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Personality Disorders

Personality Disorder (PD) refers to a pattern of inner experience (cognition, mood), behavior and observed affect that deviates from the individual’s cultural norms, is pervasive, and begins by early adulthood (American Psychiatric Association, 2013). This pattern is also maladaptive, meaning that it causes distress and negative consequences for the individuals with PD as well as challenges for those with whom they are in relationship. The pattern persists over time and across venues and functions to thwart individuals with PD from accomplishing what they strive for and having their needs met. This working definition of PD as a deviant, maladaptive pattern also implies both a referent and an adjudicator. In other words, clinical identification needs to consider who is asking what of the person with PD, and what traits are being appraised as being reflective of pathology (a disorder) within a particular context. These considerations highlight an essential distinction between what is appraised as a “personality style” rather than a “personality disorder” (Segal, Coolidge & Rosowsky, 2006).

The prevalence data generally reported for PD among older adults in the community is estimated at 3-13%; for those receiving outpatient mental health services, 5-33%; and for psychiatric inpatients, 7-62% (Lair & Lefkowitz, 1990; Molinari & Marmion, 1993). In nursing homes, the prevalence estimate is 65%-81% (Burns et al., 1993; Lair & Lefkowitz, 1990). The extremely broad range is indicative of the difficulty of accurately identifying these older adults, let alone the difficulty in assessing the specificity and degree of their pathology. The broad range also reflects sampling bias (studies limited to older adults living independently in the community), sample size, measurement administration factors, as well as (especially important) a poor fit with the PD criteria being used for case identification. For example, symptom expression relying heavily on energy, mobility, work status, sexual desire and opportunity are likely to be less evident in older than in younger adults (Agronin & Maletta, 2000; Rosowsky, 1999; Sadavoy,1996; Segal, Coolidge, & Rosowsky, 2006).

Further, there is likely a selective mortality secondary to seriously problematic lifestyle choices made and experiences endured over the life course. Many older adults with PD have managed to be protected by an individual who is able to run adaptive interference for them or in other ways ward off or reduce the more florid manifestations of the PD. The older adult then will often come to clinical attention when that protective person is no longer present or able to function in that role, especially when forced to live in a communal environment (e.g., hospital, nursing home). Another frequent way older adults with PD attract clinical attention is around an acute medical or co-morbid psychiatric event, (Rosowsky, 1999; van Alphen et al., 2012). Throughout life, PDs are highly co-morbid with Axis I conditions, most typically depression and anxiety disorders (Segal, Qualls, & Smyer (2011).

While the personality pattern is understood to be generally stable over the life course, its manifestations and expressions can and do change reflecting maturation, task, and context, in support of the concept of heterotypic continuity (Debast, et.al., in press). While personality traits can become altered with age, what remains most stable are the personality trait manifestations supporting the maladaptive pattern. At the core is an essential vulnerability expressed through attachment conflict and maladaptive reactivity, especially within close relationships, including those with their care providers (Rosowsky, 1999).

PDs in older adults reflect an under recognized biopsychosocial pathology having highly significant public health implications. PDs are distressing to older adults, and also to those with whom they are in relationship and who care for them. There is also an enormous impact on the health and mortality of these individuals, thus taxing the healthcare system and raising health care costs.

The study of PDs in older adults is a relatively nascent area within the greater field of geriatric mental health. Valid and reliable assessment measures remain a work in progress. This is reflected in the paucity of studies addressing treatment efficacy for this challenging and costly clinical population. Geriatric mental health practitioners recognize the need for utilizing a coordinated clinical team approach and forging an alliance with family members (Balsis, Zweig & Molinari, in press). Research moving forward needs to investigate how to modify evidence-based intervention strategies that have been developed for younger adults with PD to treat older adults with PD, how to create distinct gero-specific approaches based on late-life developmental considerations, and how diagnostic manuals can better guide clinician behavior in treating PDs in older adults.

Written by Erlene Rosowsky, PsyD, Massachusetts School of Professional Psychology

GENERAL

Sadavoy, J. (1996). Personality disorder in old age: Symptom Expression. Clinical Gerontologist, 16, 19-36.

Sadavoy, J. (1996). Personality disorder in old age: Symptom Expression. Clinical Gerontologist, 16, 19-36.

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Molinari, V. & Marmion, J. (1993). Personality disorders in geriatric outpatients. Psychological Reports, 73, 265-258.

Molinari, V. & Marmion, J. (1993). Personality disorders in geriatric outpatients. Psychological Reports, 73, 265-258.

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Lair, T. &Lefkowitz, D. (1990). Mental health and functional status of residents of nursing and personal care homes. In National Medical Expenditure Survey Research Findings, 7 (DHHS Publication No. PHS90-3470). Rockville, MD: Public Health Service, Agency for Health Care Policy and Research.

Lair, T. &Lefkowitz, D. (1990). Mental health and functional status of residents of nursing and personal care homes. In National Medical Expenditure Survey Research Findings, 7 (DHHS Publication No. PHS90-3470). Rockville, MD: Public Health Service, Agency for Health Care Policy and Research.

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Debast, I., Van Alphen, S.P.J., Rossi, G., Tummers, J.H.A., Bolwerk, N., Derksen, J.L.L., & Rosowsky, E. (in press). Personality traits and personality disorders in late middle and old age: do they remain stable? A literature review. Clinical Gerontologist.

Debast, I., Van Alphen, S.P.J., Rossi, G., Tummers, J.H.A., Bolwerk, N., Derksen, J.L.L., & Rosowsky, E. (in press). Personality traits and personality disorders in late middle and old age: do they remain stable? A literature review. Clinical Gerontologist.

Posted in reference | Tagged , | Comments Off on Debast, I., Van Alphen, S.P.J., Rossi, G., Tummers, J.H.A., Bolwerk, N., Derksen, J.L.L., & Rosowsky, E. (in press). Personality traits and personality disorders in late middle and old age: do they remain stable? A literature review. Clinical Gerontologist.

Balsis, S., Zweig, R., & Molinari, V. (in press). Personality disorders. In P. Lichtenberg & B. Mast (Eds.), APA handbook of clinical geropsychology. Washington DC: American Psychological Association Press.

Balsis, S., Zweig, R., & Molinari, V. (in press). Personality disorders. In P. Lichtenberg & B. Mast (Eds.), APA handbook of clinical geropsychology. Washington DC: American Psychological Association Press.

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Agronin, M. E., & Maletta, G. (2000). Personality disorders in late life: Understanding and overcoming the gap in research. American Journal of Geriatric Psychiatry, 8, 4–18.

Agronin, M. E., & Maletta, G. (2000). Personality disorders in late life: Understanding and overcoming the gap in research. American Journal of Geriatric Psychiatry, 8, 4–18.

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Karlin, B. E., Duffy, M., & Gleavs, D. H. (2008). Patterns and predictors of mental health service use and mental illness among older and younger adults in the United States. Psychological Services, 5, 275- 294.

Karlin, B. E., Duffy, M., & Gleavs, D. H. (2008). Patterns and predictors of mental health service use and mental illness among older and younger adults in the United States. Psychological Services, 5, 275- 294.

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ASSESSMENT

van Alphen, S. P. J., Bolwerk, N., Videler, A. C., Tumers J. H. A., van Roye, R. J. J., Barendse, H. P. J., Verheul, R. & Rosowsky, E. (2012). Age-related aspects and clinical implications of diagnosis and treatment of personality disorders in older adults. Clinical Gerontologist, 35, 27-41.

van Alphen, S. P. J., Bolwerk, N., Videler, A. C., Tumers J. H. A., van Roye, R. J. J., Barendse, H. P. J., Verheul, R. & Rosowsky, E. (2012). Age-related aspects and clinical implications of diagnosis and treatment of personality disorders in older adults. Clinical Gerontologist, 35, 27-41.

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Balsis, S., Woods, C., Gleason, M., & Oltmans, T. (2007). Over and underdiagnosis of personality disorders in older adults. American Journal of Geriatric Psychiatry, 15 (9), 742-753.

Balsis, S., Woods, C., Gleason, M., & Oltmans, T. (2007). Over and underdiagnosis of personality disorders in older adults. American Journal of Geriatric Psychiatry, 15 (9), 742-753.

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Zweig, R.A. (2008). Personality Disorder in Older Adults: Assessment Challenges and Strategies. Professional Psychology: Research and Practice, 39 (3), 298-305

Zweig, R.A. (2008). Personality Disorder in Older Adults: Assessment Challenges and Strategies. Professional Psychology: Research and Practice, 39 (3), 298-305

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Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.

Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.

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Segal, D, Hersen, M, Van Hasselt, V, Silberman, C, & Roth, L. (1996). Diagnosis and Assessment of Personality Disorders in Older Adults: A Critical Review. Journal of Personality Disorders 10 (4), 384-399.

Segal, D, Hersen, M, Van Hasselt, V, Silberman, C, & Roth, L. (1996). Diagnosis and Assessment of Personality Disorders in Older Adults: A Critical Review. Journal of Personality Disorders 10 (4), 384-399.

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Segal, D.L., Coolidge, F.L., & Rosowsky, E. (2006). Personality disorders and older adults: Diagnosis, assessment, and treatment . Hoboken, N.J.: John Wiley & Sons.

Segal, D.L., Coolidge, F.L., & Rosowsky, E. (2006). Personality disorders and older adults: Diagnosis, assessment, and treatment . Hoboken, N.J.: John Wiley & Sons.

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Qualls, S. H., & Noecker, T L. (2009). Caregiver family therapy for conflicted families. In S. H. Qualls & S. H. Zarit (Eds.), Aging families and caregiving: A clinician’s guide to research, practice, and technology (pp. 155-188). Hoboken, NJ: Wiley.

Qualls, S. H., & Noecker, T L. (2009). Caregiver family therapy for conflicted families. In S. H. Qualls & S. H. Zarit (Eds.), Aging families and caregiving: A clinician’s guide to research, practice, and technology (pp. 155-188). Hoboken, NJ: Wiley.

Posted in reference | Tagged , , , | Comments Off on Qualls, S. H., & Noecker, T L. (2009). Caregiver family therapy for conflicted families. In S. H. Qualls & S. H. Zarit (Eds.), Aging families and caregiving: A clinician’s guide to research, practice, and technology (pp. 155-188). Hoboken, NJ: Wiley.

Oltmanns, T.F., & Balsis, S. (2011). Personality disorders in later life: Questions about the measurement, course, and impact of disorders. Annual Review of Clinical Psychology, 7 , 321-349.

Oltmanns, T.F., & Balsis, S. (2011). Personality disorders in later life: Questions about the measurement, course, and impact of disorders. Annual Review of Clinical Psychology, 7 , 321-349.

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Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

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Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

Posted in reference | Tagged , , , , , | Comments Off on Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

Edelstein, B., & Segal, D. L. (2011). Assessment of emotional and personality disorders in older adults. In K. W. Schaie & B. G. Knight (Eds.), Handbook of the psychology aging (7th ed., pp. 325-337). New York: Academic Press.

Edelstein, B., & Segal, D. L. (2011). Assessment of emotional and personality disorders in older adults. In K. W. Schaie & B. G. Knight (Eds.), Handbook of the psychology aging (7th ed., pp. 325-337). New York: Academic Press.

Posted in reference | Tagged , , | Comments Off on Edelstein, B., & Segal, D. L. (2011). Assessment of emotional and personality disorders in older adults. In K. W. Schaie & B. G. Knight (Eds.), Handbook of the psychology aging (7th ed., pp. 325-337). New York: Academic Press.

MEASURES

Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.

TREATMENT

van Alphen, S. P. J., Bolwerk, N., Videler, A. C., Tumers J. H. A., van Roye, R. J. J., Barendse, H. P. J., Verheul, R. & Rosowsky, E. (2012). Age-related aspects and clinical implications of diagnosis and treatment of personality disorders in older adults. Clinical Gerontologist, 35, 27-41.

van Alphen, S. P. J., Bolwerk, N., Videler, A. C., Tumers J. H. A., van Roye, R. J. J., Barendse, H. P. J., Verheul, R. & Rosowsky, E. (2012). Age-related aspects and clinical implications of diagnosis and treatment of personality disorders in older adults. Clinical Gerontologist, 35, 27-41.

Posted in reference | Tagged , , | Comments Off on van Alphen, S. P. J., Bolwerk, N., Videler, A. C., Tumers J. H. A., van Roye, R. J. J., Barendse, H. P. J., Verheul, R. & Rosowsky, E. (2012). Age-related aspects and clinical implications of diagnosis and treatment of personality disorders in older adults. Clinical Gerontologist, 35, 27-41.

Rosowsky, E. (1999). The patient-therapist relationship and the psychotherapy of the older adult with personality disorder. In E. Rosowsky, R. Abrams, & R. Zweig (Eds.), Personality disorders in older adults: Emerging issues in diagnosis and treatment (pp.153-175). Mahwah, New Jersey: Lawrence Erlbaum Associates.

Rosowsky, E. (1999). The patient-therapist relationship and the psychotherapy of the older adult with personality disorder. In E. Rosowsky, R. Abrams, & R. Zweig (Eds.), Personality disorders in older adults: Emerging issues in diagnosis and treatment (pp.153-175). Mahwah, New Jersey: Lawrence Erlbaum Associates.

Posted in reference | Tagged , | Comments Off on Rosowsky, E. (1999). The patient-therapist relationship and the psychotherapy of the older adult with personality disorder. In E. Rosowsky, R. Abrams, & R. Zweig (Eds.), Personality disorders in older adults: Emerging issues in diagnosis and treatment (pp.153-175). Mahwah, New Jersey: Lawrence Erlbaum Associates.

Burns, B., Wagner, R., Taube, J., Magaziner, J., Permutt, T. & Landerman, L. (1993). Mental health service use by the elderly in nursing homes. American Journal of Public Health, 83, 331-337.

Burns, B., Wagner, R., Taube, J., Magaziner, J., Permutt, T. & Landerman, L. (1993). Mental health service use by the elderly in nursing homes. American Journal of Public Health, 83, 331-337.  

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Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.

Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.

Posted in reference | Tagged , , , , , , | Comments Off on Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.

Segal, D.L., Coolidge, F.L., & Rosowsky, E. (2006). Personality disorders and older adults: Diagnosis, assessment, and treatment . Hoboken, N.J.: John Wiley & Sons.

Segal, D.L., Coolidge, F.L., & Rosowsky, E. (2006). Personality disorders and older adults: Diagnosis, assessment, and treatment . Hoboken, N.J.: John Wiley & Sons.

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Morse, J.Q., Pilkonis, P., Houck, P.R., Frank, E., Reynolds, C. (2005). Impact of cluster C personality disorders on outcomes of acute and maintenance treatment in late-life depression. American Journal of Geriatric Psychiatry , 13 , 808-814.

Morse, J.Q., Pilkonis, P., Houck, P.R., Frank, E., Reynolds, C. (2005). Impact of cluster C personality disorders on outcomes of acute and maintenance treatment in late-life depression. American Journal of Geriatric Psychiatry , 13 , 808-814.

Posted in reference | Tagged , , | Comments Off on Morse, J.Q., Pilkonis, P., Houck, P.R., Frank, E., Reynolds, C. (2005). Impact of cluster C personality disorders on outcomes of acute and maintenance treatment in late-life depression. American Journal of Geriatric Psychiatry , 13 , 808-814.

Karlin, B. E., Duffy, M., & Gleavs, D. H. (2008). Patterns and predictors of mental health service use and mental illness among older and younger adults in the United States. Psychological Services, 5, 275- 294.

Karlin, B. E., Duffy, M., & Gleavs, D. H. (2008). Patterns and predictors of mental health service use and mental illness among older and younger adults in the United States. Psychological Services, 5, 275- 294.

Posted in reference | Tagged , , , , | Comments Off on Karlin, B. E., Duffy, M., & Gleavs, D. H. (2008). Patterns and predictors of mental health service use and mental illness among older and younger adults in the United States. Psychological Services, 5, 275- 294.