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Personality Disorders May Worsen With Age

      Mitchel L. Zoler is with the Philadelphia bureau of Elsevier Global Medical News.
      PHILADELPHIA — Personality disorders may appear to worsen with age, although the prevalence remains stable with 10%–20% of people age 65 or older having a personality disorder, according to geropsychologist Erlene Rosowsky, PsyD.
      In general, personality disorders do not appear for the first time in old 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, Dr. Rosowsky said at a conference sponsored by the American Society on Aging.
      Certain 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 disorders.
      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.
      Dr. Rosowsky, who also is affiliated with the department of psychiatry at Harvard Medical School, Boston, said this is 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, the caregiver 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 less effective when a personality disorder is also present.
      Effective interventions are developed with clues from the patient's past that suggest a personality disorder, such as a history of chaotic 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.
      Personality disorder can interact with dementia. The disorder may adapt to the memory loss of dementia and may respond to negative societal feedback. Drugs used to slow progress of dementia also may affect a personality disorder. Dementia brings apathy and withdrawal and often coarsens the patient's affect, which interact with the personality disorder.
      The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) divides personality disorder into four categories: Cluster A has the Odd-Eccentric behaviors and includes paranoid, schizoid, and schizotypal disorders. Cluster B has the Dramatic-Emotional behaviors and includes antisocial, borderline, histrionic, and narcissistic disorders. Cluster C has Anxious-Fearful behaviors and includes avoidant, dependent, and obsessive-compulsive disorders. The fourth category is unspecified personality disorder.
      Each type can be explored in patients using tailored questions. For those with Cluster A disorders, a caregiver should deal with privacy needs, willingness to accept help or medical treatment, and the ability of a caregiver to become close enough to provide meaningful treatment.
      Patients with Cluster B disorders should be assessed for symptom conversions, such as noncompliance or drug sharing. Energy conservation in older age may dampen a more florid expression of a patient's personality. Cluster B patients also raise questions about narcissism in old age. Patients with Cluster C disorders need to have relevant traits identified. Some traits may require strengthening, while others need reduction.