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

GENERAL

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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Balsis, S., Zweig, R., & Molinari, V. (2015). Personality disorders in later life. In P. A. Lichtenberg, T. A. Mast, B. D. Carpenter, & J. Loebach Wetherell (Eds.), APA handbook of clinical geropsychology, Vol 2. Assessment, treatment, and issues of later life (pp. 79-94). American Psychological Association.

Balsis, S., Zweig, R., & Molinari, V. (2015). Personality disorders in later life. In P. A. Lichtenberg, T. A. Mast, B. D. Carpenter, & J. Loebach Wetherell (Eds.), APA handbook of clinical geropsychology, Vol 2. Assessment, treatment, and issues of later life (pp. 79-94). American Psychological Association.

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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. (2014). Personality traits and personality disorders in late middle and old age: do they remain stable? A literature review. Clinical Gerontologist. Clinical Gerontologist, 37(3), 253-271. https://doi.org/10.1080/07317115.2014.885917

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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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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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Lederer, G. H. F., Freedman, D. C., Zamora, A., & Zweig, R. A. (2020). Personality disorders in later life. Reference Module in Neuroscience and Biobehavioral Psychology, 1-26. https://doi.org/10.1016/B978-0-12-818697-8.00022-4

Lederer, G. H. F., Freedman, D. C., Zamora, A., & Zweig, R. A. (2020). Personality disorders in later life. Reference Module in Neuroscience and Biobehavioral Psychology, 1-26. https://doi.org/10.1016/B978-0-12-818697-8.00022-4

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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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Penders, K. A. P., Peeters, I. G. P., Metsemakers, J. F. M., & van Alphen, S. P. J. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry Reports, 22(14), 1-14. https://doi.org/10.1007/s11920-020-1133-x

Penders, K. A. P., Peeters, I. G. P., Metsemakers, J. F. M., & van Alphen, S. P. J. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry Reports, 22(14), 1-14. https://doi.org/10.1007/s11920-020-1133-x

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Powers, A. D., & Oltmanns, T. F. (2012). Personality disorders and physical health: A longitudinal examination of physical functioning, healthcare utilization, and health-related behaviors in middle-aged adults. Journal of Personality Disorders, 26(4), 524-538. https://doi.org/10.1521/pedi.2012.26.4.524

Powers, A. D., & Oltmanns, T. F. (2012). Personality disorders and physical health: A longitudinal examination of physical functioning, healthcare utilization, and health-related behaviors in middle-aged adults. Journal of Personality Disorders, 26(4), 524-538. https://doi.org/10.1521/pedi.2012.26.4.524

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Rosowsky, E., Lodish, E., Ellison, J. M., & van Alphen, S. P. J. (2019). A Delphi study of late-onset personality disorders. International Psychogeriatrics, 31(7), 1007-1013. https://doi.org/10.1017/S1041610218001473

Rosowsky, E., Lodish, E., Ellison, J. M., & van Alphen, S. P. J. (2019). A Delphi study of late-onset personality disorders. International Psychogeriatrics, 31(7), 1007-1013. https://doi.org/10.1017/S1041610218001473

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Rosowsky, E., Young, A. S., Malloy, M. C., van Alphen, S. P. J., & Ellison, J. M. (2018). A cross-validation Delphi method approach to the diagnosis and treatment of personality disorders in older adults. Aging & Mental Health, 22(3), 371-378. https://doi.org/10.1080/13607863.2016.1261796

Rosowsky, E., Young, A. S., Malloy, M. C., van Alphen, S. P. J., & Ellison, J. M. (2018). A cross-validation Delphi method approach to the diagnosis and treatment of personality disorders in older adults. Aging & Mental Health, 22(3), 371-378. https://doi.org/10.1080/13607863.2016.1261796

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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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Schuster, J-P., Hoertel, N., Le Strat, Y., Manetti, A., & Limosin, F. (2013). Personality disorders in older adults: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. American Journal of Geriatric Psychiatry, 21(8), 757-768. https://doi.org/10.1016/j.jagp.2013.01.055

Schuster, J-P., Hoertel, N., Le Strat, Y., Manetti, A., & Limosin, F. (2013). Personality disorders in older adults: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. American Journal of Geriatric Psychiatry, 21(8), 757-768. https://doi.org/10.1016/j.jagp.2013.01.055

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Segal, D. L., Qualls, S. H., & Smyer, M. A. (2018). Aging and mental health (3rd edition). Wiley/Blackwell.

Segal, D. L., Qualls, S. H., & Smyer, M. A. (2018). Aging and mental health (3rd edition). Wiley/Blackwell.

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Stone, L. E., & Segal, D. L. (2021). An empirical evaluation of the DSM-5 alternative model of personality disorders in later life. International Journal of Aging & Human Development, 93(3), 904-926.  https://doi.org/10.1177/0091415020980762

Stone, L. E., & Segal, D. L. (2021). An empirical evaluation of the DSM-5 alternative model of personality disorders in later life. International Journal of Aging & Human Development, 93(3), 904-926.  https://doi.org/10.1177/0091415020980762

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ASSESSMENT

Balsis, S. B., Gleason, M. E., Woods, C. M., & Oltmanns, T. F. (2007a). An item response theory analysis of DSM-IV personality disorder criteria across younger and older age groups. Psychology and Aging, 22(1), 171-185. https://doi.org/10.1037/0882-7974.22.1.171

Balsis, S. B., Gleason, M. E., Woods, C. M., & Oltmanns, T. F. (2007a). An item response theory analysis of DSM-IV personality disorder criteria across younger and older age groups. Psychology and Aging, 22(1), 171-185. https://doi.org/10.1037/0882-7974.22.1.171

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Balsis, S. B., Woods, C. M., Gleason, M. E. J., & Oltmanns, T. F. (2007b). Overdiagnosis and underdiagnosis of personality disorders in older adults. American Journal of Geriatric Psychiatry, 15(9), 742-753. https://doi.org/10.1097/JGP.0b013e31813c6b4e

Balsis, S. B., Woods, C. M., Gleason, M. E. J., & Oltmanns, T. F. (2007b). Overdiagnosis and underdiagnosis of personality disorders in older adults. American Journal of Geriatric Psychiatry, 15(9), 742-753. https://doi.org/10.1097/JGP.0b013e31813c6b4e

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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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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.

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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.

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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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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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Penders, K. A. P., Peeters, I. G. P., Metsemakers, J. F. M., & van Alphen, S. P. J. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry Reports, 22(14), 1-14. https://doi.org/10.1007/s11920-020-1133-x

Penders, K. A. P., Peeters, I. G. P., Metsemakers, J. F. M., & van Alphen, S. P. J. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry Reports, 22(14), 1-14. https://doi.org/10.1007/s11920-020-1133-x

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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.

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Rosowsky, E., Lodish, E., Ellison, J. M., & van Alphen, S. P. J. (2019). A Delphi study of late-onset personality disorders. International Psychogeriatrics, 31(7), 1007-1013. https://doi.org/10.1017/S1041610218001473

Rosowsky, E., Lodish, E., Ellison, J. M., & van Alphen, S. P. J. (2019). A Delphi study of late-onset personality disorders. International Psychogeriatrics, 31(7), 1007-1013. https://doi.org/10.1017/S1041610218001473

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Rosowsky, E., Young, A. S., Malloy, M. C., van Alphen, S. P. J., & Ellison, J. M. (2018). A cross-validation Delphi method approach to the diagnosis and treatment of personality disorders in older adults. Aging & Mental Health, 22(3), 371-378. https://doi.org/10.1080/13607863.2016.1261796

Rosowsky, E., Young, A. S., Malloy, M. C., van Alphen, S. P. J., & Ellison, J. M. (2018). A cross-validation Delphi method approach to the diagnosis and treatment of personality disorders in older adults. Aging & Mental Health, 22(3), 371-378. https://doi.org/10.1080/13607863.2016.1261796

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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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Stone, L. E., & Segal, D. L. (2021). An empirical evaluation of the DSM-5 alternative model of personality disorders in later life. International Journal of Aging & Human Development, 93(3), 904-926.  https://doi.org/10.1177/0091415020980762

Stone, L. E., & Segal, D. L. (2021). An empirical evaluation of the DSM-5 alternative model of personality disorders in later life. International Journal of Aging & Human Development, 93(3), 904-926.  https://doi.org/10.1177/0091415020980762

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Stone, L. E., Segal, D. L., & Noel, O. R. (in press). Psychometric evaluation of the Levels of Personality Functioning Scale-Brief Form 2.0 among older adults. Personality Disorders: Theory, Research, and Treatment. https://doi.org/10.1037/per0000413

Stone, L. E., Segal, D. L., & Noel, O. R. (in press). Psychometric evaluation of the Levels of Personality Functioning Scale-Brief Form 2.0 among older adults. Personality Disorders: Theory, Research, and Treatment. https://doi.org/10.1037/per0000413 

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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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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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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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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

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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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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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.

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Penders, K. A. P., Peeters, I. G. P., Metsemakers, J. F. M., & van Alphen, S. P. J. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry Reports, 22(14), 1-14. https://doi.org/10.1007/s11920-020-1133-x

Penders, K. A. P., Peeters, I. G. P., Metsemakers, J. F. M., & van Alphen, S. P. J. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry Reports, 22(14), 1-14. https://doi.org/10.1007/s11920-020-1133-x

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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.

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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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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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Videler, A. C., van Alphen, S. P. J., van Royen, R. J. J., van der Feltz-Cornelis, C. M., Rossi, G., & Arntz, A. (2018). Schema therapy for personality disorders in older adults: A multiple-baseline study. Aging & Mental Health, 22(6), 738-747. https://doi.org/10.1080/13607863.2017.1318260

Videler, A. C., van Alphen, S. P. J., van Royen, R. J. J., van der Feltz-Cornelis, C. M., Rossi, G., & Arntz, A. (2018). Schema therapy for personality disorders in older adults: A multiple-baseline study. Aging & Mental Health, 22(6), 738-747. https://doi.org/10.1080/13607863.2017.1318260

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Videler, A. C., Van der Feltz-Bornelis, C. M., Rossi, G., van Royen, R. J. J., Rosowsky, E., & van Alphen, S. P. J. (2015). Psychotherapeutic treatment levels for personality disorders in older adults. Clinical Gerontologist, 38(4), 325-341. https://doi.org/10.1080/07317115.2015.1032464

Videler, A. C., Van der Feltz-Bornelis, C. M., Rossi, G., van Royen, R. J. J., Rosowsky, E., & van Alphen, S. P. J. (2015). Psychotherapeutic treatment levels for personality disorders in older adults. Clinical Gerontologist, 38(4), 325-341. https://doi.org/10.1080/07317115.2015.1032464

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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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