PHILADELPHIA — Personality disorders may appear to worsen with advancing age, although the prevalence remains stable with about 10%–20% of people age 65 or older having a personality disorder, Erlene Rosowsky, Psy.D., said at a conference sponsored by the American Society on Aging.
In general, personality disorders do not appear for the first time in old age. More commonly, the behavior first appears at a younger age. A personality disorder is an enduring pattern of behavior that is stable, of long duration, and pervasive, and causes clinically significant impairment by producing behavior that markedly deviates from social expectations. In some cases, personality disorders reappear with age after a comparatively quiescent phase during mid-life when roles and relationships keep their expression contained.
Personality disorders that are susceptible to worsening with age include paranoid, schizoid, schizotypal, obsessive compulsive, borderline, histrionic, narcissistic, avoidant, and dependent, said Dr. Rosowsky, a geropsychologist in Needham, Mass.
Certain types of disorders are especially susceptible to worsening in response to specific stressors. For example, reliance on strangers for care poses a risk for exacerbating paranoid, schizoid, schizotypal, and avoidant personality disorders. Loss of attractiveness is a problem for people with histrionic, narcissistic, or borderline personality disorders. Relocation to a new environment will have the most impact on patients with paranoid, avoidant, or obsessive-compulsive disorder.
The behaviors that make up personality disorders are not inherently pathologic. These traits can be possessed by anyone. But personality traits become disorders when they manifest to an extreme and become dysfunctional and maladaptive. The way a trait is expressed may not be appropriate for the age or stage of a person.
“Something about the age and stage, something about the degree, and something about the pattern distinguishes a personality style [which is normal] and a personality disorder,” which is not normal, said Dr. Rosowsky, who also is affiliated with the department of psychiatry at Harvard Medical School, Boston. And it's not simply a bimodal condition, in which a person is either normal or disordered. There are gradations and nuance in the expression of the personality trait, and there are gradations in its appropriateness.
When assessing an elderly patient with a personality disorder, caregivers should identify what's treatable and what is an achievable goal that the patient agrees to work toward. Treatment should be respectful and relevant to the patient to produce symptom relief, allow interdependence, accommodate change, and support healthy narcissism. Somatic treatment is often indicated for co-morbid psychiatric conditions, and may be somewhat less effective when a personality disorder is also present.
Effective interventions are developed with clues from the patient's past that suggest the presence of a personality disorder, such as a history of chaotic relationships, or an absence of relationships, or troubles with the legal system. Interventions are designed to make the smallest change possible to achieve the desired result. Specific types of therapy that have successfully treated personality disorder include cognitive-behavioral, interpersonal, and dialectical. Psychodynamic therapy usually is not appropriate, and somatic treatment is less successful. Environmental engineering also is usually needed, as are supportive therapy and psychoeducation.
Personality disorder can interact with dementia, another potential complication in the elderly. The disorder may adapt to the memory loss of dementia and may respond to negative societal feedback. The drugs used to slow progress of dementia also may affect a personality disorder. Dementia brings apathy, withdrawal, mood disturbances, and often coarsens the patient's affect, which can all interact with the personality disorder.
Each disorder type can be explored in elderly patients using tailored questions. For those with Cluster A disorders such as paranoid, schizoid, and schizotypal disorders, for example, a caregiver should deal with the patient's privacy needs, the willingness to accept help or medical treatment, and the ability of a caregiver to become close enough to provide meaningful treatment.