Conclusions

Why is the study of epidemiology and comorbidity of personality disorders so important in later adult life? Clinicians have historically been reluctant to diagnose personality disorders for a confluence of reasons. Regardless of the age of the patient, part of the resistance may stem from the very concept of personality disorders. Because their defining characteristics include pervasive, maladaptive, and inflexible behaviors that cause significant impairment and distress and are generally stable over time, clinicians may consciously avoid making personality disorder diagnoses because of negative connotations, bleak prognoses, and fiscal disincentives. Prior to 1980, another problem was that there were neither specific criteria for the personality disorders nor a specific threshold for their diagnosis (e.g., 5 of 8 criteria must be met for a diagnosis). With the advent of the multiaxial DSM-III in 1980, polythetic criteria and an overall diagnostic threshold were specified. Placing personality disorders on Axis II, however, inadvertently separated them from other clinical syndromes and relegated them to a secondary status, leading to the often used demarcation, 799.9 Diagnosis Deferred on Axis II. Ironically, a diagnosis of mental retardation is also currently placed on Axis II, with the inference that both of these classes of syndromes (mental retardation and personality disorders) become evident by adolescence or much earlier and have a chronic and unremitting life course.

We have also highlighted the dangers in overemphasizing the Axis I disorders at the expense of minimizing or ignoring personality-based factors. The identification of comorbid Axis I disorders is important, but if these symptoms are largely caused by the underlying personality pathology, then the medications and psychotherapies targeting overt manifestations are unlikely to make major inroads into the pervasive disruption in the person's life. With an appropriate diagnosis on Axis II for these patients, therapeutic changes are more likely, especially if the medications for their depression, anxiety, or aberrant thinking make them more amenable to psychotherapeutic interventions. With creative and innovative therapies being introduced frequently in clinical psychology and coupled with empirically tested and well-honed older therapies, the prognosis for the personality disorders could likely be more sanguine.

The recognition that personality disorders often occur co-morbidly not only with Axis I clinical syndromes but also with other personality disorders is important because clinicians must resist the inclination to settle on single personality disorder diagnosis without examining the near equally likely circumstance that two or more personality disorders may coexist. We have presented in Table 6.1 the most likely occurring comorbid Axis I clinical syndromes and Axis II personality disorders with each personality disorder. We have also listed the comorbid personality disorders in decreasing likelihood of their comorbidity (based on our empirical study, Coolidge et al., 2006) where this evidence was available.

Finally, we reemphasize a major point of our discussion. Despite the overall high probability that medication, psychotherapy, or their combination will not change genetically determined temperaments underlying personality disorders, these interventions can be highly successful in changing the behavioral manifestations of personality disorders such that significant improvements can take place in the patients' and their families' lives. Even after a lifetime of the disruptive behaviors and difficult relationships that are associated with personality disorders, older adults can be as amenable to treatment as younger adults. It is for these reasons that the greater recognition and understanding of the prevalence and comorbidity of personality disorders in later adult life are important. We strongly encourage further research in these areas.

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