S.P.J. van Alphen

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 disorders in older adults: emerging research issues.

Empirical research focusing on personality disorders (PDs) among older adults is mainly limited to studies on psychometric properties of age-specific personality tests, the age neutrality of specific items/scales, and validation of personality inventories for older adults. We identified only two treatment studies—one on dialectical behavior therapy and one on schema therapy—both with promising results among older patients despite small and heterogeneous populations. More rigorous studies incorporating age-specific adaptations are needed. Furthermore, in contrast to increasing numbers of psychometric studies, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 pays little attention to the characteristics of older adults with PDs. Moreover, the constructs “personality change due to another medical condition” and “late-onset personality disorder” warrant further research among older adults. These needs will become even more pressing given the aging society worldwide.

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.

Measuring personality functioning in older adults: construct validity of the Severity Indices of Personality Functioning – Short Form (SIPP-SF)

ABSTRACT Objective: The dimensional personality disorders model in the Diagnostic and Statistical Manual (DSM)-5 section III conceptually differentiates impaired personality functioning (criterion A) from the presence of pathological traits (criterion B). This study is the first to specifically address the measurement of criterion A in older adults. Moreover, the convergent/divergent validity of criterion A and criterion B will be compared in younger and older age groups. Method: The Severity Indices of Personality Functioning – Short Form (SIPP-SF) was administered in older (N = 171) and younger adults (N = 210). The factorial structure was analyzed with exploratory structural equation modeling. Differences in convergent/divergent validity between personality functioning (SIPP-SF) and pathological traits (Personality Inventory for DSM-5; Dimensional Assessment of Personality Pathology-Basic Questionnaire) were examined across age groups. Results: Identity Integration, Relational Capacities, Responsibility, Self-Control, and Social Concordance were corroborated as higher order domains. Although the SIPP-SF domains measured unique variation, some high correlations with pathological traits referred to overlapping constructs. Moreover, in older adults, personality functioning was more strongly related to Psychoticism, Disinhibition, Antagonism and Dissocial Behavior compared to younger adults. Discussion: The SIPP-SF construct validity was demonstrated in terms of a structure of five higher order domains of personality functioning. The instrument is promising as a possible measure of impaired personality functioning in older adults. As such, it is a useful clinical tool to follow up effects of therapy on levels of personality functioning. Moreover, traits were associated with different degrees of personality functioning across age groups.

Age neutrality of the young schema questionnaire in patients with a substance use disorder.

BACKGROUND Youngs Schema Focused Therapy (SFT) is gaining popularity in the treatment of older adults. In the context of this therapy, the Young Schema Questionnaire (YSQ) was developed to assess the early maladaptive schemas (EMS). EMS are considered to be relatively stable over time, but research shows that questionnaires often lack face validity in older adults, which makes it difficult to investigate EMS in older adults and their stability across the lifespan. METHODS In the present cross-sectional study, we investigated the age neutrality of the Young Schema Questionnaire--Long Form in young (aged 18-34 years), middle-aged (aged 35-59 years), and older (aged 60-75 years) adults in a clinical sample of substance use disorders (N = 321) by examining potential differential item functioning (DIF). While investigating the stability of the schemas, we controlled for substance dependency and clinical symptoms by means of, respectively, the Drug Use Screening Inventory - Revised and the Symptom Checklist-90-R. RESULTS The Bonferroni-adjusted Liu-Agresti Cumulative Common Log-Odds Ratio confirmed large DIF for six items, divided across five schema scales (Mistrust/Abuse, Subjugation, Entitlement, Enmeshment and Self-sacrifice). Of the six items that presented DIF, only one item showed differential test functioning (Entitlement). Overall results show only 3% DIF, implying age neutrality of the questionnaire. CONCLUSIONS Current results corroborate that most EMS scales are equally measured across age, and reliable comparisons can be made across the lifespan, allowing for good clinical practice and further research on SFT in older adults. Only for Entitlement, Enmeshment, and Insufficient Self-control, caution is needed when comparing mean scores across the age groups.

Psychometric properties of an informant personality questionnaire (the HAP) in a sample of older adults in the Netherlands and Belgium

In geriatric psychiatry, informant reports are often important due to cognitive problems and related impaired insight and judgment. Informant questionnaires to identify personality traits among older adults are sparse. The Dutch informant personality questionnaire (the HAP) is especially developed to address this need. The objective of this study is the psychometric evaluation of the HAP among older adults in the Netherlands and Belgium. We investigated the internal consistency, gender differences, the test–retest and inter-rater reliability, the factorial structure, and the concurrent validity. Informants completed the HAP ratings of nursing home residents (n = 385) and elderly psychiatric patients (n = 204). The internal consistency of the scales is good. Medium gender differences on three scales were found in the population Psychiatry. The inter-rater and test–retest reliability are good to excellent. There are significant similarities between a number of HAP scales and dimensions of the Big Five. The congruence between the factor structures in both samples is very high. We labeled the three factors externalizing/antagonistic, internalizing/neurotic, and compulsive. The HAP meets the need for validated and reliable informant instruments for personality assessment among older adults in geriatric psychiatry. The content scales of the questionnaire address traits of the premorbid personality. Therefore, the HAP might be useful for personality assessment and selecting treatment options in mental healthcare and can be applied in scientific research in the area of personality aspects in late life.

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.

Alcoholproblematiek bij ouderen

SamenvattingNoteborn MWJ, Sanderson RAM, Zwanikken H, Deckers K, Van Alphen SPJ. Alcoholproblematiek bij ouderen. Huisarts Wet 2013;56(5):214-8. Alcoholgebruik onder ouderen is wijdverbreid. Ruim tweederde van de 65-plussers drinkt dagelijks meer dan één glas en één op de twintig ouderen hoort zelfs tot de zware drinkers (minstens één keer per week zes of meer glazen). Symptomen van overmatig alcoholgebruik bij ouderen zijn niet specifiek en worden vaak ten onrechte toegeschreven aan normale veroudering. Door die veroudering ervaren ouderen ook sneller gezondheidsproblemen als gevolg van alcoholgebruik. Vroege herkenning van alcoholproblemen is belangrijk. De eerstelijnsgezondheidszorg beschikt over goede screeningsinstrumenten en effectieve, kortdurende interventies. Voor huisartsen en praktijkondersteuners komt het erop aan, hun alertheid op alcoholproblemen bij ouderen te trainen, en de samenwerking met de eerste- en tweedelijns verslavingszorg te organiseren.AbstractNoteborn MWJ, Sanderson RAM, Zwanikken H, Deckers K, Van Alphen SPJ. Alcohol problems in the elderly. Huisarts Wet 2013;56(5):214-8. Alcohol consumption is common among the elderly. More than two-thirds of people aged 65 years and older drink more than one glass of alcohol a day, and 1 in 20 can be considered heavy drinkers (6 or more glasses more than once a week). Symptoms of excessive alcohol consumption are not specific in older people and are often incorrectly ascribed to normal ageing. Older people experience alcohol-related health problems sooner than younger people. It is important to recognize alcohol problems in an early phase. Good screening instruments are available in primary care and these services can provide effective, short-lasting interventions. General practitioners and practice assistants need to be alert to alcohol problems in elderly patients and work together with addiction services in primary and secondary care.