1 PERSONALITY AND SOMATIC SYMPTOM AND RELATED DISORDERSSuggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement own teaching materials. -Refer to GRS9 chapter for further content. -Supplement lecture with handouts, such as tables from the GRS chapter on personality and somatic symptom and related disorders. -See GRS question #s 159, 173, 189, 249, 304 for case vignettes. -For strength of evidence (SOE) levels, please see the GRS Teaching Slides site or the GRS inside front cover. Topic

2 OBJECTIVES Know and understand:The clinical features associated with the 10 personality disorders, and the 5 somatic symptom and related disorders The 3 clusters of personality disorders How the epidemiology and characteristics of personality and somatic symptom and related disorders differ between younger and older patients Principles of diagnosis and treatment of personality and somatic symptom and related disorders in the older patient Topic

3 TOPICS COVERED Personality Disorders EpidemiologyDiagnostic Challenges Differential Diagnosis Long-Term Course Treatment Somatic Symptom and Related Disorders Clinical Characteristics and Causes Topic

4 PERSONALITY DISORDERSPresence of chronic and pervasive patterns of inflexible and maladaptive inner experiences and behaviors Leading to significant disruptions in several spheres of function, including: Cognitive perception and interpretation Affective expression Interpersonal functioning Impulse control People with personality disorders are often distinguished by repeated episodes of disruptive or noxious behaviors, and as a result they often receive pejorative labels, depending on their form. Descriptive terms often applied to those with personality disorders include “difficult,” “dramatic,” and “strange,” to name just a few. The developmental roots of personality disorders are believed to lie in childhood and adolescence, but their features can present clinically at any age in adulthood. Personality disorders are influenced by both genetic and environmental factors. Topic

5 DSM-5 CLUSTERS AND CATEGORIES10 personality disorders, grouped into 3 broad clusters based on common phenomenology No longer documented on a separate axis DSM-IV-TR categories of depressive and passive-aggressive no longer included in DSM-5 due to lack of empirical support Other DSM-5 classifications for personality disorders Other specified personality disorder Unspecified personality disorder Personality change due to another medical condition Mixed diagnoses and those that do not fit into any existing category are labeled in DSM-5 as “other specified personality disorder” and “unspecified personality disorder.” Alzheimer disease and other dementias are often associated with personality changes, including apathy, egocentricity, and impulsivity. Frontal lobe injury can result in a disinhibited impulsive syndrome, or conversely, an apathetic, avolitional syndrome. Frontotemporal dementia has been associated with distinct personality changes, including impulsivity, disinhibition, apathy, and compulsive behaviors such as hoarding. Temporal lobe epilepsy can be associated with personality change, including emotional deepening, verbosity, hypergraphia, hypersexuality, and preoccupation with religious, moral, and cosmic issues. Other disorders found in older adults that are associated with personality disorders include brain tumors, multiple sclerosis, and encephalopathies. Topic

6 CLUSTER A: ODD OR ECCENTRIC BEHAVIORSCluster A Disorder General features Features specific to geriatric patients Paranoid Pervasive suspiciousness of the motives of others, which often leads to irritability and hostility Episodes of paranoid psychosis, agitation, and aggression Schizoid Disinterest in social relationships, coupled with isolative and sometimes odd behaviors Poor, strained, or absent relationships with caregivers Schizotypal Characteristic appearance, behaviors, and beliefs that are strange, unusual, or inappropriate Beliefs that can become delusional and lead to conflicts with others; relationships with caregivers can be strained or absent Descriptions of the clusters and of the disorders in each cluster are based on the Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013. Topic

7 CLUSTER B: DRAMATIC, EMOTIONAL, OR ERRATIC BEHAVIORS (1 of 2)Cluster B Disorder General features Features specific to geriatric patients Antisocial Poor regard for social norms and laws; lack of conscience and empathy for others; frequent reckless and criminal behaviors Frequent remission of antisocial behaviors with less aggression and impulsivity Borderline Impaired control of emotional expression and impulses associated with unstable interpersonal relations, poor self-identity, and self-injurious behaviors Persistent emotional lability and unstable relationships, but less self-injurious and impulsive behaviors Topic

8 CLUSTER B: DRAMATIC, EMOTIONAL, OR ERRATIC BEHAVIORS (2 of 2)Cluster B Disorder General features Features specific to geriatric patients Histrionic Excessive emotionality and attention-seeking behaviors, sometimes appearing overly seductive or provocative Behaviors that may become excessively disinhibited and disorganized, appearing hypomanic Narcissistic Pervasive sense of entitlement, grandiosity, and arrogance, coupled with lack of empathy Can present as hostile, enraged, paranoid, or depressed Topic

9 CLUSTER C: ANXIOUS OR FEARFUL BEHAVIORSCluster C Disorder General features Features specific to geriatric patients Avoidant Excessive sensitivity to rejection and social scrutiny; social demeanor that can be timid and inhibited Social contacts that can be extremely limited, providing for inadequate support Dependent Excessive dependence on others to help make decisions and provide support Comorbid depression is common; clinical appearance often with demanding or clinging behaviors if dependency needs not met Obsessive-compulsive Pervasive preoccupation with orderliness and cleanliness; a perfectionistic, rigid, and controlling approach that can become more inflexible and indecisive under stress Obsessive-compulsive traits can become exaggerated in efforts to maintain control over somatic and environmental changes Topic

10 PERSONALITY DISORDERS AND AGE-ASSOCIATED STRESSESOlder people with personality disorders can become overwhelmed by age-associated losses and stresses, largely because they may lack: Coping skills Personal, social, or financial resources Admission to a hospital or long-term-care setting poses a unique stress on people with personality disorders The loss of a familiar environment, personal items, privacy, and the control over one’s schedule can lead to a sense of disorganization and displacement. Conflict in an institutional setting begins when patients with personality disorders try to cope with the stresses from their new environment by exaggerating their maladaptive behaviors. An obsessive-compulsive person may attempt to maintain a sense of control by demanding rigid adherence to schedules and rules of hygiene. Dependent people may feel helpless and panicked without enough attention to their needs, and they respond with clinging behaviors and excessive questions or requests for assistance. Paranoid, antisocial, and borderline patients may refuse to cooperate with treatment plans or institutional rules. Individuals with personality change, such as due to head trauma, often have great difficulty accommodating to age-related changes and may respond with characteristic labile or disinhibited moods and behaviors or, conversely, with an overall apathetic demeanor. Topic

11 PREVALENCE OF PERSONALITY DISORDERS10%–20% for all ages in the community 5%–13% for late-life personality disorders in the community 10% to over 50% for inpatient settings and with comorbid depression The most common personality disorders in late life are dependent, obsessive-compulsive, paranoid, and unspecified. Although most research has demonstrated fewer diagnoses in older age groups, it is unclear whether this represents an actual difference in prevalence or merely reflects the fact that it is more difficult to make a diagnosis in late life. Some researchers have suggested that prevalence rates may be influenced by increased mortality among those with antisocial or borderline personality traits that are associated with higher rates of reckless, impulsive, and self-injurious behaviors. Other research exploring the neural substrates of emotion has demonstrated an attenuation of emotional reactivity in late life across a number of physiologic and behavioral parameters. These findings may partially explain the reduction in prevalence of the more impulsive and emotionally reactive personality features, such as those associated with borderline personality disorder. Topic

12 DIAGNOSTIC CHALLENGESOlder patients, their informants, and the chart often do not provide sufficient history Lifelong personality characteristics must be isolated from multiple comorbid problems, such as major depression and psychosis Current diagnostic terms are not age-adjusted Clinician may erroneously consider all older patients to have disruptive personality features as a normal function of age Establishing a diagnosis of personality disorder in the older patient can be especially challenging because it requires a detailed longitudinal psychiatric and psychosocial history. Older patients and their informants are not always able to provide sufficient history, especially when it may span 50 years or more. The history may be distorted by recall bias (the tendency to present more socially desirable traits) or memory impairment. Furthermore, schizotypal and paranoid people may be reluctant to engage in clinical interviews and share personal history, and antisocial and narcissistic people who lack insight into their problems may refuse to divulge relevant experiences. Records often do not provide sufficient information to determine prior personality dynamics. Remote diagnoses from previous decades cannot be easily correlated with current ones because the diagnostic criteria for personality disorders have changed significantly in the past 50 years. Topic

13 DIFFERENTIAL DIAGNOSISNot every older person with prominent or troubling personality features has a personality disorder Some individuals are better described as suffering from certain personality traits or an adjustment disorder There is often considerable overlap between symptoms of personality disorders and those of major psychiatric disorders Rule out personality change due to a specific medical condition An adjustment disorder might best characterize previously healthy and well-adjusted people who demonstrate acute changes in personality as a result of severe stresses. For example, physical pain and disability can lead to dependent or avoidant behaviors that resemble those seen in personality disorders, but without the pervasive pattern and degree of maladaptiveness. The odd thinking and unusual perceptual experiences seen in psychotic disorders may resemble behaviors seen in schizotypal personality disorder. The emotional lability of bipolar states can mimic behaviors of borderline and histrionic diagnoses, and depressive symptoms from dysthymic and depressive disorders can be almost indistinguishable from depressive personality traits. Diagnosis of a personality disorder becomes more certain when seemingly acute behaviors emerge as enduring and pervasive personality traits. Most often, personality changes with an “organic” source involve impairments in executive functioning, consisting of poor impulse control, poor planning, and greater vulnerability to irritability or agitation. Along these lines, Alzheimer disease and other dementias are often associated with personality changes, including apathy, egocentricity, and impulsivity. Frontal lobe injury may result in a disinhibited impulsive syndrome, or conversely, an apathetic, avolitional syndrome may result. Frontotemporal dementia has been associated with distinct personality changes characterized by odd social interactions and compulsive behaviors such as hoarding. Temporal lobe epilepsy has been associated with personality change, including emotional deepening, verbosity, hypergraphia, hypersexuality, and preoccupation with religious, moral, and cosmic issues. Topic

14 Can enter quiescence in middle age and reemerge in late life LONG-TERM COURSE Can enter quiescence in middle age and reemerge in late life Follow one of 4 possible courses: Persist unchanged Evolve into a different form or major psychiatric disorder Improve Remit Some researchers have proposed that personality disorders characterized by emotional and behavioral lability, including antisocial, borderline, histrionic, narcissistic, and dependent disorders, tend to improve over time, although patients remain vulnerable to depression. Personality disorders characterized by an overcontrol of affect and impulses, including paranoid, schizoid, schizotypal, and obsessive-compulsive personality disorders, are thought either to remain stable or to worsen in late life. Only antisocial and borderline personality disorders have been looked at longitudinally, and both have shown symptom improvement and even remittance into middle and later life for a significant percentage of patients. At the same time, there can be persistent psychopathology that is not recognized within the context of existing antisocial or borderline diagnostic criteria. In other words, chronic personality dynamics can manifest in new behaviors. For example, people with antisocial personality disorders demonstrate less aggressiveness, violence, and criminal acts as they age but can still have antisocial tendencies expressed through substance abuse, disregard for safety, and noncompliance with institutional rules. Older borderline patients display less impulsivity, self-mutilation, and risk taking but more aging-related symptoms, such as the use of multiple medications and nonadherence with treatment. Topic

15 PRINCIPLES OF TREATMENTGoal is to decrease the frequency and intensity of disruptive behaviors, not cure the disorder Same basic approaches as with younger patients, but consider age-related stressors and comorbid disorders Clarify the diagnosis, then identify recent stressors that may account for the current presentation Guides the selection of realistic target symptoms and therapeutic approaches Allows treatment team to anticipate future stressors The treatment of personality disorders in late life is complicated and often has limited success. All forms of psychotherapy have been used to treat personality disorders in older adults, ranging from intensive and long-term insight-oriented approaches to equally intensive but more focused cognitive-behavioral models. In late life, however, there may be more limitations on time and intensity of therapy, and as a result treatment must focus more on short-term approaches. In outpatient settings, clinicians must rely on one-to-one interventions if the patient is willing to cooperate with treatment. With some patients, it may be necessary to convey a basic formulation of their behaviors, along with suggested approaches, to caregivers and affiliated health care professionals, such as internists, social workers, and visiting nurses. This communication is important when patients are vulnerable to self-harm or likely to cause significant disruptions in other settings when they are not understood and approached in a therapeutic manner. Topic

16 THERAPEUTIC STRATEGIES (1 of 3)Cluster A—Paranoid, Schizoid, Schizotypal Personality Disorders Always assess for and treat comorbid psychosis Do not force social interactions, but offer support and problem-solving assistance in a professional and consistent manner Do not challenge paranoid ideation; instead, solicit and empathize with emotional responses to the inner turmoil and fear of paranoid states Cluster B—Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Assess for and treat underlying mood lability, depression, anxiety, and substance abuse Adopt a consistent, structured, and predictable approach with strict boundaries to contain disruptive behaviors Adopt a team approach with all involved clinicians to devise a common plan; avoid staff splits between “supporters” and “detractors” of the patient Topic

17 THERAPEUTIC STRATEGIES (2 of 3)Cluster B—Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders (continued) Use behavioral contracts and authority figures when necessary to address recurrent disruptive behaviors Do not personalize belligerent behaviors directed toward staff members; instead, provide opportunities for staff to ventilate frustration and negative thoughts and emotions with professional colleagues Cluster C—Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders Assess for and treat underlying anxiety, panic, and depression Provide regularly scheduled clinical contacts rather than on an as-needed basis When possible, provide case managers to solicit the needs of avoidant patients and to provide extra reassurance and attention to the needs of dependent and obsessive-compulsive patients Topic

18 TREATMENT IN LONG-TERM CARE SETTINGSStaff meeting or case conference Discuss disruptive patients and coordinate a consistent treatment plan Disruptive behaviors can sometimes be traced to particular activities or staff interactions Convey treatment plan to patient, all involved staff, and caregivers Nonadherent patients may need a written contract Recognize that patient may have conflictual relationships with family Sometimes, disengagement from patients will reduce the intensity of disruptive interactions. In other situations, the continuity of staffing and daily schedules is critical. All treatment plans must provide appropriate limits to ensure the safety of patients and staff. Attention should also be given to individual staff members who must work with difficult patients. They need opportunities to discuss feelings of anxiety and frustration, and to feel acknowledged and supported by administrative and clinical staff. Topic

19 PHARMACOLOGIC THERAPY FOR PERSONALITY DISORDERSFew studies in late life Best used as adjunct to psychotherapy Avoid multiple psychotropics, particularly if there is a history of nonadherence, confusion, or impulsivity Consider potential interactions with other medications Obtain informed consent for use of psychotropics when there is a history of dementia, recent delirium, paranoia, or conflictual doctor-patient relationships Again, the goal is not to cure the disorder, but to reduce the frequency and intensity of targeted symptoms. Topic

20 PHARMACOLOGIC OPTIONS (1 of 2)Antidepressants For the symptoms of depression and anxiety found in most personality disorders Commonly used to treat impulsive aggression as well as obsessive-compulsive symptoms, but efficacy not established Mood stabilizers (eg, lithium carbonate and divalproex sodium) (off-label) Reduce mood lability and impulsivity in borderline and antisocial personality disorder Topic

21 PHARMACOLOGIC OPTIONS (2 of 2)Antianxiety agents Used for the transient agitation seen in borderline, antisocial, narcissistic, and paranoid disorders May reduce social anxiety and panic in avoidant and dependent patients Antipsychotic agents Can treat transient psychosis, agitation, and impulsivity of dramatic cluster and paranoid disorders, and the borderline psychosis and paranoia seen in odd cluster disorders Reduce mood lability and impulsivity in borderline and antisocial personality disorder Topic

22 PHARMACOLOGIC STRATEGIES ARE NOT ALWAYS APPROPRIATEComorbid substance abuse Chronic nonadherence Hx/potential for abusive or self-injurious use Often includes antisocial and borderline patients Dependent patients may insist upon medications as a means of fostering dependency on the clinician Obsessive-compulsive patients may perpetuate a maladaptive relationship with the clinician through detailed discussions of medication management Topic

23 SOMATIC SYMPTOM AND RELATED DISORDERSHeterogeneous group of 5 diagnoses Common factors: distressing physical symptoms, and abnormal thoughts, feelings, and behaviors in response to these physical symptom Especially relevant to geriatric care Affected older people are seen in all health care settings and tend to overutilize medical services Previously, under DSM IV-TR, the somatic complaints occurred without objective organic causes; however, DSM-5 does not require that the somatic symptoms be medically unexplained. Instead, somatic symptom disorder can also accompany a diagnosed medical disorder as long as the somatic symptoms are associated with significant emotional distress and impairment. Topic

24 TYPES OF SOMATIC SYMPTOM AND RELATED DISORDERS (1 of 3)Somatic Symptom Disorder The patient must have one or more distressing and/or disruptive somatic symptom(s) that is accompanied by at least one of the following: 1) concerns about the seriousness of the medical symptom that is out of proportion to what is typically experienced, 2) persistent high level of anxiety about the symptom, and/or 3) excessive time and energy focused on the somatic symptom. Clinician can also specify if the somatic symptom disorder occurs with predominant pain The DSM IV-TR diagnoses of somatization disorder, undifferentiated somatoform disorder, hypochondriasis, and some presentations of pain disorder are now included under the DSM-5 criteria as somatic symptom disorder. Topic

25 TYPES OF SOMATIC SYMPTOM AND RELATED DISORDERS (2 of 3)Illness Anxiety Disorder Preoccupation with being susceptible to or having an illness Tend to have milder somatic symptoms but higher anxiety levels than those with somatic symptom disorder Symptoms must be persistent for ≥6 months Patient behaviors can be described as care seeking or care avoidant Conversion Disorder One or more symptoms of altered voluntary motor and/or sensory function that causes significant social and occupational impairment and is not explained by a neurologic disease A preoccupation with fears of having a serious illness Based on misinterpretation of bodily symptoms and resistant to appropriate medical evaluation and reassurance Motor symptoms of conversion disorders may include weakness, paralysis, and abnormal movements (eg, tremor) and gait disorders. Sensory symptoms include changes in vision or hearing, or skin sensations. Topic

26 TYPES OF SOMATIC SYMPTOM AND RELATED DISORDERS (3 of 3)Psychological Factors Affecting Medical Conditions Psychological or behavioral factors that have an adverse effect on a diagnosed medical condition DSM-5 also includes factitious disorders in this category, which are characterized by false symptoms associated with deception on the part of the patient Other or Unspecified Somatic Symptom and Related Disorders Distressing somatic symptoms that do not fit any of the above diagnoses For example, a patient with factitious disorder may exacerbate symptoms of COPD because of anxiety, or may manipulate insulin dosage in an attempt to lose weight. Patients with factitious disorder present as ill or injured without any obvious evidence of external reward or reinforcement. Topic

27 EPIDEMIOLOGY OF SOMATIC SYMPTOMS AND RELATED DISORDERSPrevalence in middle and late life <1% More common in women Generally not associated with increasing age Weak evidence for slight increase in hypochondriasis with age Depression in late life is associated with increased somatic preoccupation and symptoms Somatoform disorders in late life have not been well studied, and existing research has usually focused on select diagnoses, such as hypochondriasis, in limited or biased samples. Another problem is that research has looked at somatic symptom reporting rather than at specific diagnoses. In addition to depression, increased somatic preoccupation is associated with the presence of the personality trait of neuroticism, in which a person displays a tendency to experience more negative emotions. Late onset of a somatoform disorder may suggest associated neurologic illness. Topic

28 CLINICAL CHARACTERISTICS AND CAUSESNot an intentional, conscious attempt by older patients to present fictitious physical symptoms Symptoms are experienced by the affected person as real physical pain and discomfort, usually without insight into associated psychological factors Represent a complex interaction between mind and brain—the affected person unknowingly expresses psychological stress or conflict through the body It is not surprising that depression and anxiety are associated with increased somatic expressions. In late life, somatic symptom disorders, in particular illness anxiety disorder, can be a way for a person to express anxiety and attempt to cope with accumulating fears and losses. These may include fears of abandonment by family and caregivers, loss of beauty and strength, financial setbacks, loss of independence, loss of social role (eg, through retirement, loss of spouse, occupational disability), and loneliness. The psychologic distress and anxiety over such losses can be less threatening and more controllable when shifted to somatic complaints or symptoms. In turn, the resultant state of debility might be reinforced by increased social contacts and support. Topic

29 CAUSES OF SOMATIC SYMPTOM AND RELATED DISORDERSUsually multifactorial Often rooted in early developmental experiences and personality traits Comorbid medical problems and use of multiple medications may provide somatic symptoms around which psychological conflict can center Older adults are faced with many overwhelming losses, and their own bodies often serve as the last bastion of control Psychodynamic approaches suggest that these disorders result from unconscious conflict in which intolerable impulses or affects are expressed through more tolerable somatic symptoms or complaints. One reason for this may be the presence of alexithymia, in which a person is unable to identify and express emotional states, so that the body becomes the available mode of expression. Although psychodynamic explanations can apply across the life span, these conflicts often begin early in life, perhaps accounting for the relatively young age of onset for most somatic symptom disorders. In late life, psychological conflict that results in significant depression and anxiety are for the most part the same conflicts that can lead to somatization. Somatic preoccupation can serve as a means of coping with stress, even though it is maladaptive and may result in excessive and unnecessary disability. Topic

30 TREATMENT OF SOMATIC SYMPTOM AND RELATED DISORDERSFoster an ongoing, supportive, consistent, and professional relationship with the patient Focus on symptom reduction and rehabilitation Respond to individual complaints, perhaps with regularly scheduled appointments Set limits on work-up and treatment Continuously entertain the possibility of an underlying or coexisting medical problem Consider referral to mental health clinician From the perspective of the patient, the symptoms and complaints of a somatoform disorder are quite real and disturbing. It is never wise to challenge the patient or to suggest that the symptoms are “all in your mind,” even after work-up has made it obvious that psychological factors are involved. The typical response to such advice is for the patient to seek additional opinions and medical tests, which can perpetuate a cycle of somatization that never addresses the underlying issues. The physician must endeavor to remain professional and not personalize the situation or feel that he or she is failing the patient. It would be hazardous to prematurely diagnose a somatoform disorder when there might actually be an underlying medical problem that has eluded diagnosis. For example, disorders such as multiple sclerosis, systemic lupus erythematosus, and acute intermittent porphyria commonly have complex presentations that elude initial diagnostic work-up. Moreover, many somatoform disorders coexist with actual disease states; for example, many people with pseudoseizures also have an actual seizure disorder. At the same time, it is important for the physician to set limits on what he or she can offer, and to make appropriate referrals to specialists and mental health clinicians. Topic

31 SUMMARY (1 of 3) Personality disorders persist into late life and pose complex challenges to clinicians across various medical and psychiatric settings Personality disorders may be especially difficult to detect in late life because of: Age-associated changes in symptoms Comorbid psychopathology Lack of age-adjusted diagnostic instruments Topic

32 SUMMARY (2 of 3) The goal of treatment of personality disorders in late life is not to cure the disorder, but to decrease the frequency and intensity of symptoms Both psychotherapeutic and psychopharmacologic strategies are needed in the treatment of personality disorders Somatic symptom and related disorders involve the presence of distressing physical symptoms and abnormal thoughts, feelings, and behaviors in response to these physical symptoms. Topic

33 SUMMARY (3 of 3) Treatment of somatic symptom and related disorders should focus on reducing symptoms and rehabilitating the patient Most somatic symptom and related disorders tend to be lifelong; the goal of treatment is not to cure but to control symptoms Topic

34 CASE 1 (1 of 4) A 76-year-old man accompanied by his wife, who reports changes in the patient’s behavior He is taking his antihypertensive medicine irregularly. He is increasingly irritable. He no longer expresses interest in activities that they used to enjoy. He has started to gamble impulsively and is losing a lot of money in poker games. His wife believes that he ignores her protests because he is domineering and self-absorbed. Topic

35 CASE 1 (2 of 4) The patient counters his wife’s concerns, stating:He enjoys poker and loses money because his friends cheat. He takes his medication regularly. He is only irritable around his wife. The patient seems unusually suspicious and mistrusting when asked for information about his daily routine, and he angrily leaves the office during a memory screen. Topic

36 CASE 1 (3 of 4) Which one of the following is the most likely diagnosis? Borderline personality disorder Temporal lobe epilepsy Dementia (major neurocognitive disorder) Major depressive disorder Paranoid personality disorder Topic

37 CASE 1 (4 of 4) Which one of the following is the most likely diagnosis? Borderline personality disorder Temporal lobe epilepsy Dementia (major neurocognitive disorder) Major depressive disorder Paranoid personality disorder ANSWER: C Personality, behavior, and mood changes are common at the onset of dementia. The personality changes may include apathy, egocentricity, and increased impulsivity; such changes may precede marked decrements in cognition. The personality changes may mask or coincide with underlying impairment in executive functioning and may be associated with irritability, agitation, or reduced impulse control (SOE=B). Changes in executive functioning and memory may be subtle and may first manifest as irregular adherence to medication regimen or reluctance to pursue former hobbies. The patient exhibits maladaptive symptoms and behaviors—such as poor emotion regulation, self-absorption, mistrustfulness, impulsivity, and irritability—that can indicate personality disorder. However, because the behaviors are atypical for the patient and are of recent onset rather than pervasive and chronic, a personality disorder is unlikely. Reduced interest and irritability may also signal depression, but in major depressive disorder the symptoms are pervasive rather than situational. Persons with temporal lobe epilepsy also demonstrate personality changes, but the changes are more likely to include exaggerated emotionality, verbosity, hypergraphia, hypersexuality, and preoccupation with religious and moral issues. Topic

38 CASE 2 (1 of 4) A 67-year-old woman has episodes of dizziness, headaches, and insomnia. The symptoms fluctuate daily, have persisted for >1 year, and have prompted several office visits. When symptoms are severe, she confines herself to home and is unable to engage in usual routines, including caring for grandchildren. When directly asked, she describes feeling stressed and annoyed by mounting family responsibilities since her retirement 2 years ago. She does not ruminate about these concerns, enjoys socializing with friends, and has had no changes in appetite or energy level.

39 CASE 2 (2 of 4) History: non-H. pylori gastritis, reflux esophagitisPrevious diagnostic tests Normal CBC, CMP, and TSH Neurologic evaluation found no focal deficit. MRI excluded acoustic neuroma. Trials of meclizine, zolpidem, and acetaminophen provided little benefit.

40 CASE 2 (3 of 4) Which one of the following is the most likely diagnosis? Hypochondriasis (illness anxiety disorder) Somatic symptom disorder Unspecified somatic symptom disorder Major depressive disorder

41 CASE 2 (4 of 4) Which one of the following is the most likely diagnosis? Hypochondriasis (illness anxiety disorder) Somatic symptom disorder Unspecified somatic symptom disorder Major depressive disorder ANSWER: B Somatic symptom disorder is characterized by 1 or more physical complaints, typically lasting 6 months, that are associated with significant distress or impairment in functioning. It is among the most common somatoform disorders in late life. The symptoms and impairment are not explained by or exceed what would be expected based on medical findings. Psychological factors are presumed to play a strong role in the onset and persistence of the physical symptoms. In this case, the patient’s acknowledged stress and resentment in the context of family responsibilities is temporally associated with the onset of her physical symptoms, and her symptoms appear to relieve her of expectations that she will routinely provide child care for her grandchildren. In addition, her symptoms’ duration and severity exceed criteria for unspecified somatic symptom disorder. Hypochondriasis (illness anxiety disorder) is a somatoform disorder in which a person’s fears of having a serious disease persist despite repeated medical evaluation and reassurance. It is based on a misinterpretation of bodily symptoms and leads to anxious ruminations about disease. Somatization disorder is also strongly associated with psychological factors and physical symptoms that are excessive relative to medical findings. It has an early onset (before age 30) and chronic history, and involves multiple organ systems (4 sites of pain, 2 gastrointestinal symptoms, 1 sexual, and 1 pseudoneurologic symptom other than pain). This patient does not ruminate excessively or express fears of having a serious illness, as seen in hypochondriasis, or exhibit the early onset and multiple system involvement seen in somatization disorder. Somatic preoccupations may mask depressive disorder in late life. This patient reports distress and insomnia, not the near-daily depressed mood, anhedonia, or neurovegetative symptoms seen in major depressive disorder. Somatic preoccupation or hypochondriac symptoms that appear in the context of late-life depression and persist after treatment may predict early recurrence of depressive symptoms (SOE=B).

42 Copyright © 2016 American Geriatrics SocietyGRS9 Slide Editor: Tia Kostas, MD GRS9 Chapter Author: Marc E. Agronin, MD GRS9 Question Author: Richard A. Zweig, PhD Managing Editor: Andrea N. Sherman, MS Copyright © 2016 American Geriatrics Society Topic