Personality Disorders

Definition

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), defines a personality disorder as “an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” Personality disorders represent long-standing and maladaptive patterns of perceiving and responding to other people and to stressful circumstances.

Description

DSM-IV defines 10 personality disorders, grouped into three clusters, plus an eleventh, Personality disorder not otherwise specified (PDNOS).

Cluster A disorders

People diagnosed with personality disorders in Cluster A are characterized by odd or eccentric behavior.

The three personality disorders in this cluster are:

• Paranoid personality disorder (PPD). People with this disorder are frankly suspicious and distrustful of others. They may think that others are “out to get them,” plotting behind their backs, or deceiving or manipulating them in some way. They have a recurrent pattern of interpreting the behavior of others as hostile or malicious.
• Schizoid personality disorder. People with this type of personality disorder are seen by others as cold and aloof, uninterested in close relationships, and socially isolated.
• Schizotypal personality disorder. People with schizotypal personality disorder have strange beliefs and hallucinations or other disturbances of perception. They may dress in a peculiar or highly individualistic fashion. They often display magical thinking (the notion that their words or thoughts can affect the outside world) or ideas of reference (the notion that people in their vicinity are talking about them, or that events in the outside world have been arranged or contrived to send them a personal message).

Cluster B disorders

People diagnosed with Cluster B personality disorders behave in exaggerated, dramatic, and highly emotional ways.

There are four personality disorders in Cluster B:

• Antisocial personality disorder. People with antisocial personality disorder act out their emotions and ignore the usual rules of social behavior. They are typically aggressive, angry, and irresponsible, and often have a long history of arrests, imprisonment, or other legal problems. They are at high risk of alcoholism and substance abuse because they use alcohol and drugs to relieve boredom or angry feelings.
• Borderline personality disorder (BPD). BPD is considered a major mental health problem as of the early 2000s because of its impact on family members, teachers, employers, and others involved with people with this disorder. People with BPD are extremely unstable, alternating between clinging to other people and pushing them away. They have problems with a sense of personal identity, and typically view the world in stark all-or-nothing terms; people are either all good or totally evil. Common symptoms of BPD include recurrent suicide threats or attempts, self-mutilation (cutting), temper tantrums, sexual promiscuity, and other impulsive actions.
• Histrionic personality disorder. People with histrionic personality disorder are “drama queens,” seeking attention from others through displays of emotionality or dramatic gestures. They are often sexually seductive or provocative. The term histrionic comes from the Latin word for actor.
• Narcissistic personality disorder (NPD). People with NPD are characteristically grandiose, arrogant, have a strong sense of entitlement, demand constant admiration from others, and take what they want from others without any sense of reciprocity or empathy. Unlike those with other personality disorders, however, people with NPD may be quite successful in business, politics, or professional life.

Cluster C disorders

People with these personality disorders are typically anxious and fearful.

There are three personality disorders in Cluster C:

• Avoidant personality disorder. People with avoidant personality disorder are extremely fearful of rejection or criticism and will typically avoid social events or relationships unless they are sure they will be liked and accepted. Unlike people with schizoid personality disorder, people with avoidant personality disorder would like to have relationships but are paralyzed by their anxiety and low self-esteem.
• Dependent personality disorder. People with dependent personality disorder have an excessive need to be taken care of and often exhibit clinging or submissive behavior. They typically have difficulty making decisions for themselves or disagreeing with others, want others to take responsibility for most areas in their lives, and are extremely afraid of being alone or having to fend for themselves.
• Obsessive-compulsive personality disorder. People with this type of personality disorder are often workaholics and may do quite well in occupations that call for attention to detail or following standard methods and procedures. They are conscientious, dependable, and thorough, but are often perfectionistic, may take on more responsibilities than they can handle, and often find it hard to complete tasks because they are overly concerned with details. They are also often stingy, moralistic, and stubborn.

Demographics

The demographics of personality disorders in seniors are difficult to assess for several reasons. First, the category itself is relatively new; in the 1950s and early 1960s, these disorders were referred to as character disorders, and defined as “patterns of behavior and emotional response that are socially disapproved or unacceptable, with little evidence of anxiety or other symptoms seen in neuroses.” They were called “character” disorders to distinguish them from issues of temperament, which refers to the genetically or biologically based dimension of personality. Beginning in the 1950s, such researchers as Alexander Thomas and Stella Chess studied children in order to discover how temperament affected their social and psychological adjustment in later life. They identified nine factors, ranging from activity level and regularity of eating and sleeping patterns to attention span and intensity of emotion, which they analyzed as influential in shaping children's relationships with other family members, adjustment to school, and other milestones throughout the lifespan. In contrast to temperament, which is innate, character is defined as the set of qualities, behavior patterns, or traits that a person develops in the course of interacting with family members and the outside world. The term “character disorder” was then coined to describe problematic patterns of interaction that seemed normal or natural to the individuals who had them.

Second, the list of disturbances now called personality disorders has changed from one edition of the DSM to the next. The present list of ten is neither long-standing nor universally accepted. In addition, many of the DSM criteria overlap, so that a person can be diagnosed with more than one personality disorder. Moreover, most people who meet the criteria for a personality disorder also meet criteria for one or more anxiety disorders, mood disorders, eating disorders, substance abuse disorders, or post-traumatic syndromes, which adds to the complications of obtaining reliable demographic statistics.

Third, DSM-IV criteria for personality disorders were derived from studies of disturbed young and middle-aged adults in the 1980s and 1990s, not from studies of seniors. The reason why this factor is significant is that the demographics of mental disorders have changed over the years because of broad-based cultural changes. Many of the disorders that Freud wrote about in the 1880s and 1890s are now unusual, while some others are much more commonplace. People who are 75 or older as of the early 2000s grew up in a much different society from that which shaped baby boomers or later generations; it is therefore highly unlikely that demographic statistics for personality disorders in the general American population in the early 2000s would hold true for older seniors.

Fourth, it is difficult to sort out which changes in a senior's personality are the result of a personality disorder and which are simply side effects, so to speak, of aging. An example would be the increased cautiousness that many seniors display as they grow older. Although some seniors may indeed meet the criteria for paranoid personality disorder, it would be a mistake to assume that any older adult who becomes less trusting or more careful of strangers as they get older is necessarily developing PPD. What is known as of the early 2000s is that personality disorders emerge in late adolescence or the early adult years; they rarely develop for the first time in adults over 40, and they often moderate by middle age. A senior who seems to be undergoing rapid changes in personality should be evaluated for an organic brain disorder or depression or anxiety before being evaluated for a personality disorder.

Fifth, some personality disorders as defined by DSM-IV are underrepresented among seniors because those who suffer from them are more likely to die at relatively early ages from suicide , substance abuse, reckless driving, or other self-destructive behaviors.

According to DSM-IV, between 10 and 15 percent of the general adult population in the United States is affected by personality disorders. The distribution of specific personality disorders in the general population is estimated to be:

• Paranoid: Between 0.5 and 2.5 percent of adults.
• Schizoid: Less than 1 percent; slightly more common in men than in women.
• Schizotypal: About 3 percent.
• Antisocial: 1 percent of women, 3 percent of men.
• Borderline: 2 percent; 75 percent of these are women.
• Histrionic: 2–3 percent. l Narcissistic: 1 percent; 50–75 percent of these are men.
• Avoidant: Between 0.5 and 1 percent.
• Dependent: About 2 percent, possibly less.
• Obsessive-compulsive: About 1 percent; 67 percent of these are men.

Causes and symptoms

At one time personality disorders were thought to be almost entirely the result of childhood trauma. Researchers in the early 2000s think, however, that these disorders are better understood as resulting from a combination of genetic or temperamental vulnerability and dysfunctional parenting or other early traumatic experiences.

Personality disorders affect several different dimensions of a person's functioning, and specific symptoms appear in one or more of these areas:

• Cognition (thinking). People with personality disorders understand or interpret themselves, other people, and events in distorted or narrow ways.
• Affect (feelings). People with personality disorders run to emotional extremes, have wide emotional swings within brief periods of time, experience emotions that are inappropriate to the immediate circumstances (such as laughing at a funeral), or express emotions inappropriately.
• Interpersonal functioning. People with personality disorders have a longstanding history of serious difficulties in school, the workplace, or family life because they do not get along well with others. They may have a history of school failure, being fired from one job after another, changing occupations frequently, having a number of short-term unsuccessful relationships, or being estranged from their family.
• Problems with impulse control. These may appear in regard to drugs, alcohol, food, money (gambling and compulsive spending), sex, or anger.

Diagnosis The diagnosis of a personality disorder is made on the basis of a psychiatric interview. It is unusual, however, for adults with personality disorders to seek help on their own initiative because they regard their thought patterns and behaviors as normal and natural; they typically fail to see the effects of their behavior on others or the part they play in causing problems with others. In some cases an older adult with a personality disorder may be brought for an evaluation by friends or family members who have been distressed for some time by the senior's attitudes or actions. People with BPD or NPD are particularly likely to be brought for treatment by family members because their behaviors (suicide threats or attempts, substance abuse, exploitativeness, reckless driving, arrogance and lack of empathy, etc.) can cause severe emotional, financial, or legal problems for others around them.

In other cases the senior's primary care physician may detect indications of a personality disorder in his or her interactions with the senior, as many “difficult patients” in family practice have personality disorders. Common signs of personality disorders in the doctor's office include behavior that is inappropriate to the situation (hostile, seductive, overly friendly, etc.); unrealistic expectations of the doctor or excessive demands on his or her time; and refusal to comply with medical treatment.

There may be physical evidence that the senior is abusing alcohol or other substances, or has scars from a failed suicide attempt, but otherwise there are no physical symptoms associated with any of the personality disorders as such.

In most cases the primary care physician will give the senior a mental status examination to check for dementia and refer the senior to a psychiatrist for more detailed evaluation. If the psychiatrist thinks that a personality disorder would explain the senior's symptoms more adequately than a mood or anxiety disorder, he or she may administer one or more questionnaires designed to identify personality disorders. The tests most widely used are the International Personality Disorder Examination (IPDE), first published in 1994, and the Millon Clinical Multiaxial Inventory-III (MCMI-III), first used in 1995. The IPDE takes about an hour and a half to administer and the MCMI-III takes about half an hour. Other tests that may be given are the Minnesota Multiphasic Personality Inventory (MMPI) and the Eysenck Personality Inventory.

Treatment

Treatment of personality disorders is usually a combination of psychotherapy and medications. Psychotherapy is the core of treatment for personality disorders. The approaches most often used are psychodynamic psychotherapy and cognitive behavioral therapy (CBT). Psychodynamic psychotherapy is insight-oriented; the patient explores his or her history in order to identify the sources of his or her perceptual and cognitive distortions and to correct them through feedback from the therapist. The patient also learns more adaptive behaviors and responses to other people. Treatment usually lasts several years at a frequency from several times a week to once a month.

A cognitive behavioral approach to personality disorders is based on the notion that cognitive errors rooted in longstanding beliefs influence and distort the patient's perceptions of and reactions to others. It is aimed at identifying the distortions and helping the patient develop more appropriate behaviors. Patients are often given homework assignments to complete between sessions, such as keeping a diary of their dysfunctional thoughts and how they handled them. CBT is typically shorter than psychodynamic therapy; the usual pattern is weekly appointments over a period of 6 to 20 weeks. Patients with personality disorders may require several courses of CBT therapy spaced over several years, or occasional booster sessions when under stress .

QUESTIONS TO ASK YOUR DOCTOR

• Does the older person in my life have a personality disorder?
• What should I know about his or her condition?
• How is it treated?
• How can I help with his or her treatment?
• Will I need professional help or advice in coping with this disorder?

Group psychotherapy is sometimes recommended for patients with personality disorders in that they can receive feedback from other group members as well as the therapist. Family therapy is often recommended for families coping with a member with BPD or NPD, as these particular personality disorders frequently cause serious problems for care givers and other family members.

Medications are given sparingly, and usually only to treat depression or anxiety that the senior may be experiencing as a result of the personality disorder. There are no drugs as of the early 2000s that can cure personality disorders. The drugs most commonly given are the selective serotonin reuptake inhibitors (SSRIs) rather than the tricyclic antidepressants (TCAs), because the poor impulse control of many patients with personality disorders increases the risk of an intentional overdose; such drugs as fluoxetine (Prozac) and sertraline (Zoloft) are safer than the TCAs. Because of the additional risk of interactions with drugs that the senior may be taking for other conditions, antidepressants are given for as short a period of time as possible.

Nutrition/Dietetic concerns

Nutritional concerns are not usually prominent in personality disorders unless the patient is abusing alcohol or other drugs or has a concurrent eating disorder. In that case the senior may be referred to a dietitian for advice about nutrition or a diet plan.

KEY TERMS

Character disorder —An older term for what are now called personality disorders.

Ideas of reference —The notion that irrelevant or unrelated events are related to the self in a special way. An example would be the thought that a radio announcer is talking directly to or about oneself, or that a small group of people at a large party who are laughing about a joke are laughing specifically at oneself.

Magical thinking —Thinking that one's words or thoughts can affect the external world. An example would be the notion that being angry with someone will cause them to die.

Temperament —The dimension of an individual's personality that is rooted in genetic or biological factors.

Therapy

Therapy for personality disorders is primarily psychotherapy, with medications as needed.

Prognosis

The prognosis for recovery from a personality disorder depends on the specific disorder, the coexistence of other mental disorders or chronic physical illnesses, the availability of family and social support, and the senior's cognitive status. Since psychotherapy for personality disorders relies heavily on cognitive and insight-oriented approaches, a senior in the early stages of cognitive decline is unlikely to benefit from these techniques.

Prevention

The only known preventive for personality disorders is adequate parenting in childhood combined with lack of exposure to overwhelming traumatic experiences at an early age.

Caregiver concerns

Caregiver concerns for a senior with a personality disorder include making sure the senior is compliant with his or her treatment, including attending therapy sessions and taking medications as directed by the doctor. Care givers of seniors with borderline or narcissistic personality disorder should seek professional advice on coping with the stresses and disruptions these disorders are likely to cause in their own lives. In addition, they should be on the lookout for indications of suicidal thinking in seniors with these disorders. Older people with NPD are at increased risk of suicide as they age, even if they have been highly successful in their earlier years, because they see the aging process as a blow to their sense of superiority and perfection.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Beck, Aaron T., Arthur Freeman, and Denise D. Davis. Cognitive Therapy of Personality Disorders, 2nd ed. New York: Guilford Press, 2004.

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 32, “Aging and Mental Health.” Whitehouse Station, NJ: Merck, 2005.

Donaldson-Pressman, Stephanie, and Robert M. Pressman. The Narcissistic Family: Diagnosis and Treatment. San Francisco, CA: Jossey-Bass Publishers, 1997.

Mason, P. T., and R. Kreger. Stop Walking on Eggshells: Taking Your Life Back When Someone You Care about Has Borderline Personality Disorder. Oakland, CA: New Harbinger Publications, 1998.

PERIODICALS

Balsis, S., et al. “Overdiagnosis and Underdiagnosis of Personality Disorders in Older Adults.” American Journal of Geriatric Psychiatry 15 (September 2007):742–753.

Haas, Leonard J., et al. “Management of the Difficult Patient.” American Family Physician 72 (November 15, 2005): 2063–2068.

Heisel, M. J., P. S. Links, D. Conn, et al. “Narcissistic Personality and Vulnerability to Late-Life Suicidality.” American Journal of Geriatric Psychiatry 15 (September 2007): 734–741.

Lenzenweger, M. F., et al. “DSM-IV Personality Disorders in the National Comorbidity Survey Replication.” Biological Psychiatry 62 (September 15, 2007): 553–564. Pietrzak, R. H., J. A. Wagner, and N. M. Petry. “DSM-IV Personality Disorders and Coronary Heart Disease in Older Adults: Results from The National Epidemiologic Survey on Alcohol And Related Conditions.” Journals of Gerontology, Series B, Psychological Sciences and Social Sciences 62 (September 2007): P295–P299.

Ward, Randy K. “Assessment and Management of Personality Disorders.” American Family Physician 70 (October 15, 2004): 1505–1512.

Zanni, G. R. “The Graying of Personality Disorders: Persistent, But Different.” Consultant Pharmacist 22 (December 2007): 995–1003.

OTHER

Bienenfeld, David. “Personality Disorders.” eMedicine, November 13, 2006. http://www.emedicine.com/med/topic3472.htm [cited March 19, 2008] Gunderson, John, MD. A BPD Brief, revised edition.

Belmont, MA: McLean Hospital, 2006. Available online at http://www.borderlinepersonalitydisorder.com/documents/A%20BPD%20BRIEF%20revised% 202006%20WORD%20version%20–%20Jun%2006.pdf [cited March 19, 2008].

National Mental Health Association (NMHA) Fact Sheet. Personality Disorders. Available online at http://www1.nmha.org/infoctr/factsheets/91.cfm [cited March 19, 2008].

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA, 22209, (703) 907-7300, [email protected], http://www.psych.org/.

National Alliance on Mental Illness (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA, 22201, (703) 524-7600, (800) 950-NAMI (6264), (703) 524-9094, http://www.nami.org/Hometemplate.cfm.

National Institute of Mental Health (NIMH), 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD, 20892, (301) 443-4513, (866) 615-6464, (301) 443 4279, [email protected], http://www.nimh.nih.gov/index.shtml.

National Mental Health Association (NMHA), 2000 N.

Beauregard Street, 6th Floor, Alexandria, VA, 22311, (703) 684-7722, (800) 969-NMHA, (703) 684-5968, http://www1.nmha.org/.

Rebecca J. Frey Ph.D.