PHARMACOLOGIC TREATMENT OF PERSONALITY DISORDERS IN LATE LIFE

Abstract

Despite intense interest among clinicians and researchers in the pharmacologic treatment of personality disorders, there is virtually nothing in the literature that focuses on their use in late life. Clinicians who treat elderly individuals with personality disorders are thus faced with the dilemma of using psychotropic medications without clear guidelines, or based on extrapolations from their use in adults with personality disorders. There are, however, important treatment considerations that apply across the lifespan, and several that are specific to late life. These considerations stem, in part, from informative studies that have been conducted in younger individuals with several types of personality disorders. These considerations are also based on psychobiologic models that link biologic trait vulnerabilities with underlying neurotransmitter systems. Given the complexity of personality disorders in late life, the goal of pharmacologic treatment is not to cure the personality disorder, but to diminish the intensity of expression of maladaptive personality traits and the dysfunctional behaviors they inspire. There are three avenues to accomplish this: 1) target the personality disorder itself, 2) focus on treating discrete symptom clusters, and/or 3) reduce the effects of comorbid axis I disorders. Given their heterogeneous presentation, however, it is extremely difficult to develop consistent pharmacologic treatment strategies for the entire range of dysfunctional traits and behaviors subsumed under individual personality disorders. It is more practical to target specific maladaptive traits and behaviors that lend themselves to pharmacologic treatment. Treatment of comorbid axis I disorders usually means reducing symptoms of depression, anxiety, or psychosis that are preventing therapeutic progress with core symptoms of the personality disorder. Identification of target traits does not, however, guarantee the success of pharmacologic treatment. The act of prescribing medications has unique meaning to individuals with personality disorders, and their specific psychopathology can easily present the most formidable barrier to treatment. For this reason, the use of pharmacologic agents is sometimes contraindicated.