Personality Change Due to Another Medical Condition

Personality Change Due to Another Medical Condition

Personality Change Due to Another Medical Condition

Some medical conditions can cause a personality change, which is defined as an alteration (usually, a worsening) of a patient’s previous personality traits. If the medical condition occurs early enough in childhood, the change can last throughout the person’s life. Most instances of personality change are caused by an injury to the brain or by some other central nervous system disorder, such as epilepsy or Huntington’s disease; however, systemic diseases that affect the brain (for example, systemic lupus erythematosis) are also sometimes implicated.

ORDER COMPREHENSIVE SOLUTION PAPERS ON Personality Change Due to Another Medical Condition

Several sorts of personality changes commonly occur. Mood may become unstable, perhaps with outbursts of rage or suspiciousness; other patients may become apathetic and passive. Changes in mood are especially common with damage to the frontal lobes of the brain. Patients with temporal lobe epilepsy may become overly religious, verbose, and lacking in a sense of humor; some may turn markedly aggressive. Paranoid ideas are also common. Belligerence can accompany outbursts of temper, to the extent that the social judgment of some patients becomes markedly impaired. Use the type specifiers in the Coding Notes to categorize the nature of the personality change.

If there is a major alteration in the structure of the brain, these personality changes will probably persist. If the problem stems from a correctable chemical problem, they may resolve. When severe, they can ultimately lead to dementia, as is sometimes the case in patients with multiple sclerosis.

Essential Features of Personality Change Due to Another Medical Condition

A physical illness or injury appears to have caused a patient to suffer a lasting personality change.

The Fine Print

From their expected developmental pattern, children will experience a personality change that lasts at least 1 year.

The D’s: • Duration (enduring) • Distress or disability (work/educational, social, or personal) • Differential diagnosis (delirium, other physical or mental disorders)

Coding Notes

Depending on the main feature, specify type:

Aggressive type

Apathetic type

Disinhibited type

Labile type

Paranoid type

Other type

Combined type

Unspecified type

Use the actual name of the general medical condition when you code this disorder, and also code separately the medical condition.

Eddie Ortway

Eddie Ortway, now age 28, had been born in central Los Angeles, where he was reared by his mother—whenever she was neither hospitalized (for drug and alcohol use) nor jailed (for prostitution). His parents, Eddie always suspected, had been only briefly acquainted.

Eddie avoided school whenever possible, and grew up with no role model in sight. His principal accomplishment was learning to use his fists. By the time he was 15, he and his gang had participated in several turf wars. He was making a name for himself as an aggressive enemy.

But Eddie was not a criminal, and the necessity for earning a living soon set him to work. With little education and no training, he found his opportunities pretty much limited to fast food and hard labor. Sometimes he held several jobs at a time. But, as an old probation report noted, he still had “a raging sense of injustice.” Although he gradually stopped associating with his gang, through his middle 20s he continued to deal aggressively with any situation that seemed to require direct action.

His 27th birthday was one of these. Eddie was delivering a pizza to an apartment building in his old neighborhood when he encountered a teenager forcing an old woman into an alley at gunpoint. Eddie stepped forward and for his pains received a bullet that entered his head through the left eye socket and exited at the hairline.

He was admitted to the hospital by way of the operating room, where surgeons debrided his wound. He never even lost consciousness and was released in less than a week. But he didn’t return to work. The social worker’s report noted that Eddie’s physical condition had rebounded within a month, but that he “lacked drive.” He appeared for every scheduled job interview, but his prospective employers uniformly reported that he “just didn’t seem very interested in working.”

“I needed time to recuperate,” Eddie told the interviewer. He was a good-looking young man whose hair had begun receding from his forehead. An incisional scar ran up onto his scalp. “I still don’t think I’m quite ready.”

He had been recuperating for 2 years. Now he was being tested to try to learn why. Other than a slight droop to his left eyelid, his neurological examination was completely normal. An EEG showed some slow waves over the frontal lobes; the MRI revealed a localized absence of brain tissue.

Eddie never failed to cooperate with testing procedures, and all of the clinicians who examined him noted that he was polite and pleasant. However, as one of them put it, “There seems something slightly mechanical about his cooperation. He complies but never anticipates, and he shows little interest in the proceedings.”

His affect was about medium and showed almost no lability. His speech was clear, coherent, and relevant. He denied delusions, hallucinations, obsessions, compulsions, or phobias. When asked what he was interested in, he thought for a few seconds and then answered that he guessed he was interested in going back home. He made a perfect score on the MMSE.

In the time since his injury, Eddie admitted, he had lived on workers’ compensation and spent most of his time watching television. He didn’t argue with anyone any more. When one examiner asked him what he would do if he again saw someone being mugged, he shrugged and said that he thought people should “just live and let live.”

Evaluation of Eddie Ortway

Eddie’s history and examinations presented an obvious general medical cause for his persistent personality change (criterion A). Note that it was the physiology of trauma to the brain that produced Eddie’s personality change. This is the explicit requirement (B) for this diagnosis, which cannot be made when personality change accompanies a nonspecific medical condition such as severe pain.

Eddie’s normal attention span and lack of memory deficit would rule out delirium (D) and major neurocognitive disorder (dementia); however, neuropsychological testing should be requested. A PD such as dependent PD could not explain Eddie’s condition, because his behavior represented a marked change from his premorbid personality (that is, the way he was until his injury). And the features of Eddie’s personality change were not better explained by a different physically induced mental disorder. A mood disorder due to brain trauma would be one of several possible examples.

Besides head trauma, a variety of neurological conditions can cause personality change. These include multiple sclerosis, cerebrovascular accidents, brain tumors, and temporal lobe epilepsy. Other causes of behavioral change that could resemble a change in personality include delusional disorder, intermittent explosive disorder, and schizophrenia. But Eddie’s personality change began abruptly after he was shot, and he had no prior history that was consistent with any of the other disorders mentioned (C). However, many other patients experience apparent personality change associated with mental disorders, including addiction to substances.

The fact that Eddie’s condition impaired him both occupationally and socially completed the criteria (E) for this diagnosis. In his clinical picture, apathy (and passivity) clearly stood out as the main feature. This determined the specific subtype. His GAF score would be a heart-breaking 55.

F60.89 [301.89] Other Specified Personality Disorder

F60.9 [301.9] Unspecified Personality Disorder

The discussion in DSM-5 suggests that patients who have some traits of certain PDs, but who don’t fully meet criteria for any of them, could be listed in one of these two categories. Here’s my problem with that strategy: We would be branding someone who may be much less impaired than is the typical patient with a PD. My personal belief is that it would be better just to note in the summary the traits we’ve identified, and not make a firm diagnosis of any sort.