Whereas the extant cross-sectional data suggest some tendency for personality disorders overall to be less prevalent in older persons, a different issue is the stability or change in personality disorder signs and symptoms across the life span. Definitive data are lacking about this issue, and in fact, there is some controversy in the geropsychological literature about whether personality disorders decline or mellow with advancing age (Coolidge et al., 1992; Molinari, Kunik, Snow-Turek, Deleon, & Williams, 1999; Segal & Coolidge, 1998; Segal, Hersen, Van Hasselt, Silberman, & Roth, 1996; Segal et al., 2001). The DSM-IV (American Psychiatric Association, 1994) was the first version of the manual to include a specific section (along with cultural and gender topics) on the developmental issue of aging in the diagnosis of personality disorders. This trend was continued in DSM-IV-TR. Regarding their course, the DSM-IV-TR states:
[B]y definition, a Personality Disorder is an enduring pattern of thinking, feeling, and behaving that is relatively stable over time. Some types of Personality Disorders (notably Antisocial and Borderline Personality Disorders) tend to become less evident or to remit with age, whereas this appears to be less true for some other types (e.g., Obsessive-Compulsive and Schizotypal Personality Disorders). (p. 688)
A commonly held belief is that Cluster B personality disorders burn out by middle age, whereas disorders in Clusters A and C show little improvement over time (Paris, 2005). An understanding of the underlying dimensions tapped by the clusters may explain this hypothesis. Trait impulsivity and erratic forms of acting out associated with the Cluster B personality disorders are more likely to decline with advancing age than the cognitive peculiarities and anxiety/fearfulness that typify the personality disorders in Clusters A and C, respectively.
In contrast to the notions of decline or stability of personality disorders, several researchers have suggested that, in some cases, personality disorders (most notably Borderline and Obsessive-Compulsive) may actually worsen or exacerbate in later life (Rose, Soares, & Joseph, 1993; Rosowsky & Gurian, 1991, 1992; Siegel & Small, 1986; Segal etal., 2001). Due to the heterogeneity of individuals with personality disorders, each of these patterns (burnout and stability) may be true for different individuals with the same personality disorder. We have noted a third possibility in many patients: Personality disorder symptoms are most pronounced during early adult life, decline in middle age, and then become exacerbated again in later life (the "reverse-J curve"), especially in response to age-related stressors. This trend was first noted in a classic community study of personality traits, although categorical personality disorders were not evaluated (Reich, Nduaguba, & Yates, 1988). The prevalence of dramatic and (to a lesser extent) anxious personality disorder traits declined up to 60 years of age, with a slight upturn in later years. In contrast, odd or eccentric traits did not change with age.
In another early cross-sectional study, Coolidge et al. (1992) examined age differences in personality disorders between a sample of community-dwelling older adults (age range = 61 to 78 years) and younger adults (age range = 16 to 58 years) with the self-report form of the CATI (Coolidge & Mer-win, 1992). Results showed that the older adults were significantly higher on the schizoid and obsessive-compulsive scales than the younger adults; there were no age differences on the dependent and avoidant scales; and younger adults were higher on the remaining scales (antisocial, borderline, histrionic, narcissistic, paranoid, passive-aggressive, schizotypal, sadistic, and self-defeating). These results of age-related elevations for obsessive-compulsive and schizoid scales were replicated with larger samples (Segal et al., 2001). In a similar cross-sectional study using the self-report Millon Clinical Multiaxial Inventory (MCMI; Millon, 1981b), Molinari et al. (1999) also reported a higher rate of Obsessive-Compulsive Personality Disorder in older versus younger psychiatric inpatients, but they did not find any age effect for Schizoid Personality Disorder. Rather, the older inpatients were higher than younger inpatients on the dependent personality scale. Finally, Kenan et al. (2000) reported that among inpatient veterans, older adults obtained a lower frequency (55%) of personality disorder diagnoses than middle-aged adults (69%), who in turn were lower than young adults
(76%). For specific personality disorders, younger patients were more likely to receive a diagnosis of Borderline Personality Disorder than older patients, but older patients were more likely to receive a diagnosis of Narcissistic Personality Disorder than younger patients.
Tyrer (1988) has offered another perspective with which to understand the types of changes likely to be seen in the personality disorders over time. He suggests that mature forms of personality disorder such as obsessive-compulsive, paranoid, schizoid, and schizotypal will likely remain stable with age, whereas the more immature or flamboyant forms of personality disorders such as antisocial, borderline, histrionic, and narcissistic will likely decrease with age. His categorizations have garnered some empirical support (described earlier in the cross-sectional studies) and there is certainly some anecdotal support for his observations. The social functioning of many of our older adult patients (particularly those with Cluster B personality disorders), appears improved compared with the severe interpersonal and occupational difficulties characteristic of their earlier years. Some of these patients have shown the pattern of their symptoms becoming muted or burned out in later life. Conversely, we have seen just as many patients with the opposite pattern—symptoms of their personality disorder pathology become exacerbated or hardened in later life, usually in reaction to the accumulation of age-related losses or stressors associated with aging (described in Chapters 2 to 5), and in cases in which traits adaptive at one point in life become mal-adaptive in the later life context (described in Chapter 10).
If true age changes for some personality disorders are confirmed with further research, intriguing questions emerge: Why do some personality disorders decline with age while others intensify? Are such changes simply artifacts of age-related changes in activity level, impulsivity, and sociability? Or does evidence of change represent inadequate diagnostic criteria for detecting geriatric variants of the disorders and poor measurement of some personality disorders in the aged (Agronin & Maletta, 2000)? Another possibility hints at an organic phenomenon: To what extent do the abnormal behavioral changes associated with aging reflect underlying changes in neural substrate, hormonal, or chemical neurotransmitter functioning in the brain? Systematic research is necessary to clarify clinical manifestations and develop clearer profiles of each personality disorder in the aged. Longitudinal studies following personality disordered individuals into later life are needed to assess true age-changes over time in symptoms of personality disorders (and not age-differences in symptoms that are detected by cross-sectional studies).
It is expected that the Collaborative Longitudinal Personality Disorders study (McGlashan et al., 2000), which is in process, will yield valuable and rich data on the natural course of personality disorders. As we have emphasized and described earlier, some symptoms are robust, some appear in muted form in the aged, and some are irrelevant. To the extent that these observations are empirically validated, the development of elder-specific diagnostic criteria will become more pressing. At the present moment, however, when evaluating and diagnosing personality disorders among older people, clinicians are encouraged to recognize and be sensitive to potential age-biases in the DSM system.
Establishing prevalence rates for the personality disorders and their course across the life span is not a simple task. Prevalence rates vary as a function of the mean age and age range of the sample, where the sample was gathered (e.g., community-dwelling, inpatient psychiatric, outpatient psychiatric), the criteria used (e.g., different versions of the DSM, ICD-10), the measurement device (e.g., self-report, structured interview, psychiatric examination), and the nature of the cutoff between traits and disorder. Whereas the National Institute of Mental Health Epidemiological Catchment Area (ECA) programs (Krupnick et al., 1996) were successful at providing quality epi-demiological data for many mental disorders, the personality disorders were not included for study (with the exception of Antisocial Personality Disorder).
Although cross-sectional studies that have examined personality disorders are intriguing and suggest a general diminution of most types of personality disorders together with an intensification of a few personality disorders in later life, definitive research about the long-term course of individual personality disorders is lacking. Important research issues include whether these differential cross-sectional rates are a reflection of true changes in personality disorders across the life span (through longitudinal studies), whether these differing rates are an artifact of some kind of measurement bias (such as clinical diagnostic bias, self-report bias, or poor suitability of some criteria among older persons) or cohort effects, and whether there are differences in subthreshold cases across the adult life course (subthreshold means that the person meets some but not enough of the DSM criteria for an official personality disorder diagnosis). To provide the substantive data desired by researchers in the field requires large-scale longitudinal studies with standardized, objective, and validated diagnostic instruments to investigate the prevalence of the full-range personality disorder in later life and to address in a rigorous manner the questions about age-related changes. Such studies are infrequently conducted, largely due to pragmatic concerns (e.g., time involved and cost). Instead, longitudinal studies of a few specific personality disorders have been completed and are discussed later in this chapter.
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