Erlene Rosowsky

Issues regarding the proposed DSM-5 personality disorders in geriatric psychology and psychiatry

The official introduction of the psychiatric diagnosis of personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) began in 1952 with the publication of the first edition (American Psychiatric Association, 1952). DSM-I contained 12 main types of PDs with a total description for all types in only two paragraphs. In the following DSM-II (American Psychiatric Association, 1968), just 10 specific types of PDs were described, including a very brief general definition of PDs. The DSM-III (American Psychiatric Association, 1980) included a significant paradigm shift from the medical model by incorporating the design of a multi-axial approach, in which the combinations of symptoms of more than five primary axes were used to describe the pathological state and formulate the diagnosis. Notably, the PDs were placed on a separate axis (Axis II) to distinguish their long-standing nature from the more episodic clinical disorders placed on Axis I. PDs were recognized as important formal diagnoses and included a more comprehensive listing of polythetic diagnostic criteria for each specific PD.

Features and challenges of personality disorders in late life

A personality disorder (PD) is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (American Psychiatric Association, APA, 2000). In the DSM-IV-TR are ten specific PDs organized into three superordinate clusters based on presumed common underlying themes. Cluster A groups the paranoid, schizoid and schizotypal PDs in which individuals often appear odd or eccentric. Cluster B includes antisocial, borderline, histrionic and narcissistic PD in which individuals appear to be dramatic or erratic. Cluster C contains avoidant, dependant, and obsessive-compulsive PD in which individuals often appear fearful or anxious. Finally, the diagnosis ‘personality disorder Not Otherwise Specified’ is available for use and is assigned for cases in which the patient has clear signs of a PD but does not fit neatly into one of the ten specific PD categories (APA, 2000). The prevalence in general adult population is 13.5% and in psychiatric populations is 60.4%; PD Not Otherwise Specified is the most frequently diagnosed axis II disorder (Verheul, Bartak, & Widiger, 2007). The prevalence of PD among older people in the general population is reported as lying between 2.8% and 13% (Ames & Molinari, 1994; Weissman, 1993). For older mental health patients treated in outpatient settings, percentages between 5% and 33% have been reported (Mezzich, Fabrega, Coffman, & Glavin, 1987; Molinari & Marmion, 1993). The prevalence of (co morbid) PD in older inpatients who receive mental health treatment has been reported as between 7% and 80% (Casey & Schrodt, 1989; Silberman, Roth, Degal, & Burns, 1997). The wide spread in this range reflects the different research methods, diagnostic criteria and instruments used in the studies. In addition, the size of the samples varied widely from 30 subjects (Silberman et al., 1997) to 547 subjects (Kunik et al., 1994). The meta analysis of Abrams and Horowitz (1999) reported on 16 studies conducted in different venues: The mean prevalence of older adults with PD ( 50 years) is 20%, compared to 22% for younger adults. It should be noted that this meta analysis included studies defining ‘old age’ as 50 years or older. The authors otherwise would not have been able to incorporate adequate prevalence data for their meta analysis (Abrams & Horowitz, 1999). Cross-sectional prevalence studies on specific PDs in different venues indicate that personality disorders from the A and C clusters remain relatively stable over time, while those from the B cluster tend to diminish during midlife and older age (Coolidge, Burns, Nathan, & Mull, 1992; Engels, Duijsens, Haringsma, & Van Putten, 2003; Molinari, Ames, & Essa, 1994; Stevenson, Maeres & Comerford, 2003; Ullrich & Coid, 2009; Watson & Sinha, 1996). One factor that could contribute to the lower prevalence of cluster B disorders is a selective mortality for this group. In one study, at 10–25-year follow-up, 3–9% of borderline patients had committed suicide (Stone, 1993). Further, risky behaviours such as substance abuse or reckless driving also lead to increased mortality (Fishbain, 1996). The prevalence figures cited above could also give a distorted image as we know that PD can manifest differently in later life as a result of cognitive deterioration, somatic comorbidity, medications and psychosocial challenges (Van Alphen et al., 2012). Being able to identify and accurately diagnose PD in older adults (defined as 65 years) has critical clinical relevance as well as important relevance for providers and settings responsible for their care. The presence of a PD is typically manifested through a complex presentation of symptoms and syndromes challenging both diagnosis and treatment. Specific therapeutic effects and side effects of treatment may also cause problems. While patients with primary or comorbid PD can be expected to benefit from regular, directive and symptom-focused treatment, it is likely that the response to treatment will take more time. In addition, patients with a PD have an increased risk of relapse, and the course of their illness is likely to be more complicated and chronic compared to those without a PD. Overall it is difficult to manage their care in any context. For example in designing a treatment plan for older adults in a psychiatric hospital, it is important that the plan address the specific PD, in order to avoid a premature termination of treatment (Sadavoy, 1999). The presence of PD also has great relevance to the relationships of the older adult. The nature and severity of PD of necessity need inform the care management and specific behavioural advice should be provided to relatives of the patient as well as to

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.

Personality Traits and Personality Disorders in Late Middle and Old Age: Do They Remain Stable? A Literature Review

We reviewed the evidence regarding which personality traits and personality disorders remain stable into later middle and old age (age >60 years of age) and how expressions of (maladaptive) personality traits affect personality assessment among older adults. Our study was a literature review of longitudinal and cross-sectional studies of the Five Factor Model (FFM) or DSM personality disorders in old age, using PsychInfo, Psychlit, and PubMed (period 1980–2012). Combinations of the following keywords were used: personality, development, stability, five factor personality model, big 5, (borderline) personality disorder(s), aging, older adults. Of the 22 relevant articles that were found, 17 longitudinal or cross-sectional studies of the FFM mainly supported the hypothesis that personality characteristics are susceptible to change over a person’s entire lifetime. Neuroticism, Extraversion, and Openness appear to diminish as a person ages, while, conversely, Agreeableness and Conscientiousness appear to increase with age. Two longitudinal studies and three cross-sectional studies of DSM-IV personality disorders suggested there are age-related changes in the ways in which maladaptive personality traits manifest themselves. The temporal instability of personality traits in old age, both adaptive and maladaptive, affects the validity of personality assessment of older adults, especially the face validity. We recommend personality assessment measures that include only age-neutral items. Informant contributions to the personality assessment could also be helpful in improving the reliability in epidemiological research.

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.

Methylphenidate Treatment of Minor Depression in Very Old Patients

Seven patients age 80-106 who presented with signs and symptoms of depression were successfully treated with 1.25-10 mg of methylphenidate per day without evidence of toxicity or tolerance. Treatment was continued for up to 24 months with sustained benefits.

Attention Deficit Hyperactivity Disorder and Co-Morbidity in Old Age

Attention deficit hyperactivity disorder (ADHD) may persist into old age with prevalence rates up to 4.4%. We present a case report of an 80-year old man with ADHD complicated by personality pathology and a mild impairment in some executive functions. We illustrate that ADHD in older adults may be misdiagnosed for a neurodegenerative disease or personality disorder. To differentiate ADHD from neurodegenerative diseases or personality disorders, it is important to focus on the course of the problems by obtaining a complete history and a long term follow-up.

EMDR as a Treatment Approach of PTSD Complicated by Comorbid Psychiatric, Somatic, and Cognitive Disorders: A Case Report of an Older Woman With a Borderline and Avoidant Personality Disorder

Traumatic life events can result in severe psychiatric conditions among which posttraumatic stress disorder (PTSD) is the most prevalent. Due to high comorbidity with other psychiatric diagnoses, PTSD treatment is challenging. In older adults, the presentation of PTSD symptoms is especially complicated because of even higher comorbidity, higher rates with other mental disorders, and cognitive and somatic conditions. Eye movement desensitization and reprocessing (EMDR) is an evidence-based treatment for trauma in younger adults. There is limited empirical research on the treatment effects of EMDR in older adults. Moreover, the impact of successful EMDR treatment on the comorbid disorders, especially personality and cognitive dysfunctions, is unclear. In this case report, EMDR treatment effects for late-onset PTSD with comorbid borderline and avoidant personality disorders, as well as cognitive disorders and multiple somatic problems, will be presented in an older woman.

Commentary on Special Issue on Geriatric Assessment

We provide commentary about the articles in this special section of “Assessment in Older Adults” by using van Alphen’s framework of a systematic multidimensional approach for diagnosis and treatment in older adults.