Chapter 18. Personality Disorders
© American Psychiatric Publishing
Compared with many other psychiatric disorders, personality disorders are relatively difficult and time intensive to diagnose and treat. In elderly persons, personality problems are confounded by a variety of additional issues, both negative and positive. The natural history of personality in later life is affected by the combination of increasing medical-neuropsychiatric comorbidity with ongoing normal psychosocial development.
As a person ages, the likelihood of multiple chronic diseases increases. The existence of comorbidity results in more functional impairment and requires adaptation (Marengoni et al. 2011). It can become more difficult to ascertain the primary cause of increased impairment and to determine where best to focus therapeutic interventions. The risk of neurocognitive disorders also increases dramatically in later life. A common feature of dementias is a change in personality or an exacerbation of preexisting characteristics. Without longitudinal history it can be difficult to know whether such presentations are manifestations of a personality disorder, a neurocognitive disorder, or both.
It is not uncommon for geriatric psychiatrists to comment that problems related to personality disorders are less frequently a focus in their patients compared with the patients of their general psychiatry colleagues. Prevalence studies tend to support this observation. If these prevalence studies are valid, there are several explanations as to why at least some personality disorders might fade with age. One that deserves attention is that of maturation, described in adult development theory and research.
Although general research in personality disorders has increased, there is a relative dearth of such studies with respect to elderly persons (Agronin and Maletta 2000). This lack is particularly clear in the area of treatment. Substantial evidence shows the negative effect of personality disorders on the outcome of depressive disorders in elderly persons. In contrast to research on personality disorders, there has been a dramatic increase in research on the relationship of personality traits in the elderly to cognitive dysfunction, morbidity, and mortality (Oldham and Skodol 2013). Although certain personality traits are significantly related to poor outcomes, evidence on the benefits of treatment for personality traits or disorders in elderly persons remains limited. There is even less evidence on treatment and outcomes in nursing homes and general hospitals, the settings in which the geriatric psychiatrist is most likely to be called on to diagnose and treat personality disorders and traits.
Definitions
Personality refers to an individual’s “enduring patterns of perceiving, relating to, and thinking about the environment and oneself” (American Psychiatric Association 2013, p. 826). Personality consists of both temperament (i.e., genetic dispositions) and character (i.e., qualities developed through interaction with the environment) (Robinson 2005). For a patient to be diagnosed with a personality disorder, DSM-5 requires that the individual have an enduring pattern of experience and behavior that is noticeably different from cultural expectations, as manifested in two or more of the following domains: cognition, affectivity, interpersonal functioning, and impulse control. The pattern must have developed by early adulthood and must be intractable and relatively stable across the lifespan. A personality disorder influences a wide range of both social and personal situations. As is the case with all DSM-5 disorders, a personality disorder results in significant distress or functional impairment. Finally, the enduring pattern must not be a manifestation of another mental disorder, a medical disorder, or use of a substance.
In treating elderly persons, ruling out manifestations of other disorders is particularly important because of the high prevalence of chronic medical disorders. When a change in personality occurs because of the comorbidity of another mental disorder, a medical disorder, or use of a substance, the DSM-5 diagnosis of personality change due to another medical condition is the appropriate diagnosis. However, dementias are also increasingly prevalent with age and are often associated with changes in personality. A change in personality is often the chief complaint when an older individual is brought by caregivers for a specialist evaluation (Duchek et al. 2007). These changes may be totally unrelated to premorbid personality, as occurs in frontal lobe dementias (Rabinovici and Miller 2010), or may be marked exaggerations of preexisting traits, as occurs in Alzheimer’s disease (Archer et al. 2007). Because of the progressive pervasiveness of neurocognitive disorders, the DSM-5 diagnosis of personality change due to another medical condition does not apply. Although these issues are important in differential diagnosis, for the purposes of this chapter the discussion of personality disorder is focused more closely on conditions that meet DSM-5 personality disorder criteria.
After making a global assessment of the presence or absence of a general personality disorder based on the key features listed previously, the next step is to identify a specific personality disorder or a personality cluster. Since 1980, DSM has categorized three different personality disorder clusters (Table 18–1): Cluster A—odd, eccentric (including paranoid, schizoid, and schizotypal personality disorders); Cluster B—dramatic, emotional, erratic (including antisocial, borderline, histrionic, and narcissistic personality disorders); and Cluster C—anxious, fearful (including avoidant, dependent, and obsessive-compulsive personality disorders). The number of specific disorders has varied slightly over the past 20 years. Likewise, over the length of a lifespan often reaching 75–85 years, both personality and a personality disorder are likely to change somewhat; therefore, attention to identification of a cluster is particularly helpful. Because older patients with personality disorders commonly show symptoms of more than one personality disorder, diagnosis of a specific disorder is likely to be more difficult than in younger adults; in these cases, patients should be diagnosed with other specified personality disorder or unspecified personality disorder.
Definitions Personality disorders and related aspects of aging
Cluster and types | Characteristics | Developmental needs | Related aspects of aging |
|---|---|---|---|
A. Odd, eccentric | |||
Paranoid
|
Perception that people are dangerous; vigilance, suspiciousness
|
Trust, acceptance
|
Forced intimate contact from physical dependence highlights the disorder.
|
Schizoid
|
Isolation, autonomy
|
Reciprocity, intimacy
|
The disorder is relatively persistent.
|
Schizotypal
|
Bizarre behavior
|
Trust, social skills, abstract thinking
|
Individuals without the disorder who experience theft and ageism, leading to appropriate suspiciousness, may be misdiagnosed.
|
B. Dramatic, erratic | |||
Antisocial
|
Exploitiveness, taking advantage of others
|
Empathy
|
Elderly individuals are more law abiding, and antisocial personality is less common in older prisoners.
|
Borderline
|
Sensitivity to rejection, feelings of abandonment
|
Reflection, systematization
|
Prevalence and/or severity of the disorder declines.
|
Histrionic
|
Expressiveness, exhibitionism
|
Self-esteem beyond attractiveness, reflection
|
With older age there is less energy and less opportunity for promiscuity, shoplifting, and impulse expression.
|
Narcissistic
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Self-aggrandizement, perceived specialness, competitiveness
|
Group identification, ability to share
|
Increased losses, such as retirement and bereavement, aggravate regulation of self-esteem.
|
C. Anxious, fearful | |||
Avoidant
|
Vulnerability, inhibition
|
Self-assertion, expressiveness
|
This disorder is associated with poor outcome in major depression.
|
Dependent
|
Helplessness, attachment
|
Mobility, self-reliance
|
Individuals without the disorder who have fewer social opportunities and more medical illnesses may be subject to overdiagnosis.
|
Obsessive-compulsive
|
Perfectionism, responsibility, systematization
|
Playfulness, spontaneity
|
The disorder is relatively persistent.
|
Prevalence, Criteria, and Controversies
The prevalence of personality disorders in the general population is less accurately known than that of other mental disorders but is estimated at 9%–15% for all ages, with a high prevalence of other comorbid mental disorders (Grant et al. 2004; Lenzenweger et al. 2007). The prevalence of personality disorders in psychiatric settings is usually two to three times higher than that in the community (Schuster et al. 2013).
The prevalence of personality disorders in the general population of older persons (3%–13%) is lower by about half than in younger persons (Agronin and Maletta 2000; Schuster et al. 2013). As in the general population, the prevalence in selected outpatient or inpatient samples of older persons is much higher than in community settings (Agronin and Maletta 2000; Ames and Molinari 1994). In part, the lower prevalence of personality disorders in the elderly appears to be due to a decline in severity over the years, especially of Cluster B disorders (Hunt 2007; Tracie Shea et al. 2009; Tyrer and Seiverwright 1988). Zanarini et al. (2007) reported the results of a 10-year follow-up study of 362 patients with personality disorders diagnosed at an inpatient admission. Twelve of 24 symptoms followed showed patterns of sharp decline, reported by less than 15% of patients who reported them at baseline. Symptoms related to impulsivity (such as self-mutilation and suicide attempts) and entitlement resolved relatively quickly. Mood symptoms such as anger, loneliness, and emptiness were more stable. In a subsequent 16-year follow-up, Zanarini et al. (2013) found a corresponding improvement to more mature, adaptive defense mechanisms in patients with borderline personality disorder.
The association of personality disorders with depressive disorders in the elderly population is probably the single most reported psychiatric comorbidity. This association of personality disorders and depressive disorders is an important relationship because the presence of a personality disorder in the context of a depressive disorder complicates differential diagnosis and treatment planning (Lynch et al. 2007). For depressive disorders, the worst outcomes occur among patients with comorbid personality disorders (Abrams et al. 2001; Morse and Lynch 2004). This comorbidity is associated with a longer time to response and greater nonresponse to treatment. Expectations about treatment outcomes with antidepressants, electroconvulsive therapy, or hospitalization are thus lowered, and decisions about the need for psychotherapy are increased. The relationship between personality disorder and depression may be etiological; that is, personality disorders predispose to the occurrence of affective dysregulation and depressive disorders (Galione and Oltmanns 2013).
The reports of lower prevalence of personality disorders in older individuals have raised substantial controversy. There is some concern that the criteria for personality disorders may not be equally valid across the lifespan (Balsis et al. 2007) and therefore falsely lower the prevalence in the elderly population. One suggested response is to modify the criteria for personality disorders in later life (Agronin and Maletta 2000).
Another suggested response is to adopt a dimensional approach (Oldham and Skodol 2013). Personality researchers frequently use dimensional concepts relating to personality traits, rather than the categorical language of disorders (Widiger and Mullins-Sweatt 2009). From this perspective, the categorical diagnostic approach is problematic because of co-occurring disorders, heterogeneity within diagnoses, and the limited evidence base. There has been a relative explosion of aging-related research linking personality traits to a variety of outcomes, including depression (Hayward et al. 2013), cognitive function (Kuzma et al. 2011), dementia (Dar-Nimrod et al. 2012; Low et al. 2013), telomere length (van Ockenburg et al. 2014), health and physical functioning (Roberts et al. 2009), and mortality (Iwasa et al. 2008). The most frequent model of personality traits is the five-factor model consisting of neuroticism, extraversion, openness, agreeableness, and conscientiousness (Digman 1990). In general, higher levels of neuroticism (having more anxiety, depression, and vulnerability to stress) are associated with poorer outcomes, whereas higher levels of extraversion (being more outgoing and sociable) and conscientiousness (being better organized and having more self-discipline and willpower) are associated with better outcomes. In nonclinical samples younger persons are somewhat higher on traits of extraversion, neuroticism, and openness, whereas older persons are higher on agreeableness and conscientiousness, with most of the change occurring in young adulthood rather than later life (Roberts et al. 2006). Perhaps most important with respect to geriatrics is that longitudinal studies of twins show that childhood personality change is primarily due to genetics, whereas the majority of personality change in adulthood is environmental, including change caused by experience and by disease (Roberts et al. 2006).
The developers of DSM-5 revisited a dimensional versus a categorical approach but ultimately remained with the DSM-IV categorical model (Oldham and Skodol 2013). Although a dimensional approach may improve description and identification, it is less clear how the approach would be used in treatment, other than to revert to a categorical approach that uses cutoff scores on the dimensional scales. The dimensional approach included for further study in Appendix B of DSM-IV (American Psychiatric Association 1994, 2000) involved a “Defensive Functioning Scale” for defense mechanisms (Vaillant 1994). In this approach, defense mechanisms were categorized into seven levels ranging from high adaptive (e.g., altruism) to defensive dysregulation (e.g., delusional projection). This approach has been replaced with the “Alternative DSM-5 Model for Personality Disorders,” based on the five-factor model, which is located in Section III of DSM-5 (Widiger and Mullins-Sweatt 2009). This DSM-5 approach is proposed as a truly alternative model for clinical use, if preferred, rather than as a proposed axis for further study.
Rather than different criteria being needed for the elderly population, it is possible that the criteria are relevant but that prevalence is reduced by mortality, particularly if there is comorbid substance abuse (Vaillant 2012). It is also possible that at least some disorders, particularly those in Cluster B, do improve with age (Tyrer and Seiverwright 1988; Zanarini et al. 2007). For example, older substance abusers show lower levels of crime and drug use compared with when they were younger (Hanlon et al. 1990), older homicide offenders are far less likely to have personality disorders than younger offenders are (Putkonen et al. 2010), and in general the elderly are more law abiding, with far fewer arrests (Harlow 1998). Therefore, it is not inconsistent for older patients with personality disorders to exhibit fewer “high-energy” diagnostic criteria (e.g., lawbreaking, identity disturbance, promiscuity). Do these findings mean that a maturational change has occurred or merely that the symptom displays are more subtle because of physical and institutional restrictions (Hillman et al. 1997)? Although arguments for modified criteria may ultimately be valid, equal theory and evidence from adult development research at least support the current criteria and the resulting epidemiological findings.
Adult Development
Erikson’s concept of epigenesis is important in understanding how personality disorders might improve with age. Erikson was a strong proponent of the interaction of the psychosocial environment with development across the lifespan. Erikson’s stage theory of late-life development (Erikson et al. 1986) proposed that the major developmental task of older age is to look back and seek meaning across the lifespan, rather than looking forward as in previous developmental modes that are now in decline. The goal of this task, as discussed by Erikson, is to maintain more integrity than despair about one’s life. In this process, as at previous life stages, each earlier life stage conflict must be reconciled and integrated with the current stage, allowing resolution of earlier conflicts. Individuals with personality disorders might be expected to have greater difficulty in accomplishing this resolution than other individuals. However, this resolution is not an all-or-nothing phenomenon. The achievement of even some resolution may contribute to the mellowing of a personality disorder. As Vaillant (2012) has pointed out through his extended involvement with longitudinal research, “If you follow lives long enough, they change as do the factors that affect healthy adjustment” (p. 52).
Vaillant and others (e.g., Diehl et al. 1996) have provided empirical verification for Erikson’s life-stage concepts through longitudinal study of the maturation of defenses across the lifespan (Vaillant 2012). Defenses are involuntary mental mechanisms for regulating the realities that persons are powerless to change. Vaillant and others (Haan 1977) have described a hierarchy of defenses from immature and maladaptive to mature and adaptive. Mature defenses include humor, altruism, sublimation, anticipation, and suppression. Mature and adaptive defenses synthesize and attenuate conflicts rather than distorting or denying them. Across several longitudinal studies that included privileged persons (Vaillant 2012), gifted persons (Terman 1925), and persons from the core inner cities (Glueck and Glueck 1968), Vaillant established that mature defenses were more consistently identified primarily in Erikson’s later developmental stages (Vaillant 1993) and that the development of these defenses was independent of education and social privilege (Vaillant 1993, 2012). Similarly, others have identified a socioemotional selectiveness for optimizing positive emotional meaningfulness with age (Charles and Carstensen 2010) and improved coping skills with aging (Ryff 1999).
Events with psychological and social impact can reveal previously submerged difficulty. For example, the death of a spouse may unmask dependency problems. Retirement or bereavement may lead to narcissistic problems such as poor regulation of self-esteem and faulty adaptation to loss. However, experience—something that the elderly have more of than any other age group—may attenuate the impact of such later-life events, even for older persons with personality disorders (Birditt and Fingerman 2005; Ryff 1999). For example, to cope effectively with stress, individuals must learn to recognize the difference between situations that can and cannot be changed and then must match the right coping skill with the right situation. Emotion-focused coping is used when a situation cannot be changed; problem-focused coping is used when a situation can be changed. It is only through repeated experience that these skills develop (Ryff 1999). Although stressful situations certainly exacerbate the symptoms of personality disorders, Neugarten (1970) pointed out how the meaning of stressful situations changes over time. People expect to experience the death of loved ones and anticipate their own declining health as they age and have time to mentally rehearse how they will respond to these “on-time” losses. When these losses occur “off time”—at earlier stages of life—the stress is usually experienced as much greater. The improvement in coping skills with aging is also accompanied by socioemotional selectivity—that is, the tendency of elderly persons to remember more pleasant events and positive emotions in favor of unpleasant ones (Charles and Carstensen 2010; Erikson et al. 1986; Nashiro et al. 2012; Vaillant 2012).
Consideration of this line of evidence should not minimize the impact of personality disorders or the need for some management of them in later life. Even if the prevalence of personality disorders truly does decline, there are still some elderly persons with continuing disorders that cause impairment to themselves and their environment. Consideration of adult development helps us understand how some persons with personality disorders may improve and to understand that this improvement is consistent with the epidemiological findings of reduced psychopathology in later life. Equally important, adult developmental theory helps the clinician consider the positive aspects of development, even in individuals with severe psychopathology (Erikson et al. 1986; Ryff 1999). Some people who experienced a terrible childhood and young adulthood can still find enjoyment at the end of life. Waiting 50 or more years for relative happiness is a long time, so assisting in positive adaptation can certainly be worthwhile (Vaillant 2012). Until the debate on the validity of the epidemiological findings versus the criteria used to make those findings is more definitively settled, perhaps designations of personality disorder “in remission” or “in partial remission” would be a more appropriate and parsimonious way of addressing diagnoses of personality disorder in the elderly population.
Evaluation
Because personality disorders typically have a lifelong pattern, diagnosis generally requires greater historical and collateral information than for many other disorders. Complete understanding of the causes of signs and symptoms in geriatric psychiatry is a difficult accomplishment. The interplay of multiple etiological factors is the rule rather than the exception. The Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II; First et al. 1997) and the Personality Disorders Examination (PDE; Loranger 1988) are semistructured interviews for personality disorders that can be used to guide a diagnostic interview and increase reliability. Historical information, from medical records and from persons who have known a patient over a long period, is still an essential component of an accurate and valid diagnosis. The interview requires a longitudinal inquiry about various life stages to establish the historical presence of a personality disorder, even if not all current criteria are met. Several ancillary self-report instruments are available for initial screening purposes. However, the results of these self-reports have a low concordance with the results of interview methods (Perry 1992), and their use is best established and tolerated in younger populations, not among elderly persons, in whom acquired brain disease is an increasing issue.
General personality inventories, as opposed to personality disorder instruments, are more valid and reliable dimensional assessment tools that have also been used with elderly patients. Originally derived through empirical lexical research into natural language trait descriptions, a significant body of research has repeatedly identified five broad domains of personality (Digman 1990). The NEO Personality Inventory—Revised (NEO PI-R; Costa and McCrae 1992), which uses a neuroticism (e.g., worrying vs. calm), extraversion (e.g., joiner vs. loner), openness (e.g., preference for variety vs. routine), agreeableness (e.g., trusting vs. suspicious), and conscientiousness (e.g., hardworking vs. lazy) five-factor model with 30 facets, is the most commonly used and researched personality inventory (Widiger and Mullins-Sweatt 2009). The NEO PI-R has also proved useful as a screening tool for personality disorders (Miller et al. 2005). The NEO PI-R has been validated in a geriatric population and appears valid for screening of paranoid, borderline, histrionic, avoidant, and dependent personality disorders (Van den Broeck et al. 2013). However, the NEO PI-R has more than 200 items, and copyright fee issues make it unwieldy for routine clinical use. Although DSM-5 did not make the recommended paradigm shift to a dimensional model of personality disorders (Oldham and Skodol 2013; Widiger and Mullins-Sweatt 2009), Section III of DSM-5 provided an “Alternative DSM-5 Model for Personality Disorders,” including a five-factor personality trait model with personality disorders understood as maladaptive variants of five domains and 25 facets. The five broad trait domains in DSM-5 are negative affectivity versus emotional stability, detachment versus extraversion, antagonism versus agreeableness, disinhibition versus conscientiousness, and psychoticism versus lucidity. The Personality Inventory for DSM-5 (PID-5; Krueger et al. 2012), an instrument derived from this model, is an “emerging measure” available for free at the American Psychiatric Association Web site (www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures). For most clinicians, patients, and families, the full-length 220-item instrument is probably too cumbersome for routine use; therefore, brief forms are also available. Notably for geriatric psychiatry, the PID-5 does not sufficiently focus on the positive dimensions of adult development, which should be accorded equal importance with negative dimensions when personality is being evaluated.
Geriatric psychiatrists are familiar with the phenomenon that acquired brain disease in later life appears to strengthen undesirable personality traits that were present, although less intense and conspicuous, in earlier adult life. However, if signs and symptoms of personality disorder were not present before the onset of a neurocognitive illness or brain injury, it is rational to assume that such illnesses play a causative role in the personality change. A reasonable approach to a diagnosis in geriatrics, as always, includes these elements: 1) careful and detailed review of the medical and psychosocial history; 2) mental status and physical examinations, with special attention to the neurological examination; and 3) a screening laboratory examination—including, in some cases, brain imaging, an electroencephalogram, and neuropsychological tests.
In many instances, family members are better able than older patients to provide the historical information that provides the best clues about the patient. Whenever possible, their help should be sought concerning the older patient in whom personality disorder is suspected. Viewing the patient within the family context usually gives added depth of understanding to the clinical perspective.
Syndromes based on frontal lobe pathology that result in loss of normal executive function present some of the most difficult diagnostic challenges, especially if the onset of symptoms is subtle, the rate of progression is slow, and the main attributes of the premorbid personality are obscure. Individuals with frontal or frontotemporal lobe disease may show good preservation of memory function. They are, however, prone to trouble with “mechanistic planning, verbal reasoning, or problem solving” and “obeying the rules of interpersonal social behaviour, the experience of reward and punishment, and the interpretation of complex emotions” (Grafman and Litvan 1999, p. 1921; Passant et al. 2005).
These difficulties are similar to some of the problems experienced by many people with borderline, narcissistic, histrionic, paranoid, and antisocial personality disorders. A question of interest is whether a person can develop a later-life personality disorder de novo, without the presence of underlying brain disease or substance abuse. The answer is not definitively known, but the occurrence is probably rare and such a diagnosis is not allowed in DSM-5, which requires onset of personality disorder by early adulthood. Also of relevance, signs and symptoms of personality disorders can be quite evident in early adult life, then be diminished or quiescent in mid-adult life, and then reemerge under the stress of social losses or physical illness in later life (Rosowsky and Gurian 1992). Additionally, the manifestations of personality disorders may vary in different parts of the life cycle. For example, in persons with borderline personality disorder, phenomena such as splitting, intense and unstable interpersonal relationships, impaired affective regulation, and extreme difficulty with control and regulation of anger often persist throughout the life cycle. Problems such as severe impulsivity, risky behavior, and self-mutilation tend to diminish with advancing age (Zanarini et al. 2007). However, other self-injurious behaviors may take their place. These include self-starvation, abuse of medications, and noncompliance with medical treatment (Rosowsky and Gurian 1992). These behaviors may occur for other reasons, but their presence should at least alert the clinician to the possibility of borderline personality disorder. Notably, late-onset obsessive-compulsive symptoms or traits are particularly likely to have a basis in brain disease.
Treatment Issues
The broad focus of personality disorder treatment is on reducing symptoms, improving social functioning, and changing responses to the environment (Robinson 2005). Off-label use of psychotropic agents is sometimes valuable for symptom reduction, whereas psychotherapy and caregiver education are helpful for addressing environmental response. All of these possibilities should be considered for their contribution to improved function of older persons.
Psychotherapy
In contrast to the unconscious maturation of defenses, the conscious alteration of personality is unusual. Although individuals are sometimes able to change patterns of behavior, attitudes, ways of thinking, and ways of feeling, changing the fundamental personality structure is extremely difficult. At the same time, it is possible and important to try to help patients avoid behavior that significantly harms themselves or others. Validating feelings and empathizing with distress, without necessarily agreeing to the proportionality of the response, is a first step in the therapeutic relationship (Hunt 2007). Helping patients recognize and alter erroneous or distorted thinking is thus also important and possible. Cognitive-behavioral therapy, and its variant Dialectical Behavior Therapy (Lynch et al. 2007), or insight-oriented psychotherapy may significantly help older individuals who are functioning at higher levels and who are not otherwise seriously ill or incapacitated (Beck et al. 2004; Clarkin et al. 2007; Hunt 2007). For patients in psychiatric hospitals and for residents of group homes or nursing homes, intensive psychotherapy with a goal of changing lifelong maladaptive personality features is neither an available nor an indicated treatment modality. However, for such individuals, supportive and consistent psychotherapeutic contact can be of great benefit (Hunt 2007).
As noted, psychotherapy of any type, either by itself or in combination with pharmacotherapy, with a goal of a global revision of maladaptive aspects of personality in later life, is unlikely to succeed. Individualized treatment targeting specific symptoms that discomfort, threaten, or endanger patients or their family or caregivers—for example, behavioral management to minimize harm from impaired social judgment—is far more realistic and more likely to realize success. However, it is still important not to be rigid or negative about the psychotherapeutic potential of older individuals. It is illness, not merely age, that limits or impairs the plasticity of the personality and the potential for self-change. Older patients are often impressive in their resilience, courage, open-mindedness, and willingness to try new ways of thinking and behaving—and those showing these characteristics include some individuals whose adaptation to life in earlier years was far from optimal (Vaillant 2012). This observation is in keeping with Erikson’s view of progressive development throughout life. Psychoanalytically oriented psychotherapy, cognitive-behavioral therapy, interpersonal therapy, dialectical behavior therapy, and other forms of psychotherapy all have their adherents and proponents (De Leo et al. 1999). All are probably helpful to certain individuals. The principal features of successful psychotherapy for geriatric patients are a structure with consistency, availability, empathic and respectful listening, flexibility, and open-mindedness on the part of the psychotherapist. These features are probably more important than a particular theoretical orientation (Clarkin et al. 2007).
Therapists who are not yet old themselves have a difficult challenge. They have no direct experience with or memory of being old (Rosowsky 1999). Some geriatric psychiatrists may be two full generations younger than their patients. Extraordinary empathy is required of these clinicians, but also of most practicing geriatric psychiatrists, who are usually caring for persons older than themselves.
A diagnosis of personality disorder should not preclude pharmacological treatment of concomitant psychiatric disorders, such as affective illness or psychosis, as well as specific symptoms that may respond to psychotropic medications. Successful treatment of affective or psychotic symptoms may show that the symptoms were the result of these eminently treatable diseases rather than entrenched maladaptive personality traits. Personality disorder, depressive illness, and acquired brain disease share overlapping symptom constellations: symptoms such as irritability, hostility, and uncooperativeness can derive from all three. Even the most perspicacious diagnostician may not be able to tease out a clear etiological diagnosis for these difficult behavioral symptoms. In such cases, an empirical treatment trial with antidepressant medicine is indicated. Preliminary evidence suggests that selective serotonin reuptake inhibitors (SSRIs) (Knutson et al. 1998; Tang et al. 2009) and second-generation antipsychotics (Black et al. 2014) may alter aspects of personality separate from specific symptoms.
Individuals with other symptoms—such as anger outbursts, apathy, and impaired social judgment—may also benefit from pharmacotherapy (Hollander et al. 2003). Pharmacological treatment should be a systematic trial guided by three principles. First, a medication should be selected for an identified target symptom area (e.g., affect, impulsivity, aggression, anxiety) (Table 18–2). Second, such trials should include a repeatable assessment strategy (e.g., global rating, self-report, or caregiver report targeted to the symptom area). Third, trials should have a specified duration at the end of which a decision is made whether or not to continue the medication. SSRIs and other newer antidepressant drugs, anticonvulsants, and atypical antipsychotic drugs, used alone or in combinations, may be useful in systematic trials for specified symptoms. The evidence is limited or mixed for geriatric patients, and caution is indicated, especially because of the side effects of antipsychotics (Maglione et al. 2011).
Pharmacotherapy Symptom areas and pharmacotherapy classes in personality disorders
Symptom area and types | Pharmacotherapy class |
|---|---|
Cognition/perception | |
Loose associations, thought blocking
|
Antipsychotics
|
Overvalued ideas, delusions
| |
Hallucinations, depersonalization
| |
Affect/mood | |
Harm/avoidance
|
SSRIs
|
Depression, lability
|
Mood stabilizers
|
Anger
|
Benzodiazepines
|
Anxiety
| |
Behavior | |
Impulsivity
|
Mood stabilizers
|
Aggression
|
TCAs, MAOIs
|
Novelty seeking
|
Antipsychotics
|
Reward/dependence
| |
Note. MAOI = monoamine oxidase inhibitor; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant.
| |
Caregiver Education
Education of caregivers is an important function of geriatric psychiatrists. Family members may be having great difficulty in dealing with unfamiliar negative, disinhibited, or inappropriate behavior. If an underlying medical or neurological etiology can be discerned, caregivers can be reassured about the cause of the otherwise inexplicable changes in their relationship with their loved one. This reassurance helps reduce guilt, anxiety, and uncertainty in the family of the afflicted person.
Primary caregivers in nursing homes, who are usually overworked and underpaid, may not realize that much of the unpleasant behavior of patients that they encounter in their work is not under full volitional control. Uncooperativeness or angry outbursts may have the appearance of simple willfulness or intentionally oppositional behavior. Patients with long-standing personality disorders (as well as those with dementia, stroke, or other types of brain injury) typically have significant deficits in volitional capacity. Understanding this point does not necessarily make the care of these patients easier, but it does provide a perspective on behavior that is otherwise difficult to comprehend and tolerate. However, at times it may be necessary for the psychiatrist to evaluate the competence of a patient with personality disorder and consider proposing guardianship (Little and Little 2010).
Conclusion
Understanding of the causes of disordered personality development is far from adequate. Diagnosis, and especially treatment, of personality disorders in elderly patients is difficult. Understanding the differentiation between lifelong development and acquired neuropsychiatric illness is an important diagnostic challenge. Geriatric psychiatrists usually try to manage personality disorder symptoms and ameliorate their harmful effects rather than attempt to cure the underlying disorder. Behavioral management, psychotherapy, pharmacotherapy, and caregiver support are the tools that must be judiciously used.
Key Points
- The natural history of personality in later life is influenced by the combination of increasing medical-neuropsychiatric comorbidity and ongoing normal psychosocial maturation.
- Longitudinal history is necessary for determining whether presumed personality problems in later life are a manifestation of a personality disorder, a neurocognitive disorder, or both.
- The prevalence of personality disorders in older persons is generally lower than that in younger persons in the general population.
- Positive adaptation in late-life development can mediate the severity and presentation of personality disorders.
- Substantial evidence shows the negative effect of personality disorders on the outcome of depressive disorders in elderly persons.
- It is possible and important to use psychotherapeutic and caregiver interventions to try to help older patients with personality disorders avoid behavior that significantly harms themselves or others.
- Systematic pharmacological treatment should include a target symptom area, an assessment strategy for that symptom area, and a specified duration of treatment
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