Somatic Treatments

In this section we examine biologically based interventions and discuss potential applications and issues with older adult patients.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) has been a highly controversial intervention for many years, but it is the treatment of choice for severe recalcitrant depression, which has not responded to psychological and pharmacological approaches. Electroconvulsive therapy may also be used in cases of severe depression where treatment must work quickly and when it cannot wait for drug therapy to become effective (e.g., with the catatonic or suicidal patient). There have been a number of studies of ECT with patients with Borderline Personality Disorder, but not specifically in older patients (DeBattista & Meuller, 2001). Electroconvulsive therapy is generally found to be a good, effective treatment that appears to treat the depression but which does not have a significant effect on the underlying personality disorder condition. Another study has suggested that those with comorbid personality disorder have a poorer outcome, especially those with a Cluster B personality disorder, and have a higher relapse rate of the depression (Sareen, Enns, & Guertin, 2000). Although there are some well-supported benefits of ECT, its use is especially problematic with older adults because some common side effects of the treatment with older adults include falls, confusion, and cardiovascular problems (Sackeim, 1994). Electroconvulsive therapy also can produce memory problems, and there is controversy about whether these effects are more serious and chronic among older adults. Caution is advised due to the chance of accentuated cognitive problems among older people treated with ECT.

Pharmacotherapy

The purposes of pharmacotherapy are twofold: (1) to reduce selective maladaptive signs and symptoms of the personality disorder and (2) to treat any comorbid psychopathology. Drugs are not used to directly treat the underlying personality disorder.

Medications are often used adjunctively to other forms of treatment and are aimed at specific targets, including anxiety, depression, agitation, impulsivity, affective lability, and transient psychosis.

Among the challenges to pharmacotherapy with this population is the likelihood that the prescribing physician may not know that the patient has a personality disorder, what this means, and what effect this might have on their treatment. In addition, there are special and significant challenges to the pharmacotherapy of older adults with personality disorders, which reflects our understanding of personality disorders and old age. First, it is generally acknowledged that there is likely an underlying biologic vulnerability to personality disorders (Cloninger, Surakic, & Przybeck, 1993; Siever & Davis, 1991). We also recognize that brain changes occur in old age, which increase the brain's vulnerability. Therefore, the older adult with a personality disorder may be selectively at risk for the expression of psychopathology. Second, those with a personality disorder may not be as compliant, or reliably compliant, with medication regimens, which may also be true for older adults in general who have more conditions for which medications are prescribed. Third, there may be cognitive and fiscal concerns further compromising their compliance. Fourth, there is also the risk of polypharmacy and synergistic drug interactions with older adults taking multiple medications. Finally, age-related changes in the pharmacokinetics and pharmacodynamics make prescribing complex and challenging.

Specific personality disorders can be expected to present specific challenges to the prescribing clinician. For example, someone with Dependent Personality Disorder might not adequately question the doctor, or seek a second opinion, even when one is indicated. Someone with Obsessive-Compulsive Personality Disorder might be overly demanding, seeking more information than is necessary, and might rule out potentially helpful medications. Those with Paranoid Personality Disorder might be excessively suspicious about why the medication was being suggested; who was engineering this, and why?

Cluster B presents its own special challenges. For example, among individuals with Narcissistic Personality Disorder, their propensity toward specialness and special sensitivity could result in reporting peculiar or excessive side effects to medications. Others may do doctor shopping, and not be forthright about what drugs they use or the providers with whom they are involved. This could lead to unintentional polyphar-macy or intentional drug abuse and self-harming behaviors (Kean et al., 2004).

Effectiveness of Pharmacotherapy

Pharmacological studies have examined the efficacy of atypical antipsychotics, selective serotonin reuptake inhibitors (SSRIs), and antiepileptics (Markovitz, 2004). There have been few controlled trials conducted, and most trials have focused on the Cluster B disorders, usually Borderline Personality Disorder, with scant representation of older adults.

In general, the conclusions of these studies suggest that (a) drugs can be helpful for the reduction of certain symptoms and behavioral traits (e.g., aggression or impulsivity); (b) comorbid Axis I conditions (e.g., depression, anxiety) can be helped with appropriate medications, and (c) combinations of drugs are likely indicated and will achieve a better treatment outcome.

The message is, that while drugs can help the symptom expression of a personality disorder, there is no evidence that they can directly treat (or cure) the personality disorder. However (and this is an important point), if the expressions of a personality disorder are ameliorated, the response by others to the individual will be altered, and therefore the patient's life will be altered and the quality of life improved. This indirect effect often justifies drug (or any) therapy.

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