personality disorders in lt liflate life

Personality Disorders in Personality Disorders in L t LifL t LifLate LifeLate Life

KeriKeri--Leigh Cassidy, MD FRCPCLeigh Cassidy, MD FRCPCThanks to Dr. Joel SadavoyThanks to Dr. Joel SadavoyThanks to Dr. Joel SadavoyThanks to Dr. Joel Sadavoy

Personality DisordersPersonality DisordersPersonality DisordersPersonality Disorders

Defined as:Defined as:Defined as:Defined as:Pervasive, persistent pattern of Pervasive, persistent pattern of maladaptive interpersonalmaladaptive interpersonalmaladaptive interpersonal maladaptive interpersonal behavioursbehavioursAAcross multiple domains andcross multiple domains andAAcross multiple domains and cross multiple domains and consistent over timeconsistent over timeImpairing several domains ofImpairing several domains ofImpairing several domains of Impairing several domains of life(work, family, friendships)life(work, family, friendships)

Disorders of PersonalityDisorders of PersonalityDisorders of PersonalityDisorders of Personality

Cluster ACluster A‐‐ Odd or EccentricOdd or EccentricCluster ACluster A Odd or EccentricOdd or EccentricParanoid, Schizoid, SchizotypalParanoid, Schizoid, Schizotypal

Cl t BCl t B D ti E ti l E tiD ti E ti l E tiCluster BCluster B‐‐ Dramatic, Emotional ErraticDramatic, Emotional ErraticAntisocial, Borderline, Histrionic, Antisocial, Borderline, Histrionic, N i i tiN i i tiNarcissisticNarcissistic

Cluster CCluster C‐‐ Anxious, FearfulAnxious, FearfulAvoidant, Avoidant, DependantDependant, Obsessive , Obsessive CompulsiveCompulsive

Origin of PersonalityOrigin of PersonalityOrigin of PersonalityOrigin of Personality

Personality characteristics resultPersonality characteristics resultPersonality characteristics result Personality characteristics result from both from both

constitutional factorsconstitutional factors e g genetice g geneticconstitutional factorsconstitutional factors e.g. genetic e.g. genetic vulnerabilities/strengths, or vulnerabilities/strengths, or capacity to modulate affectcapacity to modulate affectcapacity to modulate affectcapacity to modulate affectlife experiencelife experience, especially in , especially in childhoodchildhood e.g. ineffective parentinge.g. ineffective parentingchildhoodchildhood e.g. ineffective parenting e.g. ineffective parenting or abandonmentor abandonment

Traits and PersonalityTraits and PersonalityTraits and PersonalityTraits and Personality

TraitsTraits are individual response patterns e.g. are individual response patterns e.g. aggressiveness if challenged or insultedaggressiveness if challenged or insultedaggressiveness if challenged or insulted, aggressiveness if challenged or insulted, shyness, or overshyness, or over‐‐sensitivity to criticismsensitivity to criticism

T it b ith l th l i lT it b ith l th l i lTraits may be either normal or pathologicalTraits may be either normal or pathological

personalitypersonality is made up of the sum total of is made up of the sum total of personality traitspersonality traitspersonality traitspersonality traits

Five Factor Model of PersonalityFive Factor Model of PersonalityFive Factor Model of PersonalityFive Factor Model of Personality

OpennessOpenness –– (inventive/curious vs consistent/cautious)(inventive/curious vs consistent/cautious)OpennessOpenness (inventive/curious vs. consistent/cautious). (inventive/curious vs. consistent/cautious).

ConscientiousnessConscientiousness –– (efficient/organized vs. easy(efficient/organized vs. easy‐‐going/careless)going/careless)going/careless). going/careless).

ExtraversionExtraversion –– (outgoing/energetic vs. (outgoing/energetic vs. solitary/reserved)solitary/reserved)solitary/reserved). solitary/reserved).

AgreeablenessAgreeableness –– (friendly/compassionate vs. (friendly/compassionate vs. cold/unkind).cold/unkind).cold/unkind). cold/unkind).

NeuroticismNeuroticism –– (sensitive/nervous vs. secure/confident). (sensitive/nervous vs. secure/confident).

J SadavoyJ Sadavoy 66

Personality Change in Old AgePersonality Change in Old AgePersonality Change in Old AgePersonality Change in Old Age

Longit dinal St dies in Normal Pop lations ha eLongit dinal St dies in Normal Pop lations ha eLongitudinal Studies in Normal Populations have Longitudinal Studies in Normal Populations have found that found that Traits Remain relatively StableTraits Remain relatively Stable (Tackett et (Tackett et al 2009)al 2009)

Neuroticism, Extraversion and Openness decrease Neuroticism, Extraversion and Openness decrease slightly agreeableness, & Conscientiousness increase slightly agreeableness, & Conscientiousness increase slightlyslightly (R b t t(R b t t l 2006)l 2006)slightly slightly (Roberts et (Roberts et al., 2006)al., 2006). . Maturation of traitsMaturation of traits (Vaillant 1997)(Vaillant 1997)

dysfunctional traits continue with aging but may havedysfunctional traits continue with aging but may havedysfunctional traits continue with aging but may have dysfunctional traits continue with aging but may have less detrimental effectsless detrimental effects (Valliant and Milofsky, 1980)(Valliant and Milofsky, 1980)

While symptom expression changes and often While symptom expression changes and often becomes less dramatic with age Disturbances in becomes less dramatic with age Disturbances in interpersonal relationships, affect regulation, and interpersonal relationships, affect regulation, and

selfself‐‐identity remain stable with agingidentity remain stable with aging (Stevenson 2003)(Stevenson 2003)

e.g. reduced action oriented behaviours e.g. reduced action oriented behaviours ((SadavoySadavoy1996 1996 FogelFogel; Bas Van Alphen Pers. ; Bas Van Alphen Pers. CommComm))

Neuroticism: negative personality Neuroticism: negative personality traitstraits

An enduring tendency to experience negative An enduring tendency to experience negative emotional states Respond poorly to stressemotional states Respond poorly to stressemotional states. Respond poorly to stress, emotional states. Respond poorly to stress, prone to anxiety, anger , guilt , hopelessness, prone to anxiety, anger , guilt , hopelessness, fear & depressionfear & depressionfear & depression .fear & depression .

May decline somewhat with agingMay decline somewhat with aging

J Sadavoy Dalhousie J Sadavoy Dalhousie University 2011University 2011 1010

Neuroticism associated with:Neuroticism associated with:Neuroticism associated with: Neuroticism associated with:

poor health behaviours that may contribute topoor health behaviours that may contribute topoor health behaviours that may contribute to poor health behaviours that may contribute to earlier mortality earlier mortality (Friedman, 2000).(Friedman, 2000).

lower effectiveness in managinglower effectiveness in managing stressstress andandlower effectiveness in managing lower effectiveness in managing stressstress and and higher levels of higher levels of negative emotions negative emotions (Bolger et al, (Bolger et al, 1991; Larsen1991; Larsen et al, 1991; Mroczek et al, 2004; Suls,et al, 1991; Mroczek et al, 2004; Suls, et al 1998; Watson etet al 1998; Watson et1991; Larsen 1991; Larsen et al, 1991; Mroczek et al, 2004; Suls, et al, 1991; Mroczek et al, 2004; Suls, et al 1998; Watson et et al 1998; Watson et

al, 1994). al, 1994). Both are linked to poor physical Both are linked to poor physical outcomes and mortality outcomes and mortality ((KiecoltKiecolt‐‐Glaser, et alGlaser, et al, 2002;Wilson, , 2002;Wilson, yy ,, , ; ,, ; ,et al, 2003). et al, 2003).

Protective Trait Factors in Depression Protective Trait Factors in Depression pp

Positive traits & emotions are bothPositive traits & emotions are bothPositive traits & emotions are both Positive traits & emotions are both emotionally and physiologically protectiveemotionally and physiologically protective

positive reappraisalpositive reappraisal (Folkman et al 2000)(Folkman et al 2000)positive reappraisalpositive reappraisal (Folkman et al 2000)(Folkman et al 2000)

findingfinding meaningmeaning (Taylor 1983)(Taylor 1983)

positive illusions of selfpositive illusions of self (T l t l 2000 G t l 2004)(T l t l 2000 G t l 2004)positive illusions of self positive illusions of self (Taylor et al 2000; Gana et al 2004)(Taylor et al 2000; Gana et al 2004)

situational optimismsituational optimism (Scheier et al 1992).(Scheier et al 1992).

1212J Sadavoy Dalhousie J Sadavoy Dalhousie University 2011University 2011

Lack Of Resilience And Negative Lack Of Resilience And Negative Personality Features Are ImportantPersonality Features Are ImportantPersonality Features Are Important Personality Features Are Important

Factors Leading to Failure Of Factors Leading to Failure Of AdaptationAdaptation

A common outcome is the emergence of A common outcome is the emergence of dysphoric subsyndromal emotional statesdysphoric subsyndromal emotional statesdysphoric subsyndromal emotional statesdysphoric subsyndromal emotional states


Area(s) of psychologicalvulnerability

Stress

Defenses break Symptoms downSymptoms

An Example of Development and An Example of Development and Psychological FactorsPsychological Factors

Those who have strong internal stores of selfThose who have strong internal stores of selfThose who have strong internal stores of self Those who have strong internal stores of self worth and selfworth and self‐‐calming abilities respond to calming abilities respond to aging quite differently than others whoaging quite differently than others whoaging quite differently than others who aging quite differently than others who require constant activity and feeling of require constant activity and feeling of achievement to maintain their sense ofachievement to maintain their sense ofachievement to maintain their sense of achievement to maintain their sense of personal approval and hence self esteem. personal approval and hence self esteem. (paraphrase (paraphrase

of H Muslim)of H Muslim)

Impact of adult life experience on Impact of adult life experience on late life dynamics late life dynamics

Adult relationships may sustain defences eg aAdult relationships may sustain defences eg aAdult relationships may sustain defences eg a Adult relationships may sustain defences eg a spousal in acting as a self object by spousal in acting as a self object by therapeutically containing projections of antherapeutically containing projections of antherapeutically containing projections of an therapeutically containing projections of an immature (e.g. borderline )spouse (immature (e.g. borderline )spouse (GABBARD 2000GABBARD 2000 ) ) Death or loss of spouse leaves vulnerability toDeath or loss of spouse leaves vulnerability toDeath or loss of spouse leaves vulnerability to Death or loss of spouse leaves vulnerability to return of anxieties previously defended by return of anxieties previously defended by projective or idealization defensesprojective or idealization defensesprojective or idealization defenses . projective or idealization defenses .

neurotocismti tinegative emotions

Adverse life events

Institutionalization,Illness, Loss, grief

Failed adaptation Depressive symptoms(e.g. SSD)

Personality Traits and Health Personality Traits and Health O tO tOutcomes Outcomes

Positive personality traits improve health Positive personality traits improve health p y pp y poutcomes outcomes (Kiecolt(Kiecolt‐‐Glaser 2002; Shepperd et al 1996)Glaser 2002; Shepperd et al 1996)

Pessimism predicts physical illness and Pessimism predicts physical illness and p p yp p ymortality mortality (Maruta et al 2000)(Maruta et al 2000)


Common AgeCommon Age‐‐Related Related h ll /h ll /Challenges/StressesChallenges/Stresses

•• Physical change, chronic Physical change, chronic illill

•• Loss of control, influence, Loss of control, influence, it lit l d hi dit lit l d hi dillnessillness

•• Loss/grief/bereavementLoss/grief/bereavement--actual, anticipated actual, anticipated

vitality, leadership and vitality, leadership and authorityauthority

•• Economic lossesEconomic losses•• Cognitive declineCognitive decline•• RolesRoles-- e.g. retirement, e.g. retirement,

parenting, spousalparenting, spousal

•• Displacement by youthDisplacement by youth•• Sexual Sexual

decline/attractivenessdecline/attractiveness•• Productivity/creativityProductivity/creativity•• AbandonmentAbandonment--

institutionalizationinstitutionalization

•• Facing regrets Facing regrets •• Relinquishing fantasiesRelinquishing fantasies•• Facing foreshortenedFacing foreshortened

•• Forced dependencyForced dependency•• Societal devaluationSocietal devaluation--

shame, humiliationshame, humiliation

Facing foreshortened Facing foreshortened futurefuture

•• DeathDeathshame, humiliationshame, humiliation


Attachment and seniorsAttachment and seniors 11Attachment and seniors Attachment and seniors 11

Older adults who recalled low parental Older adults who recalled low parental responsiveness were more likely toresponsiveness were more likely toresponsiveness were more likely to responsiveness were more likely to experience high levels of anxiety and low self experience high levels of anxiety and low self esteem; especially in those who lack anesteem; especially in those who lack anesteem; especially in those who lack an esteem; especially in those who lack an affectionate partner. affectionate partner.

(A d d S (1993)(A d d S (1993)(Anderson and Stevens (1993),(Anderson and Stevens (1993),


Attachment and seniorsAttachment and seniors 22Attachment and seniorsAttachment and seniors 22

securely attached seniors : securely attached seniors : higher sociability higher sociability

id l h d iid l h d i hi h hhi h havoidantly attached seniors: avoidantly attached seniors: higher shyness, higher shyness, emotional lability, and intensity of emotion emotional lability, and intensity of emotion

i di dexpression, anger, and contempt scores; expression, anger, and contempt scores; higher inhibited emotion and emotional higher inhibited emotion and emotional dididistancedistance

(Magai (Magai et al 2004) et al 2004)


Personality Change in Old AgePersonality Change in Old AgePersonality Change in Old AgePersonality Change in Old Age

Longit dinal St dies in Normal Pop lations ha eLongit dinal St dies in Normal Pop lations ha eLongitudinal Studies in Normal Populations have Longitudinal Studies in Normal Populations have found that found that Traits Remain relatively StableTraits Remain relatively Stable (Tackett et (Tackett et al 2009)al 2009)

Neuroticism, Extraversion and Openness decrease Neuroticism, Extraversion and Openness decrease slightly agreeableness, & Conscientiousness increase slightly agreeableness, & Conscientiousness increase slightlyslightly (R b t t(R b t t l 2006)l 2006)slightly slightly (Roberts et (Roberts et al., 2006)al., 2006). . Maturation of traitsMaturation of traits (Vaillant 1997)(Vaillant 1997)

dysfunctional traits continue with aging but may havedysfunctional traits continue with aging but may havedysfunctional traits continue with aging but may have dysfunctional traits continue with aging but may have less detrimental effectsless detrimental effects (Valliant and Milofsky, 1980)(Valliant and Milofsky, 1980)

Adaptive Tasks and Specific Adaptive Tasks and Specific V l biliti i L t LifV l biliti i L t LifVulnerabilities in Late Life Vulnerabilities in Late Life

capacity tocapacity to mournmourn‐‐mourningmourning‐‐liberation;liberation;capacity to capacity to mournmourn mourningmourning liberation; liberation; conflicted inner relationships; impaired in PDconflicted inner relationships; impaired in PDdevelop and maintaindevelop and maintain mature relationshipsmature relationshipsdevelop and maintain develop and maintain mature relationships mature relationships (friendship)(friendship)‐‐ impaired attachmentimpaired attachmentaccept helpaccept help‐‐impaired capacity forimpaired capacity for trusttrust e.g.e.g.accept helpaccept help impaired capacity for impaired capacity for trust trust e.g. e.g. illness, LTCillness, LTCCope withCope with AlienationAlienation; maintain vital; maintain vitalCope with Cope with AlienationAlienation; maintain vital ; maintain vital involvement involvement ‐‐ impaired secure impaired secure selfself‐‐worthworth


Adaptive Tasks and Specific Adaptive Tasks and Specific V l biliti i L t Lif 2V l biliti i L t Lif 2Vulnerabilities in Late Life 2Vulnerabilities in Late Life 2

Relinquish position authority and statureRelinquish position authority and stature‐‐Relinquish position, authority and statureRelinquish position, authority and statureuncontrolled uncontrolled narcissistic needsnarcissistic needs

maintain hope &maintain hope & continuitycontinuity absentabsentmaintain hope & maintain hope & continuitycontinuity‐‐ absent absent internalized good relationshipsinternalized good relationships

M i iM i i lflf ffiffi i i d i i lfi i d i i lfMaintain Maintain selfself‐‐efficacyefficacy –– impaired positive self impaired positive self regardregard

control control affectaffect‐‐ constitutional impairmentsconstitutional impairments


Five Psychological Conflicts that Interfere Five Psychological Conflicts that Interfere with Adaptation to Stressful Challenges inwith Adaptation to Stressful Challenges inwith Adaptation to Stressful Challenges in with Adaptation to Stressful Challenges in

Old AgeOld Age

Oversensitivity to Oversensitivity to narcissistic narcissistic assault assault (Kohut)(Kohut)

i f fi f f b db dExcessive fear of Excessive fear of abandonment abandonment (Winnicott)(Winnicott)

Conflicts over, Conflicts over, intimacy and trust intimacy and trust (Fairburn)(Fairburn)targets

Intense Intense attachment/dependency attachment/dependency needs needs (separation and autonomy) (separation and autonomy) (Mahler)(Mahler)

Overly intense Overly intense emotional reactivity emotional reactivity (affect regulation) (affect regulation) (Kernberg)(Kernberg)

PersonalityVulnerability

Stress Interacts with PsychologicalStress Interacts with Psychological Conflict Conflict to Produce Symptomsto Produce Symptomsto Produce Symptomsto Produce Symptoms

Stress Developmental SymptomsStress DevelopmentalConflict

y p

Institutionalization Intimacy/Trust Anger/with-y gdrawal/panic

Bereavement Abandonment Depression/ pAberrant Grief

Illness/infirmity Dependency Clinging/helpless/rejecting

Relinquish roles Narcissistic Demean/mistrustPhysical change Narcissistic Shame/withdraw

Cognitive loss Affect control Fear/blaming

Personality change: Age or Illness?Personality change: Age or Illness?Personality change: Age or Illness?Personality change: Age or Illness?

personality remains pretty stable into oldpersonality remains pretty stable into oldpersonality remains pretty stable into old personality remains pretty stable into old age so changes need to be investigatedage so changes need to be investigatedbut caregivers often interpret personalitybut caregivers often interpret personalitybut caregivers often interpret personality but caregivers often interpret personality change as a sign of expected normal change as a sign of expected normal personality change in old agepersonality change in old age what dowhat dopersonality change in old agepersonality change in old age-- what do what do you expect after all? you expect after all?

Definition of DementiaDefinition of DementiaDefinition of DementiaDefinition of Dementia

Multiple Cognitive deficits (particularlyMultiple Cognitive deficits (particularlyMultiple Cognitive deficits (particularly Multiple Cognitive deficits (particularly memory)memory)Caused by general medical conditionsCaused by general medical conditionsCaused by general medical conditions Caused by general medical conditions (e.g. HIV, NPH, Vit defic), substance (e.g. HIV, NPH, Vit defic), substance abuse (e g alcohol) or degenerative brainabuse (e g alcohol) or degenerative brainabuse (e.g. alcohol) or degenerative brain abuse (e.g. alcohol) or degenerative brain disease (E.g. VAD, AD) disease (E.g. VAD, AD) S h t d i lS h t d i lSevere enough to produce social or Severe enough to produce social or occupational impairment occupational impairment

Personality and DementiaPersonality and DementiaPersonality and DementiaPersonality and Dementia

2 lines of inquiry 2 lines of inquiry how does dementia change personalityhow does dementia change personalityhow does dementia change personality how does dementia change personality how does personality affect the expression of how does personality affect the expression of dementiadementia

about the first we have some data but about about the first we have some data but about the second we have less knowledge and the second we have less knowledge and understanding.understanding.

Dementia looks like personality Dementia looks like personality hhchangechange

d ti i ft t i d hd ti i ft t i d hdementia is often not recognized as such dementia is often not recognized as such by family and doctorsby family and doctors-- changes in changes in b h i ft i i t t d i lb h i ft i i t t d i lbehavior are often misinterpreted simply behavior are often misinterpreted simply as personality alterations. as personality alterations.

Most common behavioural change Most common behavioural change i d ii d iin dementiain dementia

Disengagement and increased passivity, Disengagement and increased passivity, i l di l f i t t i h bbi di l di l f i t t i h bbi dincluding loss of interest in hobbies and including loss of interest in hobbies and overall loss of spontaneity overall loss of spontaneity (Petry et al J Geriatr Psychiatry (Petry et al J Geriatr Psychiatry

N l 1989)N l 1989)Neurol 1989).Neurol 1989).

early increase in neuroticism with reduced early increase in neuroticism with reduced conscientiousness and extroversion someconscientiousness and extroversion someconscientiousness and extroversion, some conscientiousness and extroversion, some (but less) loss of agreeableness and (but less) loss of agreeableness and opennessopenness (McCrae & Costa 1990, Welleford et al 1995,(McCrae & Costa 1990, Welleford et al 1995,openness openness (McCrae & Costa 1990, Welleford et al 1995, (McCrae & Costa 1990, Welleford et al 1995,

Jacomb 1996)Jacomb 1996)

Neuropsychiatric symptoms in mild Neuropsychiatric symptoms in mild cognitive impairment (cognitive impairment (cognitive impairment (cognitive impairment (Geda et al, IPA Chicago Geda et al, IPA Chicago

2003) 2003)

compared MCI AD and normal subjectscompared MCI AD and normal subjectscompared MCI, AD and normal subjects compared MCI, AD and normal subjects using the NPI (neuropsychiatric inventory) using the NPI (neuropsychiatric inventory) clinical profile of MCI lies somewhereclinical profile of MCI lies somewhereclinical profile of MCI lies somewhere clinical profile of MCI lies somewhere between normals and AD patients.between normals and AD patients.i i li t li i l t fi i li t li i l t fi.e. even in earliest preclinical stages of i.e. even in earliest preclinical stages of dementia there are measurable changes dementia there are measurable changes th t lt lit f ti llth t lt lit f ti llthat may alter personality function as well that may alter personality function as well as cognitive functionas cognitive function

FTD and Major depressionFTD and Major depression(Thompson et al Int J Neuropsychol Soc 2004: 10;753(Thompson et al Int J Neuropsychol Soc 2004: 10;753--771)771)

MetaanalysisMetaanalysisyyStudies of cognitive change with matched controls Studies of cognitive change with matched controls ;between mild/moderate FTD and depressed patients: ;between mild/moderate FTD and depressed patients: N=312N=312N 312 N 312 Moderate FTDModerate FTD-- more impaired than depressionmore impaired than depression-- esp langesp langMild FTD (MMSE 28) similar to depression except Mild FTD (MMSE 28) similar to depression except

ti d ti f ti i ifi tlti d ti f ti i ifi tlsemantic mem and executive functions significantly semantic mem and executive functions significantly worseworseMagnitude of impairment in depression consistent across Magnitude of impairment in depression consistent across ggdomains (and no specific memory and exec function domains (and no specific memory and exec function deficits) while FTD showed greater deficits in some deficits) while FTD showed greater deficits in some domains than others.domains than others.

Why do families seek memory Why do families seek memory li i f l?li i f l?clinic referral? clinic referral? (Streams et al. Int J Geriat Psych 2003)(Streams et al. Int J Geriat Psych 2003)

almost half the caregivers reported nonalmost half the caregivers reported non--almost half the caregivers reported nonalmost half the caregivers reported noncognitive symptoms or a combination of cognitive symptoms or a combination of cognitive and noncognitive and non--cognitive symptoms as the cognitive symptoms as the triggertriggeralmost 40% specified at least one almost 40% specified at least one ““personality or personality or behavioural change as the triggerbehavioural change as the triggermost common were depressive symptoms, most common were depressive symptoms, i l di l d ““ i d bl l k f i i i ii d bl l k f i i i iviolence and violence and ““attitude problems, lack of initiative, attitude problems, lack of initiative,

paranoia and delusions, decreased cleanliness. paranoia and delusions, decreased cleanliness.

In other WordsIn other WordsIn other WordsIn other Words

Personality change in old age shouldPersonality change in old age shouldPersonality change in old age should Personality change in old age should trigger a suspicion of the beginning of trigger a suspicion of the beginning of dementiadementiadementiadementia

Past and PresentPast and PresentPast and PresentPast and Present

Dementia erodes memory and time senseDementia erodes memory and time senseDementia erodes memory and time senseDementia erodes memory and time senseIncreasing difficulty in differentiating what Increasing difficulty in differentiating what is now and what is thenis now and what is thenis now and what is thenis now and what is thenLongLong--past memories take on immediacy past memories take on immediacy and powerand powerand power and power Interpretation of current reality may be Interpretation of current reality may be contaminated by early experiences andcontaminated by early experiences andcontaminated by early experiences and contaminated by early experiences and the emotions that were associated with the emotions that were associated with themthem

Personality features change based Personality features change based B i i ff dB i i ff don Brain region affectedon Brain region affected

Dementia affects different parts of theDementia affects different parts of theDementia affects different parts of the Dementia affects different parts of the brainbrainThe part of the brain that is affected by theThe part of the brain that is affected by theThe part of the brain that is affected by the The part of the brain that is affected by the disease and the way these parts of the disease and the way these parts of the brain interact with one another determinesbrain interact with one another determinesbrain interact with one another determines brain interact with one another determines the behavioural and personality changes .the behavioural and personality changes .

Frontal lobesFrontal lobesFrontal lobesFrontal lobesdorsolateral regiondorsolateral region orbitomedial regionorbitomedial regionggRegulatesRegulates attention, attention,

spatial orientation, spatial orientation, ti l lti l l

ggregulatesregulates acquisition and acquisition and

storage of emotional storage of emotional i ti i l dii ti i l diemotional arousal; emotional arousal;

lesionlesion produces apathy, produces apathy, dulled affect lack ofdulled affect lack of

associations including associations including social restraintssocial restraints

lesionlesion producesproducesdulled affect lack of dulled affect lack of spontaneityspontaneity

lesionlesion produces produces disinhibition of disinhibition of behavior emotional behavior emotional lability and indifferencelability and indifferencelability and indifference lability and indifference to social decorum;to social decorum;

Temporal lobesTemporal lobesTemporal lobesTemporal lobes

Control memory function and affectiveControl memory function and affectiveControl memory function and affective Control memory function and affective tone tone LeftLeft-- verbal memoryverbal memoryLeftLeft verbal memoryverbal memoryRightRight-- visual memory visual memory LesionsLesionsLesions Lesions

intellectual changeintellectual changePersonality changesPersonality changesPersonality changesPersonality changesoccasionally schizophrenic like symptoms occasionally schizophrenic like symptoms depersonalization or sexual disturbances.depersonalization or sexual disturbances.pp

FrontoFronto--temporal variants of temporal variants of d id idementiadementia

present as impaired social cognition with present as impaired social cognition with p p gp p gbehavioural change without insight or empathy behavioural change without insight or empathy (orbito(orbito--frontal )frontal )

iti f titi f t i i d tt ti lfi i d tt ti lfcognitive features cognitive features --impaired attention, selfimpaired attention, self--observation , impulse control, abstract reasoning, observation , impulse control, abstract reasoning, capacity to carry complex plan of action, and ability capacity to carry complex plan of action, and ability to filter distracting stimuli. to filter distracting stimuli.

Left lesionsLeft lesions-- verbal fluency verbal fluency right lesionsright lesions-- inappropriate talking; especially associatedinappropriate talking; especially associatedright lesionsright lesions-- inappropriate talking; especially associated inappropriate talking; especially associated with profound personality changes in interpersonal with profound personality changes in interpersonal behavior, striking lack of insight (Mychack et al 2001)behavior, striking lack of insight (Mychack et al 2001)

Parietal lobesParietal lobesParietal lobesParietal lobesregulate somatic sensations, integration of regulate somatic sensations, integration of g gg gsensory input, word finding, writing, sensory input, word finding, writing, mathematics, reasoning , spatial orientation, mathematics, reasoning , spatial orientation, control of limb movement or recognizing an control of limb movement or recognizing an g gg gobject by touch. object by touch. Left lesionsLeft lesions--language deficits apraxias agraphia language deficits apraxias agraphia finger agnosia and rfinger agnosia and r L orientation deficitsL orientation deficitsfinger agnosia and rfinger agnosia and r--L orientation deficits, L orientation deficits, hemiattentional neglect. hemiattentional neglect. Right lesionsRight lesions-- visuospatial perception, body visuospatial perception, body i d i f i l i ii d i f i l i iimage and sometimes facial recognition. image and sometimes facial recognition. Personality changePersonality change-- indifference or paranoia, indifference or paranoia, apparent lying about deficitsapparent lying about deficitsapparent lying about deficits.apparent lying about deficits.

Subcortical structuresSubcortical structuresSubcortical structuresSubcortical structures

limbiclimbic system lesionssystem lesions-- change in arousalchange in arousallimbiclimbic system lesionssystem lesions change in arousal change in arousal emotional expression,drivesemotional expression,drivesbasal gangliabasal ganglia lesionslesions-- reduced insight, reduced insight, g gg g g ,g ,judgment, and impulsivityjudgment, and impulsivity

OCDOCD with lesions of the basal ganglia, striatum and with lesions of the basal ganglia, striatum and thalamusthalamus

hypothalamic and thalamichypothalamic and thalamic lesionslesions-- frontal lobe frontal lobe d i ll h ll ti l l bilitd i ll h ll ti l l bilitsyndromes especially shallow emotional lability syndromes especially shallow emotional lability

and sudden violent outbursts. and sudden violent outbursts.

Impact of Cognitive changes on Impact of Cognitive changes on P liP liPersonalityPersonality

Cognitive ChangeCognitive Change Personality impactPersonality impactg gg gImpaired attentionImpaired attentionvisual perceptionvisual perception

y py pfrustration, panicfrustration, panicidiosyncratic responses idiosyncratic responses and limited socialand limited social

verbal mediationverbal mediation

and limited social and limited social interaction interaction slowing, insecurity, and slowing, insecurity, and i d d di d d dverbal mediationverbal mediation increased dependency increased dependency

dependency on externaldependency on externalmemorymemory

dependency on external dependency on external support interpersonal support interpersonal clinging, avoidance of clinging, avoidance of others, or paranoia.others, or paranoia.others, or paranoia. others, or paranoia.

Is Premorbid PersonalityIs Premorbid PersonalityIs Premorbid Personality Is Premorbid Personality Related to the severity and Related to the severity and yy

type of Symptoms in type of Symptoms in dementia?dementia?

Relationship between premorbid personality Relationship between premorbid personality and patterns of emotion expressions in midand patterns of emotion expressions in mid--to lateto late--stage dementia stage dementia (Magai et al Int J Geriatr Psychiatry (Magai et al Int J Geriatr Psychiatry

1997)1997)Nursing home sample N=27Nursing home sample N=27Nursing home sample N 27Nursing home sample N 27Family and nurse aid observersFamily and nurse aid observersPremorbid personality (attachment) andPremorbid personality (attachment) andPremorbid personality (attachment) and Premorbid personality (attachment) and current emotional behavior measuredcurrent emotional behavior measuredResults: secure attachment=+ affect;Results: secure attachment=+ affect;Results: secure attachment=+ affect; Results: secure attachment=+ affect; premorbid hostility = negative affectpremorbid hostility = negative affectConclusions: premorbid personality showsConclusions: premorbid personality showsConclusions: premorbid personality shows Conclusions: premorbid personality shows continuity in dementia continuity in dementia (findings very similar to (findings very similar to Chatterjee et al 1992)Chatterjee et al 1992)

Impact of Premorbid personality on Impact of Premorbid personality on b h i i d i Sb h i i d i Sbehavior in dementia: Summarybehavior in dementia: SummaryData conflictData conflictData conflictData conflictPremorbid personality may alter Premorbid personality may alter behavioural symptoms of dementiabehavioural symptoms of dementiabehavioural symptoms of dementiabehavioural symptoms of dementiaUnderstanding premorbid personality and Understanding premorbid personality and d l t i d t did l t i d t didevelopment can improve understanding development can improve understanding of behavior and emotion and enhance of behavior and emotion and enhance

ifi it f tifi it f tspecificity of management specificity of management

How does Dementia Affect How does Dementia Affect Behaviour and Personality?Behaviour and Personality?

Personality change in dementia Personality change in dementia y gy g(Aitken et al Int Psychogeriatr 1999)(Aitken et al Int Psychogeriatr 1999)

almost universal almost universal negative in nature but not always negative in nature but not always associated with severity of cognitive impairment, associated with severity of cognitive impairment, y g p ,y g p ,longer duration of illness, and neurological longer duration of illness, and neurological signs.signs.

h fi di h i th bi l i lh fi di h i th bi l i lsome research findings emphasize the biological some research findings emphasize the biological basis of personality changes in dementia.basis of personality changes in dementia.Agrees with BrandtAgrees with Brandt et alet al (Int J Ger Psychiat 1998)(Int J Ger Psychiat 1998) nonoAgrees with Brandt Agrees with Brandt et alet al (Int J Ger Psychiat 1998)(Int J Ger Psychiat 1998)-- no no relationship between premorbid personality and relationship between premorbid personality and adjustment to nursing homeadjustment to nursing home

Premorbid personality less Premorbid personality less important than the disease processimportant than the disease processimportant than the disease process important than the disease process

(Low et al Int J Geriatric Psychiatry 2002) (Low et al Int J Geriatric Psychiatry 2002) higher neuroticismhigher neuroticism DelusionsDelusionsgghigher agreeableness higher agreeableness hallucinations hallucinations

aggressiveness affective aggressiveness affective di t b d lldi t b d lldisturbance and overall disturbance and overall behavioural disturbancebehavioural disturbance

higher opennesshigher opennessaffective disorder; affective disorder; (Chatterjee 1992 found higher (Chatterjee 1992 found higher ne roticism associated)ne roticism associated)neuroticism associated)neuroticism associated)

Stage of DementiaStage of DementiaStage of DementiaStage of Dementia

The stage of dementia is intimately tied toThe stage of dementia is intimately tied toThe stage of dementia is intimately tied to The stage of dementia is intimately tied to what changes in personality emerge in what changes in personality emerge in dementiadementiadementiadementiaEspecially relevant to the patientEspecially relevant to the patient’’s ability s ability to understand what is happening to herto understand what is happening to herto understand what is happening to her to understand what is happening to her capacities and sense of selfcapacities and sense of self

Defining Stages of DementiaDefining Stages of DementiaDefining Stages of DementiaDefining Stages of Dementia

Scales to define and categorize stages ofScales to define and categorize stages ofScales to define and categorize stages of Scales to define and categorize stages of deterioration include the Geriatric deterioration include the Geriatric Deterioration Scale (GDS) and FunctionalDeterioration Scale (GDS) and FunctionalDeterioration Scale (GDS) and Functional Deterioration Scale (GDS) and Functional Assessment Staging (FAST) (Assessment Staging (FAST) (Reisberg et al Reisberg et al 1982 and 19881982 and 1988))1982 and 19881982 and 1988) )

FAST/MMSEFAST/MMSE Cognitive PictureCognitive Picture Emotional ImpactEmotional Impact

[js1]

I/30 No complaints none

2/29-30 mild forgetting Slight discomfort[js1]2/29 30 mild forgetting Slight discomfort

3/25 Functional poor performance,

Early (increasing) anxiety, personalityperformance,

concentrationanxiety, personality interacts with disease

4/20 Clear deficits Denial, withdrawal

5/15 Lost independent Withdrawal/tearfulness[j 1]

function6/5 Unaware of recent

eventsAgitation peaks-

aggression

[js1]

events aggression wandering

7/0 Chair/bedridden Babbling/ screaming

Management Implications 1Management Implications 1Management Implications 1Management Implications 1Personality change in old age should trigger Personality change in old age should trigger y g g ggy g g ggsuspicion of dementia or depression suspicion of dementia or depression Recognize that behaviour in dementia is Recognize that behaviour in dementia is multideterminedmultideterminedmultideterminedmultideterminedVarious factors affect behavior: some are Various factors affect behavior: some are reactions to brain changes while others are the reactions to brain changes while others are the

ti f th t th i fti f th t th i freaction of the person to their awareness of new reaction of the person to their awareness of new and unwelcome cognitive changes and unwelcome cognitive changes The self is gradually eroded.The self is gradually eroded.e se s g adua y e odede se s g adua y e oded(i.e. knowledge of personal identity and (i.e. knowledge of personal identity and relationship to feeling states)relationship to feeling states)

Management Implications 2Management Implications 2Management Implications 2Management Implications 2

In optimal management both componentsIn optimal management both componentsIn optimal management both components In optimal management both components (brain failure and personality effects) are (brain failure and personality effects) are accurately understoodaccurately understoodaccurately understoodaccurately understood

This requiresThis requirescareful premorbid history from collateral sourcescareful premorbid history from collateral sourcescareful premorbid history from collateral sourcescareful premorbid history from collateral sourcesAccurate diagnostic separation of organically Accurate diagnostic separation of organically induced behavior change from psychologicalinduced behavior change from psychological

Management Implications 3Management Implications 3Management Implications 3Management Implications 3

During period of remaining insight and selfDuring period of remaining insight and selfDuring period of remaining insight and self During period of remaining insight and self reflection environmental and interpersonal reflection environmental and interpersonal interventions are importantinterventions are importantinterventions are importantinterventions are importantEven at later stages patientEven at later stages patient’’s may remain s may remain sensitive to those interpersonal issuessensitive to those interpersonal issuessensitive to those interpersonal issues sensitive to those interpersonal issues which they tended to react to when less which they tended to react to when less impaired e g being left alone demeanedimpaired e g being left alone demeanedimpaired e.g. being left alone, demeaned impaired e.g. being left alone, demeaned

Theory/EvidenceTheory/Evidence--Based Treatment of Based Treatment of S ifi V l bilitiS ifi V l bilitiSpecific VulnerabilitiesSpecific Vulnerabilities

I i tI i t i t ti t t lli b ildi t h illi b ildi t h iImpairments Impairments in trust in trust –– alliance building techniquesalliance building techniquesAbandonment Abandonment fearsfears‐‐ IPT or CBT with environmental IPT or CBT with environmental interventionsinterventions‐‐ nurturing, caregiver educationnurturing, caregiver education‐‐g, gg, gunspoken needs, being left aloneunspoken needs, being left aloneLoss and grief Loss and grief management management –– pharmacology, pharmacology, psychotherapypsychotherapypsychotherapy.psychotherapy.Giving up Giving up controlcontrol and accepting changes in and accepting changes in statusstatus ‐‐educational techniques, consciousness raising, family educational techniques, consciousness raising, family h i l hih i l hitherapy, interpersonal coachingtherapy, interpersonal coachingMaintenance of Maintenance of continuitycontinuity‐‐ reminiscence, life review, reminiscence, life review, narrative therapies.narrative therapies.narrative therapies.narrative therapies.


Theory/EvidenceTheory/Evidence--Based Treatment of Based Treatment of S ifi V l biliti 2S ifi V l biliti 2Specific Vulnerabilities 2Specific Vulnerabilities 2

Self efficacySelf efficacy enhancementenhancement‐‐ locus of controllocus of controlSelf efficacy Self efficacy enhancementenhancement locus of control locus of control based interventions e.g. Education, Skills based interventions e.g. Education, Skills training and PSTtraining and PSTtraining and PSTtraining and PST

Maintaining Maintaining CreativityCreativity and vital involvement and vital involvement ‐‐centers of creativitycenters of creativitycenters of creativitycenters of creativity

Dependency Dependency conflictsconflicts‐‐illness adaptation illness adaptation h l i l l bilih l i l l biliprograms psychological vulnerabilityprograms psychological vulnerability

FriendshipFriendship maintenance development maintenance development programsprograms‐‐ affiliation needsaffiliation needs


personality disorders in lt liflate life

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