Personality Disorders in Older Age

Data on treatment of personality disorders in the elderly are limited, but there have been important clinical advances in small studies. A study of dialectical behavioral therapy (DBT) in patients with depressive disorder and personality disorder showed positive results on improvement of depression. Thirty-four depressed adults over age 60 were randomized to treatment with medications only or medications plus group skill-based DBT plus a 30-minute weekly coaching session (13). Participants who received DBT were more likely to remit from depression (13). This study did not assess the effect of treatment on personality disorder as a primary outcome measure. In another study of 45 participants aged 55 or over, patients with a personality disorder and major depressive disorder were randomized to receive medication management only versus standard DBT in combination with medication management (13). Twenty of the 45 patients had obsessive-compulsive disorder, and an additional 10 had avoidant personality disorder (13). Over the course of treatment, both groups showed improvement in major depressive disorder symptoms and personality functioning (13). A total of 16 patients in both groups remitted from their personality disorders over the course of treatment (13). A small study of schema therapy has shown that this therapeutic option is promising. Eight patients with cluster C personality disorder were repeatedly assessed during a baseline phase of random length and then had schema-based therapy over the course of eight months. Authors found a high effect size, and seven patients remitted from their personality disorder (14). An earlier study with a heterogeneous patient population, including 10 patients with various personality disorders, also indicated beneficial effects of group schema therapy (15).

There are no medications for treating personality disorders in older adults that have been approved by the Food and Drug Administration, and no randomized controlled studies have assessed medications specifically for treating personality disorders in older adults. However, in practice, medications are commonly used for target symptoms such as impulsive aggression or affective instability, so it is useful to review evidence from the general adult population. Most trials of pharmacotherapy for personality disorders have been conducted for patients with borderline personality disorder. Among patients with borderline personality disorder, there is accumulating evidence that divalproex can reduce impulsive aggression, irritability, and the overall severity of borderline personality disorder (16, 17). Topiramate has been found to decrease anxiety and interpersonal rejection sensitivity in patients with borderline personality disorder (16, 18). The beneficial effects of topiramate were sustained in long-term open-label follow-up. There are suggestions that naltrexone may reduce self-harm and dissociation (16, 19). Several second-generation antipsychotics have been found to reduce impulsive aggression, psychosis, and interpersonal rejection sensitivity in patients with borderline personality disorder (20). Olanzapine and aripiprazole are the best studied second-generation antipsychotics in this regard. Aripiprazole, but not olanzapine, is effective in reducing nonsuicidal self-injury in patients with borderline personality disorder (16, 21). Small trials of omega-3 fatty acids for borderline personality disorder have shown positive effects: decreased aggression and parasuicidal behaviors, improved affect, and decreased stress reactivity (16, 20, 22). There are hints that antipsychotics are helpful for psychotic symptoms in schizotypal personality disorder, whereas guanfacine may attenuate cognitive deficits (16, 23, 24). Serotonergic agents are commonly used in avoidant personality disorder, as a comorbid social anxiety disorder is frequently present, but the impact of this approach on outcomes in avoidant personality disorder per se (rather than on outcomes in social anxiety disorder) has not been tested in clinical trials. For patients with social anxiety disorder and comorbid avoidant personality disorder, a trial of a selective serotonin reuptake inhibitor, monoamine oxidase inhibitor, gabapentin, or pregabalin is indicated (25). Information on the pharmacotherapy of other personality disorders is sparse. In all cases, care must be taken to use a consistent method to evaluate symptom severity, and the duration of an adequate trial must be defined to allow for clear decisions on whether a medication or intervention is clinically beneficial (16).

Several aspects of diagnosing a personality disorder in older adults present unique challenges. It is often impossible to ascertain that observed personality traits and impaired functioning have been present since adolescence or early adulthood. Further, personality disorder traits may not be stable over an entire lifespan (13). Given the requirement that traits have their onset in adolescence or early adulthood, a patient who develops these traits by middle age and continues to exhibit them for decades will not meet the criteria for a DSM-5 personality disorder, even in the presence of significant functional impairment because of these traits (3). Several criteria for the diagnosis of personality disorders are contextually inappropriate for older adults (1). For instance, older patients with antisocial personality disorder may be frail and physically unable to get into fights or assault others (criterion 4). Some criteria mention detrimental effects on work performance; for instance, failure to sustain work consistently in patients with antisocial personality disorder or relentless devotion to work in patients with obsessive-compulsive disorder. There criteria are irrelevant to older adults who are retired, chronically unemployed, or disabled. Older adults may naturally have a smaller sphere of social support that is highly reliant on immediate family members because of the loss of friends and extended family over time. However, this entirely common state of being in older adults satisfies criterion 5 of schizoid personality disorder: “lacks close friends or confidants other than first-degree relatives.” Further research is needed to identify psychotherapies that are effective across a range of personality disorders in older individuals. For instance, mentalization-based therapy has been found to be effective for borderline personality disorder in the general population, but this has not been evaluated in older individuals. Trials of pharmacotherapy for personality disorders in older adults are entirely lacking. Research is needed to assess for the possible existence of a late-onset personality disorder phenotype.

With a certain pragmatic cynicism, practitioners often question the value of arriving at a personality disorder diagnosis, particularly given the challenges of making this diagnosis in older adults, perceived limitations in treatment options, and possible negative effects on insurance reimbursement. Furthermore, there is a tendency for maladaptive personality traits to be dismissed or ignored in older adults. However, a diagnosis of personality disorder has important clinical implications, prompting evaluation for likely comorbidities, negatively affecting prognosis, and requiring specialized treatment that is simply impossible in the absence of diagnosis. Several screening tools have been validated in older adults to aid in the diagnosis of a personality disorder. With their high prevalence; high symptom burden; and broad impacts on treatment outcome, mortality, and suicide risk, personality disorders cannot be ignored. There is emerging evidence that DBT can be effective in patients with a comorbid depressive disorder, and schema therapy also shows promise. Technological advances have created the opportunity for delivery of in-home virtual group therapy. There is increasing evidence that mood stabilizers and second-generation antipsychotics are effective at targeting certain features of personality disorders in the general population. As yet, however, there are no studies of pharmacotherapy in older adults.