Perhaps the ultimate overarching task in late life is that of life review; looking back over one's life, reflecting on it, and making meaning from the journey. Erik Erikson's (1963) influential developmental theory posited a conflict between ego integrity and despair, with the successful outcome being the achievement of wisdom. As clinicians, we recognize that there can be many hurdles along the way. Wisdom might be a possible outcome, but simply becoming old does not guarantee its achievement.
There are certain essential requirements to negotiate this developmental task. One is an adequately intact cognitive infrastructure to support the process of life review. This assumes a degree of memory intactness, as well as the capability of abstract reasoning, judgment, and insight. As a dementing illness progresses, the capability for this becomes progressively limited and ultimately lost.
Another requirement is a characterological infrastructure that supports and enables the ability to take one's self—one's life—as object, to reflect on and analyze it. This requires that the individual is capable of both achieving an internal focus and tolerating the affect this engenders. The individual with a personality disorder who also has dementia is thus doubly, and synergistically, compromised.
Normal aging of the brain does not greatly alter one's personality, but organic brain disease does. When brain pathology serves to alter one's premorbid personality, the individual can present with what appears to be a personality disorder and almost meet criteria for a diagnosis. However, for a diagnosis of a personality disorder, the traits need to be present by early adulthood. Although the diagnosis can be difficult, the temporal factor is key.
When an individual with a personality disorder develops dementia, the effect can be to increase the degree of the personality disorder, to decrease it, or to neutralize (or cancel) it. The dementia process causes changes in premorbid personality in general. Personality changes often occur even before the dementia is diagnosed, and typically appear to correspond with the progression of the dementia. In general, dementia tends to induce an increase in self-centeredness and a decrease in flexibility. The latter can increase the maladaptive expressions of a personality disorder. The self-centeredness (reflecting increasing difficulty in creating novel responses and set-shifting) can also exacerbate premorbid personality traits, especially those defining Cluster B personality disorders. Paranoia and schizophrenic-type withdrawal are also frequently observed.
As the dementia progresses, generally the individual's personality is perceived, and described by family members, as being less than prior to the onset of the dementia. The individual is described as being less outgoing, less assertive, less task focused, and less conscientious than he had been historically. (Unfortunately, hostility often appears to hold up as a stable, dementia-resistant trait.) Caregivers frequently report that the personality changes in the individual with dementia are experienced as more burdensome than the memory deficits or the physical requirements of the caregiving (Williams, Briggs, & Coleman, 1995).
How might we understand the relationship between dementia and personality changes? They can reflect the actual degeneration of discrete areas of the brain (e.g., the hippocampus) and association areas. They can reflect the effects of coexisting medical conditions or medications the individual is taking. Thyroid dysregulation and poorly controlled diabetes, for example, can have significant effects on the personality. Steroids and psychotropic medications, often prescribed to older adults, can induce marked personality changes. The organic brain pathology can exaggerate premorbid personality traits such as repetition and perseveration superimposed on the individual with Obsessive-Compulsive Personality Disorder. What is less often considered, but highly relevant, is the effect of feedback from others as experienced by the dementing brain. Consider how a predisposition to paranoid suspiciousness and distrust, anxiety, or dependency can be enhanced, or unmasked, as the dementia declares itself and progresses.
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