Personality Disorders in Later Life

Abstract

Aging for people with personality disorders can be incredibly stressful, but assessment mechanisms and interventions are still works in progress.Personality disorders are a person-made heuristic: they can be created and eliminated at will.An official personality disorder diagnosis appeared with, and was briefly described in, the first (1952) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In DSM-II (1968), personality disorders became viewed as being "deeply ingrained" and being " different in quality from psychotic and neurotic symptoms."With DSM-III (1980), eleven specific personality disorder types were included and a multi-axial system of diagnostic notation was introduced, with these disorders assigned to Axis II. In contrast to Axis I, which included the episodic and acute psychiatric conditions, DSM-II was organized to include those conditions that illustrate the individual's chronic way of being in the world; describing a pattern of thoughts, feelings, and behaviors that transcend time and venue. DSM-III also added a longitudinal component, as follows:Personality Disorders are generally recognizable by adolescence or earlier and continue throughout most of adult life, though they often become less obvious in middle or old age (Roman emphasis added) (American Psychiatric Association [APA], 1980).The ten personality disorders listed in DSM-IV (2000) were maintained in DSM-V, the most recent DSM edition (2013). However, the multi-axial organization was abandoned in favor of the manual being organized into sections. Personality disorders appear in two sections. In Section II (Diagnostic Criteria and Codes) personality disorders are listed along with other mental disorders, formerly in Axis I, such as depressive disorders, anxiety disorders, dissociative disorders, etc. Personality disorders also appear in Section III (Emerging Measures and Models), which proposes an alternative diagnostic and research model, reflecting a different descriptive conceptualization, including gauges for severity and trait dimensions. This hybrid framework awaits more consideration and empirical support before it can be included in Section II.The "odd and eccentric" personality disorders (paranoid, schizoid, and schizotypal) were grouped together and form Cluster A; the "dramatic and erratic" disorders (antisocial, borderline, histrionic, and narcissistic) make up Cluster B; and, the "fearful and anxious" disorders (avoidant, dependent, and obsessivecompulsive) form Cluster C. Prominent characteristics of Cluster A disorders include distrust, social detachment, constricted emotional range, distorted perceptions, and odd behaviors. Characteristics of Cluster B disorders include consistent interpersonal difficulties, emotional changes or breakdown, need for attention, poor anger management, and provoking negative responses in others. Dominant features of Cluster C disorders include shyness, insecurity, hypersensitivity, fearfulness, and indecisiveness.In the older population, schizoid and paranoid personality disorders are the most common in Cluster A; narcissistic personality disorder is the most common in Cluster B; and obsessive-compulsive and dependent disorders are the most common in Cluster C.Prevalence of Personality Disorders in Older AdultsWe do not know the prevalence of personality disorders in older adults. This lack of knowledge primarily reflects problems with assessment and case identification. Based upon extant literature, prevalence estimates for those in the community are 2 percent to 13 percent (Simon, 1980; Ames and Molinari, 1994); for those receiving outpatient mental health services, 33 percent to 58 percent (Molinari and Marmion, 1993; Thompson, Gallagher, and Czirr, 1988); and for psychiatric inpatients, 7 percent to 62 percent (Kenan et al., 2000; Molinari, Ames, and Essa, 1994; Schuster et al., 2013). For older adults in nursing homes, prevalence estimates are 65 percent to 81 percent (Burns et al. …