A. C. Videler

Age-Related Aspects and Clinical Implications of Diagnosis and Treatment of Personality Disorders in Older Adults

To investigate age-related diagnostic and therapeutic aspects of personality disorders in later life (≥ 60 years) and implications in clinical practice, such as the introduction of a specific mental health care program, diagnostic assessment procedure, and treatment criteria for personality disorders in older adults, a Delphi study was conducted among 35 Dutch and Belgian experts in the field of personality disorders in older adults. Consensus on a statement was defined as agreement by two thirds or more of the experts. This Delphi study ultimately yielded consensus concerning 20 of the 21 statements. It was generally agreed that late-onset personality disorder is a useful construct in geriatric psychiatry and that aging can lead to a distinct behavioral expression of personality disorders in older adults. The experts confirmed that a specific mental health program is useful to refine the diagnostic assessment and treatment in older patients with personality disorders as well as older adults with mild psychiatric problems often superimposed on personality disorders, such as adjustment disorders, dysthymic disorders, and diffuse anxiety disorders. The Longitudinal, Expert, and All Data (LEAD) standard combined with a stepwise, multidimensional diagnostic approach appears highly suitable for personality assessment. Finally, stratification of subjects among four treatment levels was regarded as a useful strategy and there was agreement concerning specific criteria for each level of treatment. In conclusion, it is recommended that age-specific aspects in the diagnosis and treatment of personality disorders be included in guidelines and protocols and addressed in future scientific research. Further research is indicated involving cross-validation studies of these Delphi statements in other countries and evaluation of the clinical implementation of the specific mental health care program, diagnostic assessment procedure, and treatment criteria on clinical utility.

Effects of schema group therapy in older outpatients: a proof of concept study

BACKGROUND Short-term group schema cognitive behavior therapy (SCBT-g) showed improvements in overall symptomatology, early maladaptive schemas (EMS) and schema modes, both in adults and adolescents with personality disorder (PD) features and long-standing mood disorders. However, no research has yet been carried out on the effect in older adults. Therefore, in a proof of concept study, we explored the effect of SCBT-g in older outpatients with PD features and longstanding mood disorders. METHOD Thirty-one older outpatients, aged 60-78 years with PD features and/or longstanding mood disorders were included in a proof of concept study with pre-mid-post design. Primary outcome was psychological distress (Brief Symptom Inventory) and intermediate outcomes were EMS (Young Schema Questionnaire) and schema modes (Schema Mode Inventory), assessed at baseline, mid-treatment and end-of-treatment. Paired samples t-tests were conducted, and Cohens d effect sizes reported for pre mid- and post-treatment. As proof of concept analysis, hierarchical regression analyses with residual change scores were used to analyse whether early process changes in EMS (intermediate outcomes) predicted later outcome changes in symptoms. RESULTS SCBT-g led to significant improvement in all three measures of psychological symptoms, EMS and modes with medium effect sizes. Pre-treatment to mid-treatment changes in schema severity predicted symptom improvement from mid- to end-of-treatment. CONCLUSION This proof of concept study shows that SCBT-g has potential to change EMS and to show significant effect at symptom level in older outpatients with PD features. A control condition in a randomized controlled trial is a necessary step for further research.

Schema therapy with older adults: call for evidence

Although there is a considerable body of evidence supporting the efficacy of psychotherapy for personality disorders (PD), as yet, effect studies focusing on treatment of PD in older adults are lacking. In a literature search (1980–2011) with Pubmed Medline and PsycINFO with the terms “personality disorders,” “psychotherapy,” “treatment,” “elderly,” and “older adults,” it appeared that no randomized and controlled effect studies have been conducted on the treatment of PD in later life. Just one study examined the efficacy of dialectical behavior therapy (DBT) in a small randomized clinical trial among older people with comorbid depression and PD ( N = 35; Lynch et al ., 2007). However, it is surprising that the number of PD in remission (in total 16 out of 35) was almost the same with medication treatment alone ( n = 7) compared to combined treatment of medication and DBT ( n = 9). Moreover, this study was not exclusively focused on the treatment of PD.

Psychotherapeutic Treatment Levels for Personality Disorders in Older Adults

Treatment of personality disorders (PDs) in older adults is a highly underexplored topic. In this article clinical applicability of the findings from a recent Delphi study regarding treatment aspects of PDs in older adults is explored. This concerns the relevance of three psychotherapeutic treatment levels for PDs in later life: (a) personality-changing treatment, (b) adaptation-enhancing treatment, and (c) supportive-structuring treatment. By means of three cases concerning the three levels, all from a cognitive behavioral perspective, namely (a) schema therapy, (b) cognitive behavioral therapy, and (c) behavioral therapy, we illustrate the usefulness of the different levels in the selection of treatment for older adults with PDs. Throughout all treatment levels, attention to specific age-related psychotherapeutic topics—such as loss of health and autonomy, cohort beliefs, sociocultural context, beliefs about and consequences of somatic comorbidity, intergenerational linkages, and changing life perspectives—is crucial, as they often cause an exacerbation of personality pathology in later life. Suggestions as to how to adapt existing treatments within a cognitive behavioral framework in order to better mold them to the needs and experiences of older adults with PDs are discussed.

De Korte Personologische Psychotherapie als model voor de behandeling van persoonlijkheidsstoornissen bij ouderen

SamenvattingIn dit artikel wordt een kortdurende methode tot gedrags- en schemaverandering voor mensen met persoonlijkheidsstoornissen voorgesteld: de Korte Personologische Psychotherapie van Everly (1996). Deze methode hebben wij toegepast bij ouderen. Over psychotherapie bij ouderen met persoonlijkheidsstoornissen zijn opvallend weinig publicaties verschenen. De bestaande interventies bij persoonlijkheidsstoornissen kunnen geplaatst worden op een continuüm dat reikt van steunend-structurerende interventies aan de ene pool tot schemaveranderende cognitieve therapie aan de andere. Tussen deze beide behandelvormen zou de Korte Personologische Psychotherapie van Everly bruikbaar kunnen zijn. Hierbij dienen de bekrachtigers van de persoonlijkheidsstoornis als basis voor veranderingen in gedrag en cognities. De therapeut bevestigt in eerste instantie het belang van de bekrachtigers om vervolgens met de cliënt een overeenkomst aan te gaan voor de noodzaak tot gedragsverandering. De verschillende stappen van dit model worden nader toegelicht aan de hand van twee gevalsbeschrijvingen. De Korte Personologische Psychotherapie is een laagdrempelige behandelmethode die zou kunnen aansluiten bij de hulpvragen waarmee ouderen met persoonlijkheidsstoornissen zich melden bij de GGz.AbstractWe present here a brief method for initiating behaviour and schema change in personality disorders: the Brief Personologic Psychotherapy by Everly (1996). We applied this treatment model to older people. There are remarkably few publications on psychotherapy with elderly people with personality disorders. The existing interventions for personality disorders can be seen as a continuum ranging from supportive therapy to schema change cognitive therapy. Brief Personologic Psychotherapy can be placed half way on this continuum. The method begins with the reinforcers of the personality disorder. The therapist initially affirms the importance of the reinforcers, then seeks the agreement of the client that his problems necessitate behaviour change. The different phases of the model are described, illustrating how the client progresses to behaviour and schema change. Two case histories show the different phases of the therapy and illustrate that the treatment of personality disorders in elderly people is more than an adaptation therapy. It appears to be also a behaviour and schema change model of therapy. Brief Personologic Psychotherapy is a low threshold form of therapy which could closely connect to the demand for help with which elderly people with personality disorders turn to mental health services.

Schema therapy for personality disorders in older adults : a multiple-baseline study

ABSTRACT Objective: No studies have been conducted yet into the effectiveness of treatment of personality disorders in later life. This study is a first test of the effectiveness of schema therapy for personality disorders in older adults. Method: Multiple-baseline design with eight cluster C personality disorder patients, with a mean age of 69. After a baseline phase with random length, schema therapy was given during the first year, followed by follow-up sessions during six months. Participants weekly rated the credibility of dysfunctional core beliefs. Symptomatic distress, early maladaptive schemas, quality of life and target complaints were assessed every six months and personality disorder diagnosis was assessed before baseline and after follow-up. Data were analyzed with mixed regression analyses. Results: Results revealed significant linear trends during treatment phases, but not during baseline and follow-up. The scores during follow-up remained stable and were significantly lower compared to baseline, with high effect sizes. Seven participants remitted from their personality disorder diagnosis. Conclusion: Schema therapy appears an effective treatment for cluster C personality disorders in older adults. This finding is highly innovative as this is the first study exploring the effectiveness of psychotherapy, in this case schema therapy, for personality disorders in older adults.

Challenges and Developments in the Assessment of (Mal)adaptive Personality and Pathological States in Older Adults

Since older adults often show an atypical presentation of (mal)adaptive personality traits and pathological states, the articles in this special issue will concisely discuss some perennial issues in clinical assessment in older adults and thus outline the main challenges this domain faces. By bringing empirical work and meta-analytic studies from leading scholars in the field of geropsychology, the articles will also address these challenges by reporting the latest developments in the field. This way, we hope to reshape the way clinicians and researchers assess (mal)adaptive personality and pathological states in older adults into a more reliable and valid assessment method that integrates the specific biopsychosocial context of older age.

Cognitive behavioral therapy for somatic symptom disorders in later life: a prospective comparative explorative pilot study in two clinical populations

Background Elderly patients with somatic symptom disorder (SSD) put a great burden on the health care delivery system. Cognitive behavioral therapy (CBT) is effective in adults with SSD. However, no studies have been conducted yet into CBT for SSD in later life. Objectives We explored the feasibility of CBT for SSD in the elderly. Methods This is a prospective pilot study comparing two outpatient specialty mental health settings for adults (<60 years; n=13) and for elderly patients (≥60 years; n=9) with SSD. Intervention was 18 structured, protocoled, and supervised CBT sessions. Outcomes were somatic symptoms, pain intensity, pain disability, quality of life, depressive symptoms, and generalized anxiety symptoms. Feasibility of the CBT intervention was explored with self-developed questions, both for the therapists and the patients. Results Both therapists and elderly patients evaluated the treatment as positive. Somatic symptoms improved significantly in the adult group but not in the elderly group. There was a large, significant decrease in pain intensity and pain disability in elderly patients compared to the adults. Social functioning, vitality, and anxiety symptoms improved significantly in the adults. Presence of chronic medical conditions did not influence these results. Conclusion This study shows that CBT is feasible as a treatment for SSD in older adults and has encouraging results. Replication in an RCT is warranted.

Effects of schema group therapy in older outpatients: a proof of concept study – CORRIGENDUM

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Behandeling van persoonlijkheidsstoornissen bij ouderen: drie gevalsbeschrijvingen

SamenvattingBehandeling van persoonlijkheidsstoornissen bij ouderen is een sterk onderbelicht thema. In dit artikel wordt met behulp van drie gevalsbeschrijvingen geïllustreerd dat a) de behandeling van persoonlijkheidsstoornissen bij ouderen zinvol is; b) het onderscheid tussen drie behandelingsniveaus, namelijk persoonlijkheidsveranderende, adaptatiebevorderende en steunend-structurerende behandeling, relevant is in de klinische praktijk; c) op de verschillende behandelingsniveaus rekening gehouden moet worden met gerontologische aspecten, onder andere het toenemend aantal verlieservaringen, hoe ouderen aankijken tegen somatische aandoeningen en de beperkende gevolgen die deze met zich meebrengen, hun veranderend levensperspectief, cohortgebonden en socioculturele overtuigingen, en het belang van intergenerationele relaties. Empirisch onderzoek is nodig naar de generaliseerbaarheid van de bevindingen op basis van de drie gevalsbeschrijvingen.