The Clinical Interview of the Patient

When meeting an older patient for the first time, the clinician often forms some preliminary impressions of the patient as a person. How does the person come across? Is he or she formal or relaxed? Aggressive or shy? Entertaining or bland? Patently bizarre or seemingly ordinary? Does the patient take some initiative in the session or passively wait for the clinician to provide the structure? These initial impressions and clinical intuitions are followed up on during the clinical interview in which the clinician strives to gather important data about the patient's problems and the patient as a person.

An important part of the clinical interview is to take a thorough history of the patient. One issue is that older adults with a diagnosis of a personality disorder typically have a long and complicated history of problems and conflicts. One positive aspect of this is that clinicians are often presented with a wealth of information from which to raise diagnostic hypotheses. Patterns of interpersonal difficulties sometimes emerge, which can help the clinician pinpoint the specific nature of personality disorder pathology. The negative aspect to a long history of problems is that it takes a great deal of time, energy, and focus to sort through without becoming overwhelmed. Older patients with personality pathology may also have difficulty accurately reporting on their behaviors from many decades ago in part because of the long interval and in part because of inaccurate attention to historical detail and compromised self-perceptions.

In some cases, the personality disorder pathology is quickly noticeable during the interview. For example, some narcissistic patients are demanding, immediately challenging of the therapist's professional qualifications and ability to understand their unique problems, and they tend to brag. One of our patients, a narcissistic older man, started the intake session by reporting that he had terminated prematurely several recent consultations with other psychologists when he realized that he was "smarter" than the clinicians and was wasting his time with inferior people. Another one of our patients began the consultation by offering his professional resume in exchange for one of ours. Most people with Schizotypal Personality Disorder are also easy to identify—their unusual dress and language and their palpable social discomfort are immediately noticeable. Some other examples include: histrionic patients who make an immediate impression with their provocative and flamboyant behavior, dramatic dress, and overly emotional presentation; paranoid patients who are brazenly distrustful and defensive during the interview; and dependent patients who are helpless and sycophantic. It is important for clinicians to monitor their emotional reactions to the patient because this often gives valuable diagnostic clues and helps clinicians to understand the types of feelings and reactions that the patient probably engenders in others in the patient's life. We return to this important concept of countertransference later.

In other cases, however, it is not as easy to identify the dysfunctional personality. During the interview, the patient may focus excessively on symptoms of an Axis I disorder. Consider, for example, a patient who can speak at length about his or her severe depression and physical problems but not reveal much about him- or herself as a person. One way to investigate potential personality disorder pathology is to specifically focus the interview on the patient's functioning in the social arena. By asking the patient to describe his or her relationships with significant others, friends, and family members over time, the social impairment associated with a personality disorder often becomes apparent. It is important to understand if the social dysfunction is of a long-standing and pervasive nature, which is required for a personality disorder diagnosis, or if it is merely a transient, even expectable, reaction to social losses and current stressors. Consider the example of an older woman who presents with severe loneliness, isolation, and apathy. If the evaluation reveals that her loneliness is due to the recent death of her husband and her subsequent relocation to an assisted living facility away from many lifelong friends in her old neighborhood, the possibility of personality pathology is less likely. However, if the evaluation reveals a lifetime history of alienating others, the prospect of a personality disorder becomes more likely. To the extent that the history reveals social problems that have been recurrent or consistent throughout much of adult life, a personality disorder is probable.

Another strategy to detect personality disorder pathology among older adults is to evaluate the extent to which specific "triggers" exacerbate the patient's emotional distress. Triggers refer to specific social circumstances that habitually cause problems for the patient. Examples of common triggers include: situations in which the person has to fend for him- or herself and cannot rely on others, having to deal with authority figures, needing to ask for help, needing to cooperate with medical professionals, having to be assertive with family members or care professionals, reacting to abandonment (whether real or perceived), and social rejection. It can be enlightening to ask patients if their emotional symptoms (e.g., depression or anxiety) tend to develop or worsen after specific social stressors. To the extent that psychological symptoms and problems are related to chronic deficiencies in managing interpersonal relationships, a personality disorder diagnosis is likely.

The assessment of how an individual copes can also reveal clues about his or her personality organization. Most patients who seek psychotherapy do so because their ability to cope has been temporarily outstripped or overwhelmed. In some cases, the person's ability to cope is shored up with treatment and no further intervention is required. However, people with personality disorders tend to have significant and chronic deficits in their usual coping strategies, and they show patterns of ineffective coping throughout much of the life course. Thus, when patients present with a long-standing pattern of poor coping, especially with minor or typical challenges associated with life, then a personality disorder should be suspected. Problems with coping in one particular instance (e.g., an older man overwhelmed by the death of his spouse of 60 years) can be expected and easily understood. Problems with coping that seem pervasive and chronic are often signs of a personality disorder.

Another potentially challenging assessment issue relates to the extent to which the personality disorder symptoms have been "hidden" for much of adult life. As noted earlier, it is likely that most cases of personality disorder in later life reflect the continuation of the same disorder from earlier adulthood into old age. In these instances, the clear and consistent pattern of dysfunction can be readily understood. However, other cases of personality disorder may appear to be new in later life, and these can perhaps be conceptualized as representing a deterioration of more adaptive personality traits in vulnerable older adults, likely due to an accumulation of stressors in old age. In these instances, the older patient does not present with a long history of interpersonal problems or with a pattern of regressing after specific social triggers. Essentially, the personality pathology has been hidden or contained by significant others in the person's life who compensated for the person's difficulties and prevented any real dysfunction or distress from occurring. This so-called invisibility of some personality disorders is examined further in Chapter 10.

A final issue regarding the clinical interview with older patients is that all psychosocial data gathered during the interview must be viewed in the context of physical health. The nature, severity, and impact of the patient's current medical illnesses should be thoroughly assessed by the clinician. This information is vitally important because many medical problems, some common to older adults, are known to cause psychiatric conditions (American Psychiatric Association, 2000). In some cases, older adults present with exacerbations or deteriorations in their personality traits due to a dementing illness. According to Zarit and Zarit (1998), common personality changes associated with dementia include increased aggressiveness, anger, impul-sivity, disinhibition, dependency, and apathy. Besides dementia, however, a host of neurological and other medical conditions are known to cause personality changes and these are summarized in Table 9.1. If there is no evidence of dysfunctional personality traits through much of adult life, or if the negative personality traits are caused by an underlying organic illness, a personality diagnosis is not warranted. In these cases, a more appropriate DSM-IV-TR diagnostic option is Personality Change Due to a General Medical Condition.

It is also imperative to assess the patient's use of medications because many medications commonly taken by older adults are known to cause psychological symptoms. For example, some antihypertensive drugs and steroids can induce depressive symptoms, some stimulants and steroids can cause maniclike symptoms, and some analgesics, bronchodilators, and anticonvulsants can cause anxiety symptoms (American Psychiatric Association, 2000). Because older adults consume a disproportionate amount of prescribed and over the counter medications (due to age-related increases in the frequency of many chronic medical conditions), they are at increased risk for adverse drug effects. Detrimental consequences can occur because of harmful drug interactions and the build-up of medication in the body due to slower metabolization rates associated

Table 9.1 Neurological Diseases, Insults, and Other General Medical Conditions Known to Cause Personality Changes

Head trauma

Environmental toxicants (e.g., lead, cadmium, mercury, ethanol)

Brain tumor

Dementia

Cerebrovascular disease/Stroke Huntington's disease Epilepsy

Systemic lupus erythematosus Pernicious anemia

Endocrine conditions (e.g., hypothyroidism, hypoadrenocorticism, hyperadrenocorticism) Infections (e.g., meningitis, encephalitis)

with normal aging. Older adults are encouraged to bring a complete listing of medications to the clinical interview, both prescribed and over the counter. An alternative strategy is for the patient to bring in the bottles of current medications from which the clinician can compile a listing (the "brown-bag" review). Due to the significant effects that medical illness and medications can have on psychological functioning, a referral for a thorough medical workup is always indicated if the patient has not recently been medically evaluated.

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