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 0-470-84641-0108Theoretical and Management IssuesRobert C. AbramsThe New York Hospital–Cornell Medical Center, New York, USAThe elaboration by DSM-III 1 of a domain of pathologicalpersonality typologies into the well-known Axis II personalitydisorders has stimulated an outpouring of clinical research. Whilemost of this research has reaffirmed the usefulness of thepersonality disorder concept, substantial theoretical and methodologicalproblems persist. For example, there is considerableheterogeneity of symptoms within individual disorders andoverlap among different disorders 2 . It can be argued that theAxis II personality disorders to some degree lack both convergentand discriminant properties. Moreover, the theoretical underpinningof personality disorders is far from clear. Are theseentities derived from interactions of heritable traits, as suggestedby Cloningen 3 , or are they based on a pathological intrapsychicorganization, as suggested by Kernberg 4 ? Alternatively, arepersonality disorders better understood in interpersonal orlearning-behavior contexts? It has proved possible to apply eachof these theoretical models; personality disorders are, by definition,relatively enduring patterns of dysfunctional behavior thatpermeate the entire person, are not due to a single abnormalityand lead to pain and suffering of people in the patient’s world,sometimes more than in the patient him/herself. It is thus notsurprising that a variety of explanatory models have been used inefforts to understand these disorders.Very little attention, however, has been directed to the existenceof personality disorders in the elderly and their clinical management,despite the considerable interest in long-term follow-upstudies of borderline personality disorder patients 5,6 . In part, thisneglect may reflect the original perspective of DSM-III and DSM-III-R 7 , that personality disorders are largely attenuated bymiddle- and old age. Probably another reason is the ongoinguncertainty about how best to assess personality in the elderly.Aging imposes complexities on the already difficult study ofpersonality, adding the confounding factors of brain changes,environment and time. Finally, concepts of normal and pathologicaladult personality functioning may not be relevant to old age.In this chapter the topic of personality disorders in old age willbe approached first with a discussion of age-related personalitychange, followed by a review of methodological and clinicalissues, including comments on the assessment of DSM personalitydisorder criteria in the elderly. It will conclude with a discussion oftreatment and management.THE AGING PERSONALITY: DO PEOPLEACTUALLY CHANGE?Although the aging personality has been the subject of extensivespeculation 8–10 , there has been no closure on the question ofwhether, or in what ways, people change in their dealings with theworld; it is still not known whether change or persistencepredominates over time. The literature in this area to date canbe divided along theoretical and methodological lines intodimensional, categorical and psychoanalytic–developmentalmodels, each with a different set of assumptions.Using mostly dimensional approaches, conceived as continua ofstable traits along which all individuals lie, the psychologicalliterature suggests a picture of progressive changes in motivationsand values over the adult years. For example, there appear to besteady increases from early to middle adulthood in selfconfidence,independence, humanitarian concerns and personalrigidity 8–9 . Large-scale investigations of medical patients andnormal subjects have been carried out using the MinnesotaMultiphasic Personality Inventory (MMPI) 11,12 ; older adultmedical patients tended to score higher on scales measuringintroversion, concern with health, immaturity and depressionthan younger adult medical patients. A decline in criminality withadvancing age has also been well documented 13 . Together, thesedata suggest that traits related to a quiet, inner-directed attitudemost typify the aging personality. The MMPI data in particularseem to lend support to the concept of disengagement, or gradualwithdrawal from productive activity, as the pre-eminent socialpsychologicalmodel for age-related personality changes 14 . Thereduction in sociopathy and attenuation of hostile aggressivetraits have also been highly consistent MMPI findings 1,12 .However, such dimensionally-modeled studies have not pointedconclusively to the existence or direction of age-related personalitychanges. For example, the MMPI data referred to above arebased on large-scale cross-sectional studies involving thousands ofmedical patients and normal adult subjects, but have not beenconfirmed in longitudinal studies; the longitudinal MMPI studieshave instead emphasized the stability of personality profiles of theindividuals over time 15,16 . Similarly, dimensional scores on theEysenck Personality Inventory Psychoticism (P), Extraversion (E)and Neuroticism (N) subscales show substantial persistence over30 year periods 7 .Categorical models, such as the DSM-IV Axis II personalitydisorders, are operationally defined typologies of personalitypsychopathology, or clinical phenotypes. These models have beenrelatively little used to examine the aging personality. At thepresent time, for example, there is scarce cross-sectional informationon DSM-IV personality disorders in the older age groups andvirtually no longitudinal studies of personality disorder patientsthat track outcome as far as senescence. However, based uponcross-sectional regression analysis of the relationships of differentpersonality disorder traits with age, Tyrer 18 has suggested thatpersonality disorders can be divided into mature and immaturePrinciples 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