Clinical Gerontology

A Guide to Assessment and Intervention

T.L. Brink

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317840251
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Here is a major text in psychogeriatrics for all professionals in the field of aging and mental health. Leading authorities provide valuable insights into assessment and intervention techniques for use with the mentally impaired elderly. Topics include a depression scale for use in later life, family therapy, therapy in later life, and various issues concerning mental health care for the aged.

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RELATED TOPICS

23/LATER LIFE PERSONALITY MODEL

Diagnosis and Treatment

Lee Hyer, EdD
William R. Harrison, MS

Editor’s Introduction

There is a maxim to which medicine frequently returns: it is not adequate to figure out what kind of disease a patient has; we must figure out what kind of patient has the disease.

A theme running through the previous chapters has been that these assessment and treatment techniques must be employed flexibly, being intricately tied to the needs of the situation. What works with one patient may not work with another.

Hyer and Harrison give us a useful tool in deciding what to do. when, and with whom. They begin by reviewing the literature within geriatric psychotherapy, and then they describe Millon’s typology. There are eight personality types, based upon a four-by-two interaction of sources from which rewards are sought (from self, from others, from both self and others, or from neither source) and instrumental style (active or passive). These pure types cannot be found in living patients, rather “they are heuristic crutches to provide clinical structure.” The Millon Clinical Multiaxial Inventory has scales which can assess the goodness of fit between a patient and the eight personality styles. A significant contribution of this chapter is the provision of late life norms for the MCMI.

The authors present four cases which illustrate the interaction of personality style, psychometric data (IG, MMPI, BDI, STA), and background in the decision about appropriate intervention.

One of the most important topic areas of aging is personality. Despite the fact that there is no consensus about the range or essential nature of the subject matter and there exists a “crisis of paradigms” in personality theory (Neugarten, 1977), there is remarkable consistency or trait stability across time (Botwinick, 1973; Brim, 1974; Costa & McRae, 1977; George, 1978; Gutmann, 1975; Kalish, 1969; Neugarten, 1964; Thomae, 1980). “On-togenetic stability” (Kahana, 1983) is the norm. Neugarten (1977), Siegler (1980), and Thomae (1980), among others, have outlined multiple dimensions (e.g., egocentrism, introversion, locus of control, etc.) along which personality in older age has been assessed. While some results have been equivocal, longitudinal data point most clearly to consistency (Siegler, 1980).

In addition to trait consistency, personality is also a reliable predictor of adaptation or coping style (Neugarten, 1977). It is reasonably established that the relationship between personality and adaptation changes at successive adulthood periods. As a result, personality dimensions and adaptational styles which are activated at one time are not the same as those activated at other times. This is a result of both development and situational factors. Research findings, however, generally support the principle that later life adaptation is foremost a function of particular personality types. In most schemas of later life personality (e.g., Block, 1971; Maas & Kypers, 1975; Neugarten, 1974; Reichard, Livson, & Peterson, 1962; among others), four to eight personality types are represented and “predictive” of adaptation in any of a variety of settings or traits measured. Clearly, situational factors assert an influence, but personality coherence and continuity of individual differences remain robust (Siegler, 1980). As Neugarten (1973) says, personality type is the pivotal factor in predicting which individuals will age successfully.

In clinical areas, very little has been devoted to personality in later life. It is commonly reported that the age period of 25–44 is optimal for personality diagnosis (Verwoerdt, 1980). In an epidemiological demiological survey of nine community studies on the incidence of personality disorders, Simon (1980) showed that between 2 and 12% of older adults had such a diagnosis. There have been no detailed studies of the effects of aging on personality disorders (or vice versa) that have been present since adolescence or early adulthood (Simon, 1980).

This area, however, is not without clinical speculation. Verwoerdt (1977, 1980) suggests that “high energy” personality types (e.g., obsessive, compulsive, or narcissistic) result in problems with age, whereas with “lower energy” personality types (e.g., passive-dependent, schizoid), the reverse is true. The construct personality also is mentioned as an exaggerated or catastrophized component of behavior when an organic brain syndrome is present (Sloan, 1980). In addition, speculation exists among some of the better theorists of later life functioning (Lazarus, Gutman, Grune, Ripeckj, Groves, Newton, Frankei, Havasy-Galloway, 1982), as well as with some of the more validated psychotherapy research (Gallagher & Thompson, 1984), that personality is a central construct in treatment.

Few formal studies, then, have addressed personality as an influence on pathology or as a disorder in later life. In fact, it is unclear if personality style becomes more or less a “disorder” with age. What appears reasonable to infer from aging and personality literature is that personality patterns remain basically consistent, yet highly individualistic across time and assert a substantial influence on later life pathology. This condition, it is believed, exists independent of whether a person possesses a DSM-III, Axis II diagnosis or not (DSM-III, American Psychiatric Association, 1980).

MILLON MODEL

Perhaps the most influential model of pathological personality in the last decade has been that proposed by Millon (1969, 1981). This model served as a guide for DSM-III character disorders and the importance of Axis-II. It has also been an invaluable guide to clinicians in diagnostic and treatment formulation. Basically, this model posits a schema of psychopathology that holds personality as the central concept. Personality is defined as …

a complex pattern of deeply embedded psychological characteristics that are largely unconscious, cannot be eradicated easily, and express themselves automatically in most every facet of functioning. Intrinsic and pervasive, these traits form a complicated matrix of biological disposition and experiential learnings and now comprise the individual’s distinctive pattern of perceiving, feeling, thinking, and coping. (Millon, 1969, p. 221)

There are eight basic types of personalities based on reward-seeking (none or negative, others, self, and both others and self) and instrumental style (active/passive). (The eight types are listed in Table 1.) These personality styles represent a typology where centrality or relative dominance of key traits exists. In essence, this is a social or interactional schema that exists on a continuum of normal autonomous functioning to more pathological functioning based on adaptive inflexibility, the fostering of vicious circles, and tenuous stability. In addition, three more severe personality types are psychological extensions or exaggerations of the basic eight personalities. These are schizotypal, borderline, and paranoid. All eleven personalities are represented in the DSM-III.

It is recognized that there is a controversy regarding situational consistency versus situational-specific behavior. In regard to correlational studies, there is a general finding of low cross-situational consistency with respect to personality and social measures that increases for measures across similar situations (Magnusson, Gerzen, & Ayman, 1968) for longitudinal studies (Block, 1977), and for selected types of variables, especially cognitive ones (Mischel, 1969). Based on these studies and personality trait stability (Levy, 1983), “relative” consistency or “coherence” is held. This position assumes that the rank order of individuals for specific behaviors is stable or that behavior is predictable and coherent but not necessarily consistent in an absolute sense. Emphasis is on the person’s pattern of stable and changing behavior across a variety of situations. And, whether the traits at issue are of sufficient intensity and visibility to warrant a DSM-III diagnosis is moot. Millon (1969) argues for a continuum of personality–mild, moderate, severe. It is in this sense that personality is considered here; namely people retain consistent types over time that may or may not become more defined or rigid, and may or may not require a DSM-III, Axis II designation. Personality patterns become rigid or entrenched based on the criteria noted above of adapted inflexibility, the fostering of

Table 1.
Later Life Personality Model

Assessment
	Core Personality (DSM-III)	Modal Styles
1.	Passive Detached (Schizoid)	Affectivity deficit Mild cognitive slippage Interpersonal indifference Behavioral apathy Perceptual insensitivity
2.	Active Detached (Avoidant)	Affective dysphoria Mild cognitive interference Alienated self-image Aversive interpersonal behavior Perceptual hypersensitivity
3.	Passive Dependent (Dependent)	Pacific temperment Interpersonal submissiveness Inadequate self-image Pollyanna cognitive style Initiative deficit
4.	Active Dependent (Histronic)	Fickle affectivity Sociable self-image Interpersonal seductiveness Cognitive dissociation Immature stimulus-seeking
5.	Passive Independent (Narcissisic)	Inflated self-image Interpersonal exploitiveness Cognitive expansiveness Impetulate temperment Deficient social conscience
6.	Active Independent (Antisocial)	Hostile affectivity Assertive self-image Interpersonal vindictiveness Hyperthymic fearlessness Malevolent projection
7.	Passive Ambivalent (Compulsive)	Restrained affectivity Conscientious self-image Interpersonal respectfulness Cognitive constriction Behavioral rigidity
8.	Active Ambivalent (Passive Aggressive/Borderline)	Labile affectivity Behavioral contrariness Discontented self-image Deficient regulatory controls Interpersonal ambivalence

	Self-Perpetuation	Reactance	Aging Precipatants
1.	1. Impassive and cognitively insensitive behavior 2. Diminished perceptual awareness 3. Infrequent social activities	L	Over/under stimulation Depersonalization
2.	1. Restricted social experiences 2. Fearful and suspicious behavior 3. Perceptual hypersensitivity 4. Intentional cognitive interference	H	Avoidance gives way to anxiety, somatiform, depressive, obsessive disorders
3.	1. Self-deprecation 2. Avoidance of competence activities 3. Plaintive social behavior	L	Loss/separation fear Excess responsibility
4.	1. Exteroceptive preoccupation 2. Repression 3. Fleeting social attachments	(H)L	Lack of support High energy defenses faulter.
5.	1. Illusion of competence 2. Lack of self-controls 3. Social alienation	H	Narcissistic aging insult Exploitation fails Retirement/role jolt
6.	1. Perceptual and cognitive distortion 2. Demeaning affection and cooperative behavior 3. Creative of realistic antagonisms	H	High energy defenses faulter Retirement/role jolt Aging pressures to perform
7.	1. Cognitive and behavioral rigidity 2. Self-criticism and guit 3. Pursuit of rules and regulations	L > H	Stress/excessive demands Perfection goals not accomplished Aggressive drives disruptive
8.	1. Erratic and negativistic behavior 2. Anticipation of disappointment 3. Recreate disillusioning experiences 4. Repetition compulsion	H	Excessive anxiety Buildup of caotic life demands

	Treatment
	Health Care	Short-term Therapeutic	Long-term Rx
	Provider Strategies	Strategies	Considerations
1.	Provide clear directions Reward compliance	Counter withdrawal Skills training Coping skills
2.	Establish rapport Minimize fears	Trust building Reduce anxiety Modeling	Explore/reduce detachment Reduce self-defeating behavior Insight into interpersonal fears
3.	Careful history and probing Establish independence	Skills training/problem...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• I. Assessment of the Geriatric Patient
• II. Depression Scales for use in Later Life
• III. Therapy in Later Life
• IV. Family Therapy
• V. Related Topics: Diagnosis and Treatment
• Index