Personality disorders (PDs) represent a particularly complex and under-studied category of mental disorders in the DSM-5 (American Psychiatric Association, 2013). According to the DSM-5, a 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 must also be maladaptive, meaning that it causes personal distress and/or negative consequences for the individuals with the PD as well as difficulties for those with whom they are in relationships. The pattern persists over time and across venues and, in doing so, typically functions to thwart individuals with PDs from accomplishing what they strive for and having their needs met. In essence, PDs are characterized by their notable impairments and impacts in the social domain, typically through conflictual and chaotic relationships or the lack of healthy relationships. This formal definition of a PD as a deviant, pervasive, and 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 the PD, what traits are being appraised, within what context, and suggesting what pathology. These considerations highlight an essential distinction between what is appraised as a “personality style” rather than a “personality disorder” (Segal, Coolidge & Rosowsky, 2006), reflecting the underlying dimensional nature of all PDs.

The prevalence generally reported for PDs among older adults in the community is estimated at 10-14% (Penders et al., 2020); for those receiving outpatient mental health services, 5-33%; and for psychiatric inpatients, 7-80% (Schuster et al., 2013). In nursing homes, the prevalence estimate is 58% (Penders et al., 2020). The extremely broad range is indicative of the difficulty of accurately identifying PDs in 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, different measurement approaches or assessment instruments, as well as (especially important) the well-documented poor fit with the PD criteria being used for case identification. For example, symptom expressions relying heavily on energy, mobility, work status, and sexual desire and opportunity are likely to be less evident in older adults than in younger adults (Agronin & Maletta, 2000; Rosowsky, 1999; Sadavoy, 1996; Segal et al., 2006). Indeed, study of the diagnostic criteria for PDs indicates age-bias in 29% of the criteria, leading to both underdiagnosis and overdiagnosis (Balsis et al., 2007a; Balsis et al., 2007b). This age bias also reflects the well-known issue that the diagnostic criteria were originally developed with a prototypical younger person in mind (Penders et al., 2020). Segal et al. (2006) have proposed “geriatric variants” for the PDs, but these hypothesized patterns require additional empirical scrutiny. Yet another diagnostic challenge is that many older people with PDs have limited awareness of having a disorder, as it is typically ego-syntonic and, thus, may not easily come to clinical attention (Segal et al., 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 PDs 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 hurtful ramifications 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 their usual role, or when the older adult with the PD is relocated to a communal environment (e.g., hospital, nursing home) without the protecting individual. Another frequent way older adults with PDs attract clinical attention is when an acute medical or co-morbid psychiatric event occurs (Rosowsky, 1999; van Alphen et al., 2012). Throughout life, PDs are highly co-morbid with other mental health disorders, most typically depression and anxiety disorders (Segal, Qualls, & Smyer, 2018). These comorbid disorders commonly prompt the initial referral for mental health services. In some cases, it can take considerable time for the underlying PD symptoms to become more evident, especially when the client’s insight is low or nonexistent. When PDs are comorbid with other disorders (particularly depression), the PDs are associated with significant social and functional impairment and indicate a generally poor prognosis that requires treatment adaptations (Lederer et al., 2020).

Whereas the personality pattern is understood to be generally stable over the life course, it is certainly not immutable. Indeed, manifestations and expressions of PD symptoms can and do change, reflecting maturation and changes in tasks and contexts, supporting the concept of heterotypic continuity (Debast et. al., 2014). Whereas personality traits can become altered with age, what remains most stable are the personality trait manifestations in the service of the maladaptive pattern. At the core is an essential vulnerability, expressing 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 (Powers & Oltmanns, 2012). PDs are distressing to older adults, and PDs are also usually distressing to those with whom they are in relationship and who care for them. The result is that there are enormous impacts on the health, well-being, morbidity 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. Reliable and valid assessment measures remain elusive and thus a work in progress. This is reflected in the paucity of studies addressing treatment efficacy for this challenging and costly clinical population. It is understood that PDs in older adults typically do not respond well to pharmacotherapy (Rosowsky et al., 2018). In one of the few published psychological treatment studies, Videler et al. (2018) found that schema therapy was effective in reducing distress and maladaptive schemas and thus increasing quality of life among a small sample of older adults with Cluster C PDs. Emphasis on improving older adults’ functionality may also be an effective alternative approach in instances where insight or motivation is limited (Lederer et al., 2020). Additionally, geriatric mental health practitioners recognize the need for utilizing a coordinated clinical team approach and forging an alliance with family members (Balsis, Zweig & Molinari, 2015). Moving forward, research needs to investigate how to modify existing evidence-based intervention strategies that have been developed for younger adults with PDs to treat older adults with PDs, how to create distinct gero-specific approaches based on late-life developmental considerations, and how diagnostic manuals can better guide clinicians in assessing and treating PDs in older adults (Videler et al., 2018).

To address some of these issues, a series of Delphi studies have examined the nature of PDs in older adults to better guide diagnosis and treatment. Delphi studies generate conclusions about a given topic based on expert consensus. van Alphen et al. (2012) conducted a Delphi study of European experts in the field of PDs and older adults. They concluded that the aging process may lead to a distinct expression of PDs in older adults called late-onset PDs, or those who do not manifest symptoms as distressing or dysfunctional until later in life. Additionally, consensus was reached surrounding different levels of treatment that can be targeted in psychotherapy, including treatment aimed at (1) personality change, (2) adaptation enhancement, and (3) providing support and structure (van Alphen et al., 2012). These treatment levels may provide a useful way for clinicians to conceptualize PD treatment with older adults. The concept of late onset PDs has also been considered by experts in the United States (Rosowsky et al., 2018; Rosowsky et al., 2019). These Delphi studies have concluded that PDs may present for the first time at any age, including older adulthood, further questioning the DSM diagnostic criteria’s applicability to older adults.

As an alternative to the problematic DSM criteria, recent research has investigated the applicability of the proposed Alternative Model for Personality Disorders (AMPD; American Psychiatric Association, 2013) as a novel way of approaching PDs dimensionally in the hopes of eliminating age-biased criteria. The AMPD proposes two main constructs on which PDs would be diagnosed: personality functioning (or severity) and pathological personality traits (or style). Although research is limited, some studies have found evidence of validity for the AMPD’s construct of personality functioning (Stone, Segal, & Noel, in press) and pathological traits (Stone & Segal, in press). Examining alternative models to the diagnosis of PDs has promise for older adults, potentially improving diagnosis and aiding in treatment planning. However, continued research is sorely needed to empirically investigate this understudied but significant category of mental disorders for older adults.

Written by Lisa E. Stone, MA, & Daniel L. Segal, PhD,  University of Colorado at Colorado Springs, & Erlene Rosowsky, PsyD, William James College

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