Community and Psychiatric Samples

Surveys conducted in the 1980s found prevalence rates for personality disorders in the older adult community ranging from as low as 2.8% to as high as 11.0% (Cohen, 1990).

Agronin (1994) presented a review of some early epidemi-ological studies in various European older adult communities and described prevalence rates of 1.8% to 6.0%. However, he noted that many of the diagnoses would not conform to modern DSM-IV personality disorder criteria. Weissman (1993) presented somewhat higher estimates of the total lifetime prevalence rates for personality disorders in the general population, ranging from 10% to 13%.

Ames and Molinari (1994) administered a structured interview to 200 community-living older adults (mean age = 72 years), and found a 13.0% prevalence rate. They also noted that, due to the nature of their convenience sample at a senior center, Dependent Personality Disorder may have been over-reported, whereas Schizoid and Avoidant Personality Disorders may have been underreported. When they compared these rates with a sample of 797 younger adults given the same structured interview, they found a prevalence rate of 17.9%. Cohen et al. (1994) used a semistructured psychiatric examination to study personality disorders in a community-dwelling sample of 810 people. They found that older adults (defined in their study as 55 years old and older) had a 10.5% personality disorder prevalence rate, whereas younger people had a 6.6% rate. Another finding was that Antisocial and Histrionic Personality Disorders were both much less prevalent in the older than in the younger subjects. Segal, Hersen, et al. (1998) administered the self-report Personality Diagnostic Questionnaire-Revised (PDQ-R) to 189 community-dwelling older adults (mean age = 76 years) and found that 63.0% of the respondents met criteria for at least one personality disorder diagnosis. They proposed that their high prevalence rate was likely an artifact of the PDQ self-report measure which is known to be overly sensitive to pathology. This is discussed further in Chapter 9. The high prevalence also possibly reflects that sample participants were attending a senior center and, as such, may have been more likely to seek out this kind of social service because of existing personality and interpersonal problems.

To evaluate the prevalence issue from a statistical perspective, Abrams and Horowitz (1996) conducted a meta-analysis of 11 studies of prevalence rates in older adults (defined as age 50 years old and older) from 1980 through 1994 and reported an overall rate of 10% with a range from 6% to 33%. Interestingly, in the three studies that also included under-50 age groups, the overall prevalence for personality disorders was higher among the younger groups at 21% with a range from 17% to 30%. However, in all three studies there was no significant difference in the rate of personality disorders between younger and older adults. Abrams and Horowitz also found no gender differences in their older group and, contrary to their expectations, greater prevalence rates were found in outpatient or community settings than in inpatient settings. They also found consensus methods, defined as agreement among a number of clinicians, and chart reviews to yield higher rates of personality disorders compared with structured interviews.

Our recent empirical research (Coolidge, Segal, & Rosowsky, 2006) on a sample of 681 purportedly normal and healthy, community-dwelling adults ages 18 to 89 revealed that an older group (N = 114; age range = 60 to 89 years) had a prevalence rate of 11% (13 of 114 participants) for at least one personality disorder scale on the self-report form of the Coolidge Axis II Inventory (CATI; Coolidge, 2000). These rates are almost identical to those reported by Abrams and Horowitz (1996; older persons' prevalence rates = 10% and 11%, theirs and ours, respectively; younger groups' prevalence rates = 21% and 20%, theirs and ours, respectively).

A number of studies have also reported prevalence rates among older adults in mental health settings. In a retrospective chart review of a mixed sample of inpatient and outpatient older persons, Mezzich, Fabrega, Coffman, and Glavin (1987) found that 5.1% had a personality disorder diagnosis. Casey and Schrodt (1989) reviewed charts of 100 consecutive admissions to a geriatric psychiatry unit and found that 7% received a diagnosis of personality disorder that was determined by psychiatrist ratings. In a larger retrospective study, Fogel and Westlake (1990) ascertained the prevalence of personality disorders in 2,332 older inpatients suffering from major depression. Again, diagnoses were assigned by attending psychiatrists, and the results indicated a 15.8% personality disorder rate. Among older inpatients, Molinari, Ames, and Essa (1994) found a 33% prevalence rate based on clinical interviews that increased to 58% when structured interviews were used. Among depressed older adult psychiatric inpatients, Molinari and Marmion (1995) reported a 63% prevalence rate. Among older inpatient veterans, Kenan et al. (2000) found a 55% prevalence rate.

It is important to note that the prevalence rates for personality disorders in cases where an Axis I diagnosis may have been the precipitating factor in an outpatient or inpatient admission may be greatly underestimated. As explained later in this chapter, some clinicians may focus on signs and symptoms that are more obviously manifested and noted (e.g., mood, anxiety, and somatoform disorders). In some cases, the underlying maladap-tive personality traits may be overlooked. Nevertheless, despite some diagnostic barriers among younger and older personality disordered individuals, some studies have documented high prevalence rates of personality disorders in clinical settings serving adults of all ages. Turkhat (1990) found that approximately 50% of clients seeking psychotherapy services have a di-agnosable personality disorder, whereas Jackson et al. (1991) documented that 67% of patients in a state mental hospital had at least one personality disorder.

Although personality disorders among long-term-care residents have been infrequently studied, some older studies provide interesting data. Teeter, Garetz, Miller, and Heiland (1976) reported that almost 11% of nursing home residents had a personality disorder diagnosis, and Margo, Robinson, and Corea (1980) found that 15% of referrals to nursing homes were for personality problems.

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