Personality disorders in the elderly
Suzanne Holroyd
Introduction
The study of personality disorder (PD) in late life presents conceptual, diagnostic, and methodological difficulties. By definition, PD is considered a group of personality traits that relatively persistent through adulthood. However, the concept of PD persisting throughout the lifespan contradicts widespread clinical belief that they become less severe with ageing. For example, DSM-IV(1) notes that ‘some types of personality disorders … tend to become less evident or remit with age’.
There are difficulties in studying PD in the elderly. One is the instability of the definition of PD over time, making it difficult to relate earlier studies to those using current definitions of PD. In addition, diagnostic criteria are subject to criticism when applied to the elderly, in that they may be ‘age-biased’.(2,3) Finally, the methodology used to diagnose PD has been highly variable and difficult to interpret between studies.
A major issue is whether personality is fully developed by early adulthood and then remains unchanged, or whether personality continues to develop and change throughout life. The work of McCrae and Costa(4) demonstrated that personality characteristics are relatively stable within individuals over a 30-year period with correlations ranging from 0.7 to 0.8. However, this also demonstrates that complete stability is not there and suggests certain aspects of the personality may still develop and change with ageing. This suggests that PD may also change over the lifespan.
Another issue is whether underlying traits that persist throughout the lifespan can rise to the level of a PD depending on the environment. For example, traits that may be personality disordered in young adult life, such as extreme dependency, may be an appropriate and adaptive trait for an older individual with multiple physical disabilities.(5) Conversely, an individual may have a trait of extreme independence that may be adaptive in earlier life but which leads to distress and maladaptive functioning in a setting requiring dependence, such as a nursing home. Thus it is possible to have a PD diagnosed for the first time in late life, which goes against the very definition of lifelong PD.
Clinical features
Clinical features of PD and details of their classification are reviewed in Chapters 4.12.2 and 4.12.3. However, there is difficulty in simply relating these criteria, which were developed for younger individuals, to the elderly. Typical diagnostic behaviours that clinicians associate with PD in younger adults may present as different behaviours in the elderly. This may lead clinicians to overlook personality traits and disorders in older individuals. For example, a criterion of antisocial personality disorder is the repeated failure to sustain consistent work, behaviour not applicable to the older retired individual. Yet it is possible that the personality trait of irresponsibility, which led to the loss of jobs earlier in life continues, now appearing as a behaviour such as medicine non-compliance. Some authors have thus argued that the clinical
features for some PD are age-biased since certain behaviours are less likely to occur in elderly persons despite the persistence of personality traits.(2,3)
features for some PD are age-biased since certain behaviours are less likely to occur in elderly persons despite the persistence of personality traits.(2,3)
Diagnosis of personality disorders
Diagnostic criteria for PD are discussed in Chapter 4.12.3. Because features of PD may change with ageing, diagnosis can be difficult. Overlap with Axis I diagnoses such as depression or dementia make the diagnosis even more challenging. For example, depressed elderly people have symptoms normally associated with PD as they may be more dependent, avoidant, resistant, negative, and somatic.(6) In addition, depressed elderly people may view their lives negatively and overestimate personality psychopathology.(7,8)
Clinicians may be reticent to give a personality diagnosis to an individual with multiple medical problems to which maladaptive behaviours may be attributed even if a lifelong history of personality pathology is established.(8) They may also be concerned about the validity of historical information needed to make a PD diagnosis. Therefore, in making a diagnosis of PD, a clinician should take a thorough history from as many reliable outside informants as possible. If the patient is in a state of acute distress with a current Axis I diagnosis such as depression, it is best to defer diagnosis of the PD until the illness is in remission. Otherwise, it is especially important to ask outside informants to think back to when the individual was a younger person, as current symptoms can colour the perception of lifelong personality traits. Asking for specific examples of history such as, details of relationships and job history, legal history, and the like, will be more helpful than just general descriptions of personality.
If behavioural difficulties and personality problems are found to be recent, the clinician needs to search carefully for a superimposed medical condition, or a psychiatric condition such as depression. Clinicians should carefully screen for illnesses such as dementia, stroke, or other neurological disease, or a systemic medical illness. Those with frontal lobe dementia, Alzheimer’s disease, or vascular dementia may have personality changes early in their life course.(9,10,11)
Epidemiology and aetiology
The prevalence of PD in the elderly varies as to the methodology used and the population studied. It should be noted that no assessment instrument for PD in the elderly has been validated.
Community studies
Community studies have been the most useful to date. A community study,(12) using the Epidemiologic Catchment Area (ECA) data, had 841 subjects examined by psychiatrists using the semi-structured Standardized Psychiatric Examination with DSM-III criteria. Comparing those over the age of 55 with those under 55, older individuals were found significantly less likely to have a PD (6.6 to 10.5 per cent) as compared with younger individuals. This finding was almost entirely due to a three-fold higher prevalence of cluster B PD in those under the age of 55, especially antisocial and histrionic PD. Interestingly, in this study none of the older individuals were found to have cluster A PD. Table 8.5.6.1 summarizes the findings of this large community study. The strengths of this study were that it was a community rather than a clinical sample, and subjects were evaluated by psychiatrists using a structured questionnaire. Limitations of this study were those inherent to the study of PD in late life, in that older subjects may have been inaccurate in recalling maladaptive behaviours, outside informants were not used, and lack of non-validated instruments for diagnosing PD in the elderly.
Table 8.5.6.1 Weighted prevalence (%) of DSM-III personality disorders in a large community study | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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