Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0107Personality Disorders: Aetiology and GeneticsVictor Molinari 1 , Tom Siebert 2 and Marvin Swartz 21 VAMC Psychology Service, Houston, TX, USA, 2 Duke University Medical Center, Durham, NC, USAAccording to DSM-IV 1 , ‘‘A Personality Disorder is an enduringpattern of inner experience and behavior that deviates markedlyfrom the expectations of the individual’s culture, is pervasive andinflexible, has an onset in adolescence or early adulthood, is stableover time, and leads to distress or impairment’’ (p. 629). Since thefirst edition of this chapter was published, there has been an everexpandingbody of knowledge about personality disorder (PD) inolder adults. Notably, there has even been the publication of the firstbook 2 solely devoted to PD in older adults. However, as we shall see,there remain many unanswered questions spawned by thornyconceptual and methodological quandaries in this controversial area.PD in older adults is an important area of study for a number ofreasons. First, since PD affects the way an older adult copes withlife, individuals with specific PDs may be less able to successfullynegotiate age-related losses (e.g. obsessive–compulsive, dependent)or the interpersonal compromises necessary for peaceful institutionalliving (e.g. borderline, narcissistic). Second, PD can influencethe presentation of Axis I symptomatology, frequently generatingcomplicated assessment dilemmas. For example, disruptive behaviorin the nursing home may camouflage the fact that the person issuffering from a depression that is exacerbating premorbidantisocial personality features. Third, just as for young adults,the presence of PD should modify treatment strategies andprognosis of co-morbid Axis I disorders in certain geriatric settings.This chapter will summarize what is known about the etiology,genetics, epidemiology, assessment, prognosis and researchimplications of PD in older adults.AETIOLOGY AND GENETICSReviewing PD necessitates some understanding of the complexityof the terms ‘‘personality disorder’’ and ‘‘personality’’, as well astheir classification. Personality can be conceived as two interactiveelements, representing ‘‘nature’’ and ‘‘nurture’’: temperament, areflection of a genetically determined, constitutional disposition;and character, made up of learned attributes, which begincoalescing in early childhood, reflecting culture, norms andupbringing. Studies have focused on each of these elements inorder to clarify the etiology of personality and PD, but theseinvestigative efforts have been rendered more complicated bydifferent measurement approaches.Concerning PD among the elderly, it is helpful to focus ondimensional aspects of personality as well as the categoricaldiagnosis of PD. Because of the numerous biological changes thatoccur with aging, a major question for the geriatric clinicianconcerns the stability of personality traits throughout the agingprocess.Most researchers agree that there is no uniform, stereotypicchange in personality traits in late life. Cross-sectional andlongitudinal investigations of personality across the life cycle 3report the general stability of individuals’ major traits. However,it is also clear that certain adults do change for the better orworse 4 , perhaps due to some of the unique challenges they faceover the lifespan.Late-life theorists have made important contributions toconceptualizing those challenges that promote personality development.Erikson’s 5 crisis of ‘‘integrity vs. despair’’ marks theculmination of his psychosocial framework. The challenge of thisfinal stage is the individual’s acceptance of the integrity of his/herself; failure results in a fear of death and an inability to findmeaning in the life cycle. Erikson felt that the successful resolutionof this stage depends on an adequate resolution of previous crises.From the point of view of personality, failure here may alsotrigger global dissatisfaction and lowered self-esteem. Erikson’sdevelopmental stages, intended for a practitioner audience, werenot rigorously defined and were based on clinical and theoreticalconsiderations rather than research data.Levinson et al.’s 6 developmental scheme is based on theirresearch on the life cycle. They view development as a series oferas and cross-era transitions. Older adults are seen from thepoint of view of the late adult transition and late adulthood. Thelate adult transition (age 60–65) is marked by major changes inrole structure, physiology and intrapsychic challenges. It ispossible that adaptation to these challenges provokes changes inpersonality structure (i.e. a decrease in authoritarianism; locus ofsatisfaction shifting from the self to others). Haan and Day 7traced the relative prominence of different personal dimensions(such as information processing, inter-personal reaction, mannerof self-presentation and responses to socialization) throughout thelife cycle from adolescence onwards. Although most dimensionswere stable, some changed in an orderly manner with age. Stillothers changed in a stage-wise manner. The authors believed thattheir results fitted an Eriksonian developmental model with anessential ‘‘sameness’’ of major personality functions, punctuatedby times of regress before progress and longer periods of orderlychange.The investigation of constitutional factors that contribute toPD is affected by a number of methodological difficulties. Fewstudies have looked specifically at DSM Axis II criteria; manyhave looked at other variables, such as neuroticism andsociability, which cannot be compared well with PD as definedby DSM.The most intensive studies of familial factors have beenconducted on those with antisocial PD. Crowe 8 summarizeddata from twin studies in strong support of a heritable componentPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd