbors
– See a conspiracy behind every turn
• Interesting views expressed
– Readily sue other people
Schizoid Personality Disorder
• Socially withdrawn
– Do not want interpersonal relationships so they do
not seek them out
– Work history reveal jobs that require little human
– Seen by others as eccentric, isolated, lonely
– Commonly present as hidden neighbors, quiet coworkers
• Pass through life unnoticed
Schizotypal Personality Disorder
• Strikingly odd, even to lay persons
– “Hey, look at that!”
• Magical thinkers
– Tarot, astrology, UFOs
• Embrace fantasy worlds
– Star Wars, Dungeons and Dragons
• Bizarre in dress, mannerisms, speech
– Dress up like movie characters
• Poor interpersonal skills
– “Oh, grow up!”
Dramatic and Emotional
• Antisocial Personality Disorder
– Usually has history of repeated criminality or
antisocial actions
• Con men, career criminals, addicts
– Never conforms to social norms
• Early history of violence or criminality
– Lack a conscience
• “Do unto others before they do unto you”
– World is full of suckers
• Manipulative, even charming at first glance
Dramatic and Emotional
• Histrionic Personality Disorder
– Colorful, dramatic, extremely extroverted
• Excitable, but shallow emotionally
– Everyone must see them
• Like a peacock
– Cannot develop deep, long-lasting relationships
• Everything is skin deep
– Respond only to external success measures
• Money, physical beauty
• Spend time with plastic surgeons
Dramatic and Emotional
• Narcissistic Personality Disorder
– Heightened sense of self importance
• For absolutely no reason
– Grandiose about abilities, attractiveness
• Feel unique in someway
• Need to associate with other high status persons
– Unempathic
• Step over anyone, anytime
Dramatic and Emotional
• Borderline Personality Disorder
– Unstable mood, relationships, emotions
• Emotional chameleon
– Feel empty inside
• Cutters, multiple suicide attempts/gestures
– Engender chaos
• Reduces their anxiety
• Splitting
– Watch everyone around them get angry
– Multiple marriages, adventure seekers, poor decisions about
people, situations
Anxious and Fearful
• Avoidant Personality Disorder
– Similar to social phobia
– Lifestyle similar to schizoid personality
• Extreme fear of rejection
– Desire human relationships
• Opposite of Narcissism
– Need guarantees of acceptance
• Family only people trusted
Anxious and Fearful
• Dependent Personality Disorder
– Get others to assume responsibility
• “My husband does all that…”
– Subordinate their own needs for those of others
• No one asks their opinion
• Lack self-confidence
– Intensely anxious about being alone
• No personal reflection
– Exaggerated feelings of being helpless
• “Just do it”
Anxious and Fearful
• Obsessive Compulsive Personality Disorder
– Not OCD
• Morally rigid, inflexible
– No little white lies
• Seek orderliness
– Stubborn, indecisive
• Worry intensely about making a mistake
– Nothing ever finished
– Ten-year engagements, e.g.
Personality and Aging
• Can be changed by changes in the brain
– Newly introverted, avoidant due to a stroke, e.g.
– Disinhibited by frontal lobe symptoms of dementia
• Can be changed by changes in life situations
– More paranoid due to assault
– Increase in social withdrawal by moving into
community living
Personality Disorders and Aging
• Not much known so far
– Don’t see older people negatively
– Wears away, calms down
• Prevalence rates vary
– 0.5% to 10% of older people
– Can vary depending on where they are studied
– Means we have more research to do
• Need a good life history
– Come to see us because they cannot cope
• Commonly to treat anxiety, depression, psychosis
• Changes with aging create more to cope with
– Continuum theory
• Stress can move one along the continuum
• Need life history
Clues to Diagnosis
• Recurrent depressive episodes
– Driven by ongoing stress
• Poor compliance
– Multiple breaks in treatment
• More difficulty with age associated stress
– Little social support
• Chaotic lives
– Many changes in jobs, relationships, responsibilities
• You feel relieved when they cannot meet with you
Problems in LTC
• Odd and Eccentric
– Become more and more socially isolated
• Highly anxious with roommate
– Others avoid them
• Too eccentric or constant suspiciousness
– Reject care by facility providers
• Lack of trust
– Suspicious of good will
• “Trying to lure me in…”
– Report perceived abuse to the state
• Paranoia about costs, medicines, what staff does to other residents
Problems in LTC
• Dramatic and Emotional
– Take advantage of others, causes chaos
• Peers relegated to servants, take money for “favors”
• Splitting caused among workers, family, providers
• Dramatic emotional displays
– Disrupts existing peer relationships
• Anger, depression about lack of status
– Not treated uniquely
• Noncompliance
– No meds, refuses to eat or bathe
Problems in LTC
• Anxious and Fearful
– Overuse of medical and facility staff
• Want everything done for them
– Inability to make decisions leads to delays, frustration
• Simple decisions, too
– Rigidity with schedules leads to problems with busy staff
• Refuses bath at 9:01
– Fear of rejection leads to “nursing home depression”
• Planted in their room
• Attempts by facility to socialize increase anxiety and depressed mood
• Informal
– Difficult residents engender negative thoughts by
staff, providers
• Use as a barometer
– Avoid anger, confrontation
• Pulling away reinforces abandonment fears
– Will engage in more behavior to stay attached
– Regular scheduled meetings with trusted staff
• Social services director
• Behavioral modification plan
– Reward absence of disruptive behaviors
• Informal
– Consistency is the key
• Everyone needs to be on the same page
– Care plans need to be known by all caregivers
• Especially CNAs
– Emotionally limited in response
• Calm, firm approach the best
• Know where to draw lines in the sand
– Good nurse, bad nurse
• The main treatment is psychotherapy
– However psychotherapy does not work unless you want to be
– Personality disorders see nothing wrong
• Aging poses problems
Physical health
Sensory problems
Therapists without geriatric experience
Therapists do not visit LTC
• Personality disorders commonly develop other
psychiatric symptoms
– Mood
– Anxiety
– Psychosis
• Treat with appropriate medical treatment
– Medications
The Difficult Lady
• Diagnosis
– Borderline personality disorder
• Treatment plan
Behavioral treatment plan
Appropriate medication management
Anxiety log
Appointed one formal decision maker
Refused psychotherapy
Personality Disorders in LTC
• Questions?

Personality Disorders in Long Term Care