In this chapter, we have reviewed the cognitive, psychoanalytic, and interpersonal paradigms of personality disorders and aging. Cognitive theories of personality disorders tend to be framed through individuals' phenomenological world, yet their treatment of personality disorders tends to be grounded in precise behavioral assessment techniques. Thus, cognitive-behavioral assessment and interventions are ideally suited to aging persons with personality disorders. The assessments and interventions are not yet uniquely developed for groups of older persons with personality disorders, as cognitive-behavioral theorists have done for some personality disorder types like the borderline category. However, because of the emphasis on the individual phenomenological world of any person with a personality disorder, the special issues associated with aging can be appropriately assessed and treated.

Psychoanalytic theorists have also tended to ignore the particular challenges that aging poses for people with personality disorders. In general, psychoanalytic thought has always focused itself on childhood roots for adult personality problems. Freud generally ignored aging issues from his psychoanalytic perspective; ironically, he appeared to suffer greatly from his own aging issues, and he appeared to view himself as old well before his time. Kernberg, a contemporary psychoanalytic theorist, proposes that psychoanalysis still has much to offer in the diagnosis and treatment of personality disorders. The main techniques of psychoanalysis—free association, dream analysis, and the interpretation of the transference reaction—would still be highly appropriate to some of the issues of older persons with personality disorders.

Horney's interpersonal theory of neurotic types (i.e., personality disorders) perhaps addressed issues of aging more directly than the other two theories in this chapter. Horney also saw that two aging issues, a cultural bias toward the erotic attractiveness associated with youthfulness and the dependent emphasis of qualities associated with maturity, like poise, independence, autonomy of judgment, and wisdom, as critical to the mental health and growth of women. She recognized that both sexes had to be liberated at the same time to have the full development of all human personalities.

We have also seen that each of these major theories of personality disorders presented in this chapter tend to be somewhat deficient when addressing many of the specifics of personality disorders and aging. One argument could be made in their favor and that is general personality trait research has shown an overriding stability of most traits, including some traditionally abnormal ones such as neuroticism and psychoticism (e.g., Heatherton & Weinberger, 1994). However, research has also shown that individual variation in personality traits and disorders tends to be large, exceeding well-known influences on the personality, such as gender, by a factor of 30.

Regarding theories of personality, one size does not fit all. We continue to struggle to arrive at a unified theory that supports our understanding of the origin, maintenance, and presentation of personality pathology. Old theories each contribute, and must be integrated, but cannot stand alone, perhaps especially as they relate to older adults. For this population, we need to consider cohort and historical moments juxtaposed to developmental stages. The current stage and context need also to be considered in the theoretical analysis. What is being asked of the personality so that it presents as disordered?

Finally, we want to emphasize the point that personality disorders appear to be a final expression of many factors, including significant genetic and constitutional factors, which we address in Chapter 8. Studies of heritability support the existence of infrastructure factors. Psychodynamic factors and early environments also play an important role in shaping personality (healthy and disordered). From very early in life, a history of neglect, abandonment, inconsistent and fragile attachments, trauma, and abuse can lead to disordered styles of relating to the others and the world. Whereas most of the research in this area has focused on Borderline Personality Disorder showing that people with borderline personality are likely to have had early trauma experiences (Stone, 1993), it is likely that diverse unhealthy, unduly stressful, chaotic, or abusive early environments often play at least some role in the formation of each specific type of personality disorder.

Because a theoretical understanding of the older personality-disordered patient is crucial for guiding interventions, let's reconsider the quotes offered at the beginning of this chapter. As Einstein suggested, a theory is limiting if we adhere dogmatically to one particular perspective and all that we "see" is "filtered through the particular lens" of that theory: Some important details of the case may be overlooked or not given appropriate weight. We therefore encourage clinicians to become well versed in a variety of theoretical perspectives, knowing that the ability to look at older patients and their problems from different vantage points can be very useful.

Theories of Personality Disorders: Evolutionary and Neurobiological

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