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Foreword

Personality disorders (PDs) are among the most complex aspects of human behavior to understand and manage. When the vicissitudes of old age further complicate these disorders, mental health clinicians are faced with immense challenges to their therapeutic skills.

Why is the diagnosis of PD especially important in old age? Adaptation in late life is increasingly challenging, and as this book so expertly describes, PD can impair adaptive capacities in many ways. This impairment has many negative outcomes such as association with several Axis I disorders that are precipitated by or complicated by PD. The interpersonal maladaptive patterns associated with PD in late life can be destructive to elders. In addition, certain maladaptive personality traits such as undue pessimism, a tendency to helplessness, and overreliance on supportive relationships with others— so-called sociotropy—are associated with physiological reactions that may produce severe consequences if they are unrecognized or untreated. These consequences may include predisposition to depression associated with a rise in inflammatory markers such the interleukins, heart disease, and cancer. Although the cause-and-effect nature of these associations is not yet well defined, there is enough data to suggest that understanding and treating PD or trait disturbances could have important physical and mental health benefits. Similarly, other aspects of management of the problems of the elderly by care-givers will be much more challenging in the presence of the primary problem of PD: the associated impairment of interpersonal relationships. Elders, whose PD-based pathology compels them to demean and reject those on whom they must rely, can provoke rejection and abandonment at a time in their lives when they are often most in need of practical support, care, and love. The outcome can be disastrous. Even professional mental health practitioners often shrink from the task of dealing with such patients knowing instinctively or from experience that the treatment can be unrewarding, personally difficult, and complex.

To our rescue have come Segal, Coolidge, and Rosowsky, who are just the seasoned authors we need to guide the profession into this challenging arena of diagnosis, assessment, and treatment of PD in elders. Their important book synthesizes the accumulated knowledge of personality and its disorders in late life, combining the rigor of science with the sensitivity of that indefinable, essential component of practice called clinical art.

As every practitioner of mental health care for older adults will readily know from both experience and epidemiological data, the old retain the capacity to express all the psychopathol-ogy of the young including personality disorders. As is true for other disorders, however, old age creates additional clinical features that often obscure the immediate recognition of PD by the clinician who is using criteria of diagnosis created for younger patients. In old age, the many changes in health, intellectual ability, physical capacity, and social circumstance all interact to produce behaviors that, as the authors so well describe, mimic PD; for example, the withdrawal of the schizoid or the clinging neediness of the dependent personality. Similarly age-associated alterations can induce behavioral changes that obscure an underlying personality disorder such as diminishing the expression of the drama of Cluster B symptoms.

In the arena of personality disorder, the iconoclastically inclined reader may question the utility of applying the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision; DSM-IV-TR) criteria for PD to any age group. Thankfully, this book refreshingly deals with diagnosis by recognizing both the value of the formal criteria and the complexity of the issues. The criteria for each PD diagnosis are well presented and then thoroughly dissected from the perspective of diagnosis of the elderly patient using case histories to enliven the discussion. This careful analysis, supported by clinical cases, should help the framers of the next generation of DSM criteria specifically define age-appropriate criteria for PD.

Segal, Coolidge, and Rosowsky not only have established an important clinical and heuristic base for the practical application of PD diagnostic criteria to the elderly but have also highlighted those areas where the clinician must be cautious in applying the standard criteria to aging patients. This is especially true for the more dramatic personality disorders such as the borderline.

The criteria of the DSM-IV-TR appropriately rely, wherever possible, on the most observable behaviors to define diagnosis. However, behavior is multidetermined especially in the elderly. To understand the behaviors of personality disorders in elders, the clinician must be guided to elicit the full range of factors that influence behavioral expression—affect, cognition, inner conflicts, and motivations must all be explored systematically with each patient to accurately distinguish which behaviors arise out of personality-based factors and which are precipitated by other age-related problems such as brain pathology or physical limitations. In addition, the clinician must be able to gather the longitudinal data to establish the early evidence in support of habitual aspects of the behavior necessary for diagnosis of PD, a sometimes challenging task when dealing with the lifelong histories of elders. The authors have embraced the tangled diagnostic web and have begun to create a diagnostic map to guide the clinician. Their approach also highlights those areas where empirical and systematic data are lacking and need further research, thereby implicitly suggesting a research agenda for investigating diagnosis of PD in elders in a targeted fashion.

Empirical approaches to diagnosis are further strengthened by the thoughtful discussion of standardized PD diagnostic instruments, emphasizing the strengths and weaknesses of each and in particular emphasizing the utility or lack of it for the elderly. All standardized instruments have the great advantage of systematically eliciting data from the patient. But their focused nature also imposes limitations that should lead to cautious interpretation of results. Some instruments such as the Structured Clinical Interview for DSM-IV (SCID-II) simply offer a structured approach for defining the presence or absence of the symptoms used for making a DSM diagnosis. Others such as the NEO Personality Inventory (NEO-PI) rely on a theoretical base that arbitrarily restricts the features of human behavior to predetermined categories. Standardized interviews therefore are but one useful approach to understanding the diagnosis of PD in elders.

An important, but as yet unresolved, question is whether maladaptive personality-based behavior can newly emerge in late life. The authors usefully examine this ongoing debate. Firm conclusions cannot be drawn based on the data at this point in time, but clearly, behaviors can change and evolve in late life. The clinician meeting the patient in a cross-sectional fashion, must, among other possibilities, decide on the origin of the symptoms. New, previously unexpressed behaviors can arise when the patient's prior capacity to deal with psychological stress fails. Why might this occur? One possibility is that age-associated life stressors such as loss and grief may selectively assault the patient at points of long-standing personality-based vulnerabilities that were dormant earlier in life when the stresses of life required different strengths and capacities.

One of the most important aspects of this book is the careful interweaving of detailed and well-described case histories. Throughout, the reader is guided by comprehensive cases that acknowledge the complexities of diagnosis and management. The observational perspectives are integrated with the psychological, social, and psychodynamic. In addition, for each case, the authors address the challenge of effective management strategies tailored to the needs of each type of PD. This by itself is worth the price of the book.

The final section deals with the core of the matter for clini-cians—what are we, the therapists, to do with these extremely difficult patients; how do we help them? The answer derives from the way in which the problems are conceptualized, and here again Segal, Coolidge, and Rosowsky draw on their well-honed clinical experience integrating it with the existing, and admittedly small, pool of empirical data on effective outcomes. Management of PD must deal with a disorder that has by definition been present for a long time, perhaps lifelong, and that tends to permeate the fabric of the patient's life. The clinician therefore must be able to define and respond to those problems that are amenable to intervention.

The authors recognize that treatment addresses the syndro-mal (e.g., anxiety or depressive elements requiring medication) and the less well-defined elements of behavioral disturbance. They acknowledge the difficulties of trying to implement intensive psychodynamically oriented techniques in this population although the outcome data in this regard are scarce indeed. Rather they appropriately combine in-depth understanding of the patient and marry it to the most effective environmental, cognitive, and behavioral interventions.

While therapeutic optimism is important in treating any patient, the clinician must be realistic about the extent of change that is possible in certain PDs and be prepared to accept limited gains which, though small, may be significant to the patient's life. In the process, the therapist often endures intensely unpleasant interactions with these patients, who are renowned for their ability to induce some rather untherapeutic feelings in therapists. Therapy is often best when the therapist is highly self-aware during treatment, thereby avoiding being driven away by the patient or responding in an otherwise untherapeu-tic manner. It is here that the depth of understanding of the psy-chodynamics and thought patterns of these patients becomes crucial to management. Phenomenology alone will not equip the therapist adequately.

This book is the best of its kind in the field of personality disorder of the elderly. It is a landmark description of the state of current knowledge and a wise guide to move the field forward to the next phase of understanding and intervention.

Joel Sadavoy, MD University of Toronto and Mount Sinai Hospital Toronto

Toronto, Ontario, Canada

Preface

The inspiration for this book comes out of our combined experience over the past 20 to 30 plus years as teachers, researchers, and clinicians. As teachers, we appreciate the necessity of educating our students to recognize when mental health becomes mental illness and how this might present in later life. Indeed, as the baby boomers move into later life and increase the proportion of the population that is older, this need becomes ever more pressing. The rate of mental illness in the current cohort of older adults is high (estimated at about 20%) and the boomers are bringing even higher rates of illness and greater use of mental health services with them to later life (Jeste et al., 1999). Many more trained specialists in geropsychology are needed to meet the needs of older adults now and in the coming decades (Qualls, Segal, Norman, Niederehe, & Gallagher-Thompson, 2002).

As clinicians, we are called on to assess, diagnose, and treat the spectrum of older adults who come to us for help. They come for relief from suffering and for the hope that their later years might be better, or at least less difficult.

The understanding of personality disorders is limited. Our diagnostic criteria are often reductionistic and likely not adequately relevant to many older adults given the unique context of later life. However, we do need to assess, understand, and treat, and we do need a reasonable lens through which to make sense of what presentations and problems we see. Some areas within the field of clinical geropsychology are better understood; there has been more research conducted and more evidence-based treatments suggested especially for the Axis I disorders. The Axis II disorders have always been in the shadow of the Axis I disorders for a number of reasons. Perhaps chief among these is their "reputation" of immutability as well as the difficulty we have in truly understanding that the essence of the individual, the personality, is the pathology. To this is added the uncertainty about what are normal age-related changes and what effect these might have on the personality, as well as the implications of the historical moment.

Yet, it is critical, in our opinion, that clinicians and students of clinical geropsychology achieve an understanding of the personality system as well as the symptoms and expressions of personality disorders in the older individual, and how such expressions affect people and systems outside the individual. We wrote this book with the hope of providing some of this fundamental knowledge.

Daniel L. Segal Frederick L.Coolidge Colorado Springs, Colorado

Erlene Rosowsky Needham, Massachusetts

Acknowledgments

We are grateful to have had the opportunity to come together to work on this volume. We represent different professional emphases—theory, research, clinical—but are joined by a common interest (some might say passion) in the area of personality disorders in older adults. We have collaborated and worked together on each chapter with the hope of bringing the material to the reader in an interesting and clinically relevant way. We also hope to encourage interest in this area among students and trainees who come across this text, whether by intent or assignment.

No book is created in a vacuum. Therefore, we would like to gratefully acknowledge those who have helped each of us along the way. Our mentors—Bennett Gurian, Michel Hersen, C. Michael Levy, Edward J. Murray, Sara H. Qualls—are always within us as dynamic introjects, encouraging us to think clearly and creatively, and to stay the course. We appreciate the institutional support of the Department of Psychology at the University of Colorado at Colorado Springs, The Department of Psychiatry, Harvard Medical School, and the Massachusetts School of Professional Psychology. We also thank the many students we have each trained and worked with over the years for their valuable contributions to our research and thinking in this area.

A special thank you goes to our friends at John Wiley & Sons, specifically to Peggy Alexander and Tracy Belmont for sharing our vision and supporting the project, to Patricia Rossi, our senior editor, for being understanding and patient throughout the process, and to Isabel Pratt and Katherine Willert for their professionalism and diligence during production. We also wish to thank Brenda Phillips for her research assistance and Tracy Welch for her administrative management, always with a cool head and a warm heart.

Finally, we are deeply appreciative and indebted to our families and friends for their encouragement and support. They understand intuitively how to help us be less "difficult."

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Responses

  • ESTELLA
    Can maladaptive personality newly arise in later life?
    7 years ago

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