Personality Disorders in Older Age

Clinical Context

Diagnosis

The diagnosis of a personality disorder requires a pervasive pattern of maladaptive behavior that impairs functioning in at least two of the following domains: cognition, affect, interpersonal functioning, and impulse control (see Box 1). Personality disorders have their onset by adolescence or early adulthood. The observed impairment must not be better explained by another mental disorder or medical condition and should not be due to the effects of a substance. Traditionally, personality disorders have been categorized in clusters A (paranoid, schizoid, and schizotypal), B (antisocial, borderline, narcissistic, and histrionic), and C (avoidant, dependent, and obsessive-compulsive). The more recent dimensional classification relies on identification of dysfunctional personality functioning with dysfunctional personality traits. Dysfunctional personality traits are defined within these domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism (1).

Personality disorders are frequently considered in individuals with flagrantly and persistently maladaptive interpersonal relationships or obvious impulsivity. Health care providers may be less keen to diagnose a personality disorder in patients who do not present with significant interpersonal conflict. Patients with avoidant and dependent personality disorders have an extreme tendency toward conflict avoidance coupled with a compulsive drive to please others and habitual minimization of their own distress. In the health care setting, these patients are often respectful, conscientious, and adherent to treatment recommendations. As a result, the absence of interpersonal conflict between the patient and provider may decrease the provider’s suspicion of an underlying personality disorder. Among older adults, patients with cluster A and cluster B personality disorders may be dismissed as merely eccentric.

Ideally, the diagnosis of personality disorder will be made after a clinical interview, with information from the patient and from one or more reliable collateral informant(s) (2). Each of these sources provides unique, complementary information that aids diagnosis. A clinical interview alone is frequently insufficient to discover information pertinent to the diagnosis of a personality disorder, as patients are often unaware of disordered traits or may be unwilling to disclose vitally pertinent information. However, in practice, collateral information may be entirely unavailable or quite limited. Care must be taken, however, to establish chronicity of disordered thought patterns, affect, and behavior. Even in patients who do not meet the full criteria for a personality disorder on first evaluation, identifying dysfunctional personality disorder traits gives important clues to a patient’s overall functioning and can lay the foundation for a later diagnosis. Often, longitudinal clinical encounters are required to diagnose a personality disorder accurately.

Because of advances in recent decades, diagnosis of personality disorders in older adults can be aided by the use of standardized assessment tools (3). The Gerontological Personality Disorder Scale is a 16-item screening tool that has been validated with older adult outpatients. There are two versions of this screening tool, designed to be used by patients and informants, respectively. The Hetero-Anamnestic Personality Questionnaire (HAP) has been validated in older adults in long-term care. For the HAP, only an informant provides information. The Assessment of DSM-IV Personality Disorders has been found to be largely (but not entirely) age neutral. These tools can serve to augment clinical assessment and allow standardized evaluation from one patient to the next (3).

Differential Diagnosis

The differential diagnosis of personality disorder includes substance use disorder, personality change due to a general medical condition, neurocognitive disorder, and autism spectrum disorder, as well as several other mental health disorders. The presence of a substance use disorder may result in pathologically unempathic, impulsive behavior that may shatter close relationships. Obtaining a careful history of current or previous substance use is essential. Autism spectrum disorder may mimic schizoid personality disorder. However, patients with schizoid personality disorder demonstrate a complete lack of interest in close relationships, whereas patients with autism spectrum disorder frequently have close relationships with some friends, family members, or both. Impaired interpersonal functioning may occur during a time of notable crisis, such as job loss, foreclosure, death of a family member, or sudden decline in health. Also, patients presenting with, for instance, major depressive disorder or posttraumatic stress disorder may exhibit maladaptive personality traits that resolve with treatment of the underlying mental health disorder. Therefore, it is important to distinguish transient declines in interpersonal functioning related to stressors from a chronic, long-standing personality disorder.

A wide range of medical disorders may result in a change in personality. It is especially important to obtain a history of any falls, concussions, prolonged involvement in contact sports with the potential for brain trauma, motor vehicle accidents, strokes, severe illness resulting in delirium, or severe illness necessitating treatment in an intensive care unit. In a patient with a history of significant accident, illness, or injury, care must be taken to ensure that maladaptive personality traits were present and were causing clinically significant functional impairment before the accident, illness, or injury. In cases when premorbid traits and functioning cannot be determined, the most appropriate diagnosis is personality change due to a general medical condition.

Lack of empathy, apathy, social withdrawal, and impulsivity may all be seen in neurocognitive disorders or personality disorders. Personality disorders are themselves associated with subtle impairments across a range of cognitive domains, including executive function, memory, processing speed, and visuospatial abilities (4). Neuroticism is especially associated with increased cognitive decline (5). For these reasons, an evaluation of cognitive function is essential when assessing older patients with maladaptive personality traits.

Prevalence, Impact, and Comorbidity

Personality disorders are among the most common mental disorders, with a prevalence of 15% in the general adult population, similar to the prevalence in the older adult population (2, 6). Obsessive-compulsive disorder (7.6%) and narcissistic personality disorder (3.9%) are the most common, whereas histrionic (0.7%) and dependent (0.26%) personality disorders are the least common (2). Older men are more likely than older women to demonstrate any personality disorder (2). However, paranoid, avoidant, and dependent personality disorders are more common in older women. In general, personality disorder prevalence declines with increasing age (2).

On average, patients with personality disorders demonstrate increased health care utilization but suffer from worse health care outcomes. Patients with personality disorders have increased risk of stroke and heart disease and increased mortality (7). Personality disorders are associated with increased risk of obesity, underweight, smoking, alcohol use disorder, diabetes, arthritis, and gastrointestinal disorders (7). Antisocial personality disorder has been found to be associated with increased risk of accidental injury, hepatitis C infection, and HIV infection (8). Time to treatment response is prolonged, and treatment response is decreased for older patients with comorbid mood and anxiety disorders (9). Moreover, patients have decreased functional status and quality of life, even after depression remission. Overall, older patients with personality disorders generally have increased suicide risk (10). Narcissistic personality disorder is likely a risk factor for suicide among depressed older adults.

In the general adult population, patients with borderline and antisocial personality disorder are at markedly increased risk of suicide attempt and suicide completion (8, 11). The average age at suicide completion in patients with borderline personality disorder is in the 30s (11). Over the long term, nonsuicidal self-injury, suicide attempts, and unstable relationships in patients with bipolar disorder tend to decrease. However, affective symptoms of borderline personality disorder—dysphoria, feelings of emptiness, and anger—tend to be chronic (12). These are the symptoms of borderline personality disorder that clinicians commonly encounter in older adult patients. In antisocial personality disorder, homicides and accidents, as well as suicide completion, contribute to premature mortality (8). Arrests decline from a peak in the late teens (8). On average, antisocial personality disorder symptoms improve by the mid-30s (8). By older age, arrests of patients with antisocial personality disorder are typically for nonviolent crimes. However, patients with antisocial personality disorder generally continue to struggle with impaired interpersonal relationships and decreased occupational function in the long term (8).

The presence of a personality disorder may complicate rapport between patient and health care provider so that important problems are not addressed. This may be due to the patient’s failure to disclose concerns or to a lack of guideline-recommended care in time-limited visits when other problems may appear predominant, or when interpersonal conflict between a patient and provider may dominate the encounter to the detriment of the patient’s quality of care. Patients with personality disorders may also be less adherent to medical recommendations.

Patients with personality disorders are more likely to be absent from work and have lower productivity while at work. Across a range of interpersonal relationships, patients with personality disorders demonstrate impaired role functioning, with potentially devastating effects on their relationships with family, friends, and acquaintances. Personality disorders are frequently comorbid with mood, anxiety, and substance use disorders (2).

Treatment Strategies and Evidence

Data on treatment of personality disorders in the elderly are limited, but there have been important clinical advances in small studies. A study of dialectical behavioral therapy (DBT) in patients with depressive disorder and personality disorder showed positive results on improvement of depression. Thirty-four depressed adults over age 60 were randomized to treatment with medications only or medications plus group skill-based DBT plus a 30-minute weekly coaching session (13). Participants who received DBT were more likely to remit from depression (13). This study did not assess the effect of treatment on personality disorder as a primary outcome measure. In another study of 45 participants aged 55 or over, patients with a personality disorder and major depressive disorder were randomized to receive medication management only versus standard DBT in combination with medication management (13). Twenty of the 45 patients had obsessive-compulsive disorder, and an additional 10 had avoidant personality disorder (13). Over the course of treatment, both groups showed improvement in major depressive disorder symptoms and personality functioning (13). A total of 16 patients in both groups remitted from their personality disorders over the course of treatment (13). A small study of schema therapy has shown that this therapeutic option is promising. Eight patients with cluster C personality disorder were repeatedly assessed during a baseline phase of random length and then had schema-based therapy over the course of eight months. Authors found a high effect size, and seven patients remitted from their personality disorder (14). An earlier study with a heterogeneous patient population, including 10 patients with various personality disorders, also indicated beneficial effects of group schema therapy (15).

There are no medications for treating personality disorders in older adults that have been approved by the Food and Drug Administration, and no randomized controlled studies have assessed medications specifically for treating personality disorders in older adults. However, in practice, medications are commonly used for target symptoms such as impulsive aggression or affective instability, so it is useful to review evidence from the general adult population. Most trials of pharmacotherapy for personality disorders have been conducted for patients with borderline personality disorder. Among patients with borderline personality disorder, there is accumulating evidence that divalproex can reduce impulsive aggression, irritability, and the overall severity of borderline personality disorder (16, 17). Topiramate has been found to decrease anxiety and interpersonal rejection sensitivity in patients with borderline personality disorder (16, 18). The beneficial effects of topiramate were sustained in long-term open-label follow-up. There are suggestions that naltrexone may reduce self-harm and dissociation (16, 19). Several second-generation antipsychotics have been found to reduce impulsive aggression, psychosis, and interpersonal rejection sensitivity in patients with borderline personality disorder (20). Olanzapine and aripiprazole are the best studied second-generation antipsychotics in this regard. Aripiprazole, but not olanzapine, is effective in reducing nonsuicidal self-injury in patients with borderline personality disorder (16, 21). Small trials of omega-3 fatty acids for borderline personality disorder have shown positive effects: decreased aggression and parasuicidal behaviors, improved affect, and decreased stress reactivity (16, 20, 22). There are hints that antipsychotics are helpful for psychotic symptoms in schizotypal personality disorder, whereas guanfacine may attenuate cognitive deficits (16, 23, 24). Serotonergic agents are commonly used in avoidant personality disorder, as a comorbid social anxiety disorder is frequently present, but the impact of this approach on outcomes in avoidant personality disorder per se (rather than on outcomes in social anxiety disorder) has not been tested in clinical trials. For patients with social anxiety disorder and comorbid avoidant personality disorder, a trial of a selective serotonin reuptake inhibitor, monoamine oxidase inhibitor, gabapentin, or pregabalin is indicated (25). Information on the pharmacotherapy of other personality disorders is sparse. In all cases, care must be taken to use a consistent method to evaluate symptom severity, and the duration of an adequate trial must be defined to allow for clear decisions on whether a medication or intervention is clinically beneficial (16).

Questions and Controversy

Several aspects of diagnosing a personality disorder in older adults present unique challenges. It is often impossible to ascertain that observed personality traits and impaired functioning have been present since adolescence or early adulthood. Further, personality disorder traits may not be stable over an entire lifespan (13). Given the requirement that traits have their onset in adolescence or early adulthood, a patient who develops these traits by middle age and continues to exhibit them for decades will not meet the criteria for a DSM-5 personality disorder, even in the presence of significant functional impairment because of these traits (3). Several criteria for the diagnosis of personality disorders are contextually inappropriate for older adults (1). For instance, older patients with antisocial personality disorder may be frail and physically unable to get into fights or assault others (criterion 4). Some criteria mention detrimental effects on work performance; for instance, failure to sustain work consistently in patients with antisocial personality disorder or relentless devotion to work in patients with obsessive-compulsive disorder. There criteria are irrelevant to older adults who are retired, chronically unemployed, or disabled. Older adults may naturally have a smaller sphere of social support that is highly reliant on immediate family members because of the loss of friends and extended family over time. However, this entirely common state of being in older adults satisfies criterion 5 of schizoid personality disorder: “lacks close friends or confidants other than first-degree relatives.” Further research is needed to identify psychotherapies that are effective across a range of personality disorders in older individuals. For instance, mentalization-based therapy has been found to be effective for borderline personality disorder in the general population, but this has not been evaluated in older individuals. Trials of pharmacotherapy for personality disorders in older adults are entirely lacking. Research is needed to assess for the possible existence of a late-onset personality disorder phenotype.

Recommendations

With a certain pragmatic cynicism, practitioners often question the value of arriving at a personality disorder diagnosis, particularly given the challenges of making this diagnosis in older adults, perceived limitations in treatment options, and possible negative effects on insurance reimbursement. Furthermore, there is a tendency for maladaptive personality traits to be dismissed or ignored in older adults. However, a diagnosis of personality disorder has important clinical implications, prompting evaluation for likely comorbidities, negatively affecting prognosis, and requiring specialized treatment that is simply impossible in the absence of diagnosis. Several screening tools have been validated in older adults to aid in the diagnosis of a personality disorder. With their high prevalence; high symptom burden; and broad impacts on treatment outcome, mortality, and suicide risk, personality disorders cannot be ignored. There is emerging evidence that DBT can be effective in patients with a comorbid depressive disorder, and schema therapy also shows promise. Technological advances have created the opportunity for delivery of in-home virtual group therapy. There is increasing evidence that mood stabilizers and second-generation antipsychotics are effective at targeting certain features of personality disorders in the general population. As yet, however, there are no studies of pharmacotherapy in older adults.