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