Chart Records Review

In some clinical contexts in which older patients may be evaluated (e.g., nursing homes and rehabilitation hospitals), charts or records may be available. In long-term care settings in which patients have had lengthy stays, these charts may be voluminous. In cases where records are accessible, it behooves the clinician to thoroughly examine them as part of the assessment process. A review of such records may show important behavioral patterns of the patient that are observed by members of the treatment team. Such patterns may give clues to personality disorder features shown by the patient, especially if the same traits are seen by different professionals. For example, passive and helpless behaviors might be noted by nursing staff and activity directors, suggesting a dependent personality style. Aggressive, haughty, and indignant behaviors in another resident may point to the presence of narcissistic, borderline, or paranoid features. Noncompliance with treatment may be due to several factors (e.g., cognitive impairment or depression), but it may also indicate personality pathology (e.g., passive aggressive or antisocial traits), and this possibility should be explored.

Records from mental health professionals who have previously treated the patient can also be important sources of as sessment data. Due to the chronicity and severity of their problems, many personality disordered older adults have received treatment at an earlier point in life; in some cases, they have had multiple experiences with psychotherapy. It is crucial to ask patients about their past treatment history, and if the patient has previously consulted a mental health professional, the clinician should ask the patient to sign a "release of information" form so that records can be requested by the present clinician and released by the former clinician. This task is often easier said than done. It has been our experience that many older adults with personality disorders refuse to grant permission to request records. In essence, they are telling the clinician at the outset of treatment that they will not cooperate with treatment despite their desperate need for assistance. We recommend that the reasons for their refusal be gently explored, and this may give some noteworthy clues to the type of personality disorder present.

Should treatment records be obtained, they should be carefully reviewed with particular emphasis on diagnostic formulations (which should be examined closely in the present case) and on identifying aspects of the prior treatment(s) that seemed particularly effective (if any exist) and particularly ineffective (usually some ineffective aspects will be apparent). At a simplistic level, a long history of multiple treatment failures, especially those indicated by the patient dropping out of treatment prematurely and having consistent difficulties forming a bond with the clinician, should point to the possibility of an underlying personality disorder. Understanding what did and did not work in previous treatment may also be valuable in orchestrating current treatment. Specifically, if a particular type of intervention seemed effective (e.g., activity planning or challenging negative self-statements), the clinician may strive to recreate these aspects (so the clinician does not have to "reinvent the wheel"). Conversely, aspects of treatment that previously were ineffective should be avoided (so as to not "reinvent a flat tire"). Hypothesis and hunches about the patient's psychopathology generated from a review of charts or records should be followed up during conversations with the patient, and this topic is discussed next.

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