Personality Disorders In Older Adults Research Articles

Challenges and Gaps in the Diagnosis of Personality Disorders in Older Adults: A Review of Current Practices in a UK Mental Health Trust

Challenges and Gaps in the Diagnosis of Personality Disorders in Older Adults: A Review of Current Practices in a UK Mental Health Trust

Clinical Staging for Personality Disorders in Older Adults.

This scientific research aimed to investigate the feasibility of implementing a clinical staging (CS) model for personality disorders (PDs) in older adults. The CS model could provide valuable insights into the life course of personality pathology, prognosis, and treatment decisions for PDs in older adults. The study employed an international Delphi methodology with three rounds and involved 21 experts. Consensus was achieved on 12 out of 17 statements, confirming the viability of a CS model for PDs in older adults. The proposed model incorporates the Alternative Model for PDs, criterion A, and integrates life course information, distinguishing between chronic PD, re-emergent PD, late-onset PD, and past PD. The findings suggest that international experts support the implementation of a CS model for PDs in older adults, considering both the severity of personality functioning and the retrospective life course of PD expression.

Can personality disorder be accurately assessed in older age? A differential item functioning analysis of ICD-11 inventories.

The contested categorical personality disorder (PD) criteria are not well suited to inform PD diagnoses in older adults. Yet, the classification of PDs is undergoing a critical transition phase with a paradigm shift to a dimensional approach for diagnosing PDs. No special attention was given to the expression of PDs in older age when the dimensional ICD-11 model was developed. Given that PDs are highly prevalent in older adults, there is an urgent need to examine if ICD-11 related instruments are able to adequately assess for PDs in older adults. The age-neutrality of ICD-11 measures was examined in a sample of 208 Dutch community-dwelling adults (N=208, M age=54.96, SD=21.65), matched on sex into 104 younger (age range 18-64) and 104 older (age range 65-93) adults. An instrument is considered not to be age-neutral if a collective large level of differential item functioning (DIF) exists in a group of items of an instrument (i.e., 25% or more with DIF). We therefore set out to detect possible DIF in the following ICD-11 self-report measures: the Standardized Assessment of Severity of Personality Disorder (SASPD), the Personality Inventory for ICD-11 (PiCD), and the Borderline Pattern Scale (BPS). DIF analyses using a non-parametric odds ratio approach demonstrated that SASPD, PiCD, and BPS were age-neutral with less than 25% of items showing DIF. Yet, impact of DIF at scale level, examined by way of differential test functioning (DTF), indicated a DTF effect on the SASPD total score. These results of age-neutrality of the PiCD and BPS are promising for measuring ICD-11 traits and the borderline pattern. Yet, the age-neutral measurement of PD severity requires further research. With a rapidly aging population, its accurate assessment across the entire adult life span, including older age, is a prerequisite for an adequate detection of PDs.

Personality disorders in older adults: Differences in self-informant ratings.

Previous research on self-informant reports in assessing personality disorders (PDs) has been mainly focused on adults, leaving older adults under-studied. We examined self-informant agreement in PD screening among older adults (≥60 years) using the Gerontological Personality disorders Scale (GPS). Potential differences such as who reports more personality pathology on a PD screener (i.e., GPS), item accessibility and the effect of relational aspects were studied as well. Data of 326 older adult-informant dyads, of which the older adults were sampled from five general practices in the Netherlands, were used. Results indicate that self-informant agreement ranged from r = 0.26-0.73, with lower concordance on the GPS-subscale measuring intrapersonal aspects of personality pathology. Informants were more sensitive to habitual pathological personality features than older adults. Two GPS items showed differential item functioning across self- and informant-report. Of relational aspects, only congeniality affected the GPS-iv scores; lower ratings on congeniality were associated with higher GPS-iv scores (i.e., higher reporting of personality problems).

Assessment of Personality Disorders in Older Adults. A Practice Guide.

Assessment of personality disorders (PDs) in older adults is a nuanced trade of its own. The aim of this practice guide is to illustrate gerontological assessment challenges using 3 case vignettes. We argue that it is important to pay extra attention to the influence of cognitive and medical (somatic) disorders on personality functioning in older adults during personality assessment. We also note that information provided by informants contributes added value to personality assessment. Personality assessment should be sufficiently age-specific to prevent overdiagnosis or underdiagnosis in older adults. Furthermore, given the reduced psychological or somatic capacity of some older adults, phased or sequential personality assessment is recommended. This should be focused on the assessment questions to be answered, for example starting with short general screening of personality functioning, followed by more in-depth exploration. Personality assessment should be kept as brief and simple as possible in terms of formulation of the items.

Age-neutrality of the SCID-II: Differential Item Functioning in Younger Outpatients (Aged 20-45) and Older Outpatients (Aged 65+)

ABSTRACT Objectives Measurements are often developed for the assessment of personality disorders (PDs) in younger adults and seldom evaluated on the applicability in older adults. Remarkably, research has not yet been conducted into age-group appropriateness of the gold standard for the assessment of PDs, known as Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II). Therefore, the current study empirically investigated the age-neutrality of the PDs assessed by the SCID-II. Methods Age-neutrality was examined in 84 younger adults (aged 20–45 years) and 68 older adults (aged 65–85) by Differential Item Functioning (DIF). The impact of DIF on scale level was further examined using Differential Test Functioning analyzes to examine the impact of the amount of DIF variance in the items on scale level. Results Overall, the great majority, 95.8% of the categorically measured items and 87.5% of the dimensionally measured items, was endorsed in the same way by younger adults and older adults with equal scores on the PD scale. Subsequent analyzes revealed no large DTF for PD scales. Conclusions Overall the SCID-II in an outpatient population is age-neutral for both categorically and dimensionally scored PD scales. Clinical Implications The SCID-II can be used for the assessment of PDs in older adults.

Schema Therapy in the Nursing Home Setting: A Case Study of a Cognitively Impaired Patient

The use of schema therapy to treat personality disorders in older adults is gaining scientific attention. Personality disorders are prevalent in one out of ten older adults and have a detrimental effect on quality of life. Although 24% or more of nursing home residents may have personality disorders, psychotherapeutic treatment options in the case of comorbid cognitive impairment have not yet been studied. This study concerns a 63-year-old care-dependent male nursing home resident with a personality disorder, a substance use disorder, and several cognitive impairments due to cerebrovascular disease, who presented with complaints of loneliness, low self-esteem, sleeping problems and anger outbursts. Schema therapy was delivered based on the schema mode model for a period of 27 months. Post-treatment assessment demonstrated a decrease in early maladaptive schemas and dysfunctional schema modes and improved personality functioning overall. Although situational psychological distress fluctuated throughout treatment, quality of life improved after 7 months and remained stable onwards. Presented complaints either remitted or strongly diminished. Substance use was also addressed and was in remission for the last 20 months of therapy. This case study suggests that schema therapy is a viable treatment for older adults with personality disorders who present with cognitive impairments in nursing homes.

The “Lost” Personality Disorders and Their Relationships to the Alternative Model of Personality Disorders Among Older Adults

Abstract. Four personality disorders (PD) have become “lost” throughout the various editions of the DSM: Depressive, Passive-Aggressive, Sadistic, and Self-Defeating. The Alternative Model of Personality Disorders (AMPD) is a novel approach to PD classification, containing two diagnostic criteria: personality functioning and pathological personality traits. This study identifies the personality functioning and pathological personality trait features of the Lost PDs among older adults ( N = 202; Mage = 67.47 years). Results indicate that the Lost PDs related more strongly with the self-functioning domains (versus the interpersonal domains). Some pathological traits emerged in expected directions, whereas others did not, which is consistent with research on the traditional PDs. The AMPD appears to have mixed validity in capturing the Lost PDs in older adults, though overall it performed comparably well and warrants further examination.

Personality Disorders in Late Life

Abstract. Personality disorders (PDs) affect a significant portion of older adults and hinder their physical and mental health. This narrative review (1) reviews the literature on PDs in older adults and (2) presents guidelines for clinicians in recognizing and managing this population. The presentation of Cluster A or C patients may remain stable or intensify, while Cluster B patients may shift to subtler presentations. Among assessment instruments, the Hetero-Anamnestic Personality Questionnaire is most promising, as it is age-specific and dimensional. Psychotherapies such as dialectical behavior therapy and schema-based therapy may be effective treatments. However, there remains a pressing need to conduct more comprehensive and focused research on PDs in older adults.

The effectiveness of adapted schema therapy for cluster C personality disorders in older adults – integrating positive schemas

IntroductionSchema therapy (ST) is an efficacious psychotherapy for personality disorders (PDs) in adults. The first empirical support for the effectiveness of ST in older adults with cluster C PDs was provided recently. ST partly focusses on the positive, but there is an increasing awareness of imbalance in the ST community because of the emphasis on negative schemas versus attention to positive schemas. Positive schemas may be important vehicles of therapeutic change in psychotherapy with older people, as it may help strengthen the healthy adult mode, and it might also help change a negative life review. Suggestions were made to increase the efficacy and feasibility of ST in older adults, including adjusting the case conceptualisation, modifying the experiential techniques, making use of the patient's wisdom and reactivating positive schemas. The aim of the current study is to investigate the feasibility and effectiveness of adapted individual ST for older adults. Methods/designA multiple baseline design is used with positive and negative core beliefs as primary outcome measures. Ten older adults (age > 60 years) with cluster C PDs are treated with schema therapy, with weekly sessions during one year. This treatment phase is preceded by a baseline phase varying randomly from 4 to 8 weeks. After treatment, there is a 6-month follow-up phase with monthly booster sessions. Symptomatic distress, schema modes, early maladaptive schemas (EMS) and early adaptive schemas (EAS) are secondary outcome measures. PD will be diagnosed before baseline and after treatment phase. EAS are assessed with the Dutch version of the Young Positive Schema Questionnaire (YPSQ). DiscussionTo the best of our knowledge, this is the first empirical study in which positive schemas are integrated in ST treatment to examine the efficacy of an adapted form of ST for older adults. This is in line with wider developments supporting the integration of positive schema's into ST. It offers the possibility to improve the effectiveness of ST in older adults. Trial registrationThe Netherlands National Trial Register NL8346, registered 1 February 2020.

Prevalence and correlates of antisocial personality disorder in older adults

Objectives There is a paucity of research on antisocial personality disorder (ASPD) in the geriatric population and the majority of knowledge on the disorder is drawn from young adult samples. Researchers posit that the prevalence of ASPD as well as other personality disorders (PDs) is underestimated among older adults. Using a nationally representative sample, the present study examines the prevalence and correlates of ASPD in adults ages 50 and older. Methods We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions Waves I and III. Multivariate logistic regression analyses were employed to investigate associations between ASPD and sociodemographic characteristics. A series of logistic regression analyses were also conducted to study associations between ASPD and medical conditions (liver and cardiovascular disease, arthritis, and stomach ulcer), major psychiatric disorders (lifetime major depressive disorder, mania, and generalized anxiety disorder), and substance use disorders (lifetime alcohol, marijuana, cocaine, heroin, and nicotine use disorders). Results Findings indicated that the prevalence of ASPD increases through early adulthood, with a peak at 3.91% in younger adults and decline to 0.78% in adults ages ≥65. Older adults with ASPD are more likely to be diagnosed with a substance use disorder, major depression, mania, and generalized anxiety disorder as well as each medical condition. Conclusion Older adults with ASPD experience increased rates of medical and psychiatric comorbidities. These conditions exacerbate the existing challenges associated with diagnosing and treating this population and may have serious consequences for the patient, their caregivers and society.

Epidemiological aspects of personality disorders in older adults

Despite growing clinical attention to personality disorders in older adults (≥ 55 yrs.), empirical research addressing personality pathology in late life is scarce. Given the ageing of the population globally, scientific knowledge in this area is of vital importance. This article gives an overview of the epidemiological aspects of personality disorders in older adults, such as prevalence, the course and the impact on various domains of functioning.

Standardized assessment of personality disorders in older adults: State-of-the-art.

The double ageing evolution in Europe is a tremendous challenge for health care. Older adults with a personality disorder place an additional burden: they have more somatic and psychiatric co-morbidity than those without a personality disorder. Moreover, they experience less quality of life than individuals without personality disorders. This is in sharp contrast to the dearth of empirical research concerning the construct of personality disorders in later life, the very limited amount of available diagnostic tools, criteria of classification systems like DSM not being attuned to the elderly context and the lack of age-neutrality of popular instruments to measure personality disorders. Therefore, in the Netherlands and Belgium a start was made to develop and validate age-specific instruments and to examine the applicability of the alternative dimensional-hybrid DSM-5 classification of personality disorders in older adults. These recent developments and how to apply them for a personalized assessment in older adults will be discussed. Finally, we advise a phased test-based diagnostic approach in which the above-mentioned instruments, combined with measures of adaptive features or more specific tests, can contribute to an assessment optimizing the balance between restricting the load for the older patient and still being sufficiently comprehensive to result in a personalized approach of the diagnostic process.

Psychological treatment of personality disorders in older adults: a review

Despite a still reigning therapeutic nihilism, attention for the psychological treatment of personality disorders in older adults has been growing recently. The first empirical studies have been conducted, but their number is still limited, and varies from expert consensus to the first tests of effectiveness of schema therapy and dialectical behavior therapy. Therefore, there is an urgent need for further empirical studies into psychological treatments that have been optimized for older adults on all three treatment levels.

Development of a tool to detect older adults with severe personality disorders for highly specialized care

Current guidelines recommend highly specialized care for patients with severe personality disorders (PDs). However, there is little knowledge about how to detect older patients with severe PDs. The aim of the current study was to develop an age-specific tool to detect older adults with severe PDs for highly specialized mental health care. In a Delphi study, a tool to detect adults with severe PDs for highly specialized mental health care was adjusted for older adults based on expert opinion. Subsequently, the psychometric properties of the age-specific tool were evaluated. The psychometric part of the study was performed in two Dutch highly specialized centers for PDs in older adults. Patients (N = 90) from two highly specialized centers on PDs in older adults were enrolled. The age-specific tool was evaluated using clinical judgment as the gold standard. The Delphi study resulted in an age-specific tool, consisting of seven items to detect older adults with severe PDs for highly specialized mental health care. Psychometric properties of this tool were evaluated. Receiver operating curve analysis showed that the questionnaire was characterized by sufficient diagnostic accuracy. Internal consistency of the tool was sufficient and inter-rater reliability was moderate. An age-specific tool to detect older adults with severe PDs was developed based on expert opinion. Psychometric properties were evaluated showing sufficient diagnostic accuracy. The tool may preliminarily be used in mental health care to detect older adults with severe PDs to refer them to highly specialized care in an early phase.

PERSONALITY DISORDERS IN LATE LIFE: PERSPECTIVES FROM CLINIC, ER AND LONG TERM CARE SETTINGS: Session 417

Clinicians are often challenged with identifying and managing difficult personality disorders in older adults. Provocative and hostile behaviors can estrange treatment providers and interfere with care; indeed, patient attitudes in relation to caregivers and providers are often revealing of diagnosis, despite complexities of medical illness, cognitive changes and psychiatric co-morbidities. In this session, we will use case examples from multiple clinical settings (outpatient clinic, psychiatric emergency room, and long term care consultation service) to highlight the challenges geriatric psychiatrists face in working with older adults with severe personality disorders. Presenters will review age-related psychosocial stressors, including personal losses and debility, and connect them to varied dysfunction across the lifespan, including patterns of attenuation of symptoms over time, re-emergence of personality disorder in late life and chronically persistent illness. In the outpatient clinic, Dr. Marouf will review common difficulties associated with narcissistic and borderline personalities, including diagnostic dilemmas in the setting of medical and psychiatric co-morbidities and the evidence for a range of treatment options. In the acute emergency room, Dr. Needell will focus on the challenges of safety assessments in these patients and decision making around disposition planning to minimize risks. In long term care consultation, Dr. Frankel will discuss the impact of sociopathic and dependent personalities on quality of care and care delivery, including management of staff responses, milieu disruption and other challenges to facility administration.

Feasibility and Acceptability of the Gerontological Personality Disorders Scale (GPS) in General Practice: A Mixed Methods Study

ABSTRACTAlthough the Gerontological Personality Disorders Scale (GPS) can aid in detecting personality disorders (PDs) in older adults in general practice, its availability does not guarantee its use. This study therefore aimed to examine the feasibility and acceptability of the GPS from an older adult, informant, and professional perspective. A convergent parallel mixed methods study was conducted. Qualitative data were collected through semistructured interviews with four general practitioners and four nurse practitioners and were analyzed thematically. Quantitative data were collected through a 5-item questionnaire completed by 329 older adults and 329 informants. The thematic analysis revealed five major themes regarding feasibility and acceptability according to the professionals: taboo to ask intimate questions, quite unfamiliar with these disorders, assets, PDs are a topic of interest in general practice, and preconditions. Descriptive statistics showed that most older adults and informants found the GPS items to be clearly phrased, easy to understand, and nonconfrontational or not unpleasant to answer. The GPS is a feasible and acceptable instrument for detecting PDs in older adults in general practice. Educating professionals about PDs in older adults and the GPS is important prior to its use in daily practice and might further increase its acceptability.

Antisocial Personality Disorder in Older Adults: A Critical Review.

Antisocial personality disorder (ASPD) has enormous negative impacts on the affected individuals, their loved ones, and society. This burden is intensified by the social and functional changes related to age. The lower prevalence of ASPD in older adults compared to younger adults is well-documented. This discrepancy, often attributed solely to antisocial "burnout," contributes to the lack of attention given to this disorder in older adults and may signify difficulty measuring ASPD in this population. These measurement issues likely stem from problems with the validity of the diagnostic criteria for older adults which may not effectively capture changes that occur with age. This review focuses on the current literature surrounding the validity of ASPD criteria with older adults and relevant concepts, including the connection between criminality and ASPD. Issues with screening tools and the measurement of ASPD caused by problems with the criteria are also discussed. Finally, recommendations for improvement, including use of dimensional models of personality disorders, a potential geriatric subclassification of criteria, and modification of the existing criteria are presented with clinical implications and suggestions for future research.

Personality disorders in older adults: diagnosis and management

Personality disorder traits can be quite problematic in older adult patients and the effects of these traits can sometimes present as risks that the professionals working in this field must be confident in managing. It is therefore crucial that information around the presentation and management of these disorders in the older adult psychiatry patient cohort is available. Here, the authors summarise current knowledge regarding the assessment and management of personality disorders in the older adult population, based on a literature search.

Schema therapy for personality disorders in older adults: a multiple-baseline study

ABSTRACTObjective: No studies have been conducted yet into the effectiveness of treatment of personality disorders in later life. This study is a first test of the effectiveness of schema therapy for personality disorders in older adults.Method: Multiple-baseline design with eight cluster C personality disorder patients, with a mean age of 69. After a baseline phase with random length, schema therapy was given during the first year, followed by follow-up sessions during six months. Participants weekly rated the credibility of dysfunctional core beliefs. Symptomatic distress, early maladaptive schemas, quality of life and target complaints were assessed every six months and personality disorder diagnosis was assessed before baseline and after follow-up. Data were analyzed with mixed regression analyses.Results: Results revealed significant linear trends during treatment phases, but not during baseline and follow-up. The scores during follow-up remained stable and were significantly lower compared to baseline, with high effect sizes. Seven participants remitted from their personality disorder diagnosis.Conclusion: Schema therapy appears an effective treatment for cluster C personality disorders in older adults. This finding is highly innovative as this is the first study exploring the effectiveness of psychotherapy, in this case schema therapy, for personality disorders in older adults.