Personality disorders in late life

The relationship between borderline personality disorder and major depression in later life: acute versus temperamental symptoms

OBJECTIVE

A recent issue in the personality disorder field is the prevalence and course of Axis II symptoms in later life. Focusing on the presentation of personality disorder criteria over time may have some utility in exploring the relationship between borderline personality disorder (BPD) and major depression in older adults. Temperamental personality symptoms are relatively resistant to change but tend to be nonspecific to disorders, whereas acute symptoms remit relatively quickly. We predicted that temperamental BPD symptoms would be positively correlated with a history of depression and did not expect to find a relationship between major depression and acute BPD symptoms.

METHODS

A total of 1,630 participants between the ages of 55 and 64 were recruited to participate in a community-based longitudinal study representative of the St. Louis area. Participants completed a battery of assessments at baseline, including diagnostic interviews for all 10 personality disorders and major depressive disorder.

RESULTS

Temperamental and acute BPD symptoms were significantly correlated with a history of major depression. After adjustments were made for the effects of temperamental symptoms on depression, acute symptoms were no longer correlated with a history of depression. As predicted, temperamental symptoms remained significantly related to depression, even after controlling for the effects of acute symptoms. BPD acute symptoms showed a unique negative correlation with the amount of time following remission from a depressive episode.

CONCLUSIONS

Overall, this study supports associations between major depression and borderline personality in older adults. The findings indicate that a history of major depression is primarily related to stable BPD symptoms related to emotional distress, which are more prevalent in older adults than acute features.

The effect of age on prevalence, type and diagnosis of personality disorder in psychiatric inpatients

OBJECTIVE

To examine age-related differences in personality disorder (PD) comorbidity and in their diagnosis in psychiatric inpatients.

METHODS

Two hundred thirty-one consenting adults consecutively admitted to inpatient psychiatry units and aged between the age of 18 and 100 were assessed using the Structured Clinical Interview for DSM IV Axis I and II (SCID-I and -II), after excluding cognitively impaired, non-English speaking, short stay and respite patients. Hospital files were audited for clinical diagnoses, in particular for recorded PDs. Rates of PD prevalence and clinician diagnosis were compared for young (n = 76), middle-age (n = 57) and older (n = 98) patients.

RESULTS

Significant personality comorbidity was evident at all ages, but rates were lowest in the older group. PD was present in 73.7% of young, 71.9% of middle-age and 58.8% of older patients. Complex PD was more common in young patients. Only 19.8% of PDs were noted by their clinicians to have PD.

CONCLUSION

Comorbid PD is common in psychiatric inpatient groups regardless of age but seldom diagnosed clinically.

Low-income depressed older adults with psychiatric comorbidity: secondary analyses of response to psychotherapy and case management

OBJECTIVE

This study examined the influence of comorbid anxiety and personality disorders on depression treatment response in 67 low-income older adults.

METHODS

Participants were randomized to clinical case management, cognitive-behavioral group therapy, or both for 6 months. Outcomes were assessed at baseline, post-treatment, and 6 and 12 months after treatment.

RESULTS

Dropout and depression diagnoses were similar across groups. Participants with comorbidity had more depressive and anxiety symptoms at most time points; degree of improvement did not differ significantly. Of participants with personality disorder, none met criteria at post-treatment (three relapsed by 12-month follow-up).

CONCLUSIONS

Findings suggest depressed low-income elders with anxiety or personality disorders can be retained and benefit from depression treatment, but may require additional interventions to achieve similar levels of depressive symptoms.

Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach

BACKGROUND AND SIGNIFICANCE

The treatment of personality disorders in older adults, particularly those co-morbid with other Axis I disorders (e.g., Major Depressive Disorder), is an understudied clinical phenomenon. It has also been demonstrated that personality disorders in older adults complicate treatment of other psychopathology, as well as result in heightened interpersonal disturbance and emotional distress.

METHODS

Two studies utilizing standard Dialectical Behavior Therapy (DBT) to treat depression and personality disorders in older adults are reviewed. Study 1 examined 34 chronically depressed individuals aged 60 and older who were randomly assigned to receive 28 weeks of antidepressant medication plus clinical management, either alone (MED) or with the addition of DBT skills-training and scheduled telephone coaching sessions (MED + DBT). Study 2 had two phases of treatment: Phase I: 8-week open-trial of antidepressant medication (n = 65); Phase II: 24-week randomized trial of DBT + MED versus MED alone for those who prospectively failed to respond to the Phase I medication trial (n = 37).

RESULTS

Study 1 demonstrated that 71% of MED + DBT patients were in remission at post-treatment, in contrast to 47% of MED patients. This became a significant difference at the 6-month follow-up; where 75% of MED + DBT-D patients were in remission compared with only 31% of MED patients. Study 2 showed that after 8 weeks of treatment with antidepressant medication alone (Phase 1) only 14% of the sample had at least a 50% reduction in HAM-D scores. Phase II results showed on average, the DBT + MED group reached depression remission by the post-group assessment and maintained these gains while the MED group did not reach remission, until the follow-up assessment. Results demonstrated superiority of DBT + MED compared to MED alone on Interpersonal Sensitivity and Interpersonal Aggression at post-treatment and 6-month follow-up.

CONCLUSION

Results from these two treatment development studies indicate that applying standard DBT for the treatment of co-morbid MDD or MDD + PD in older adults is feasible, acceptable, and has clinical promise. Modifications to standard DBT and an overview of a new treatment manual for this population are summarized.