Personality disorder features through the life course

Clinical Staging for Personality Disorders in Older Adults

OBJECTIVE

This scientific research aimed to investigate the feasibility of implementing a clinical staging (CS) model for personality disorders (PDs) in older adults. The CS model could provide valuable insights into the life course of personality pathology, prognosis, and treatment decisions for PDs in older adults.

METHODS/DESIGN

The study employed an international Delphi methodology with three rounds and involved 21 experts.

RESULTS

Consensus was achieved on 12 out of 17 statements, confirming the viability of a CS model for PDs in older adults. The proposed model incorporates the Alternative Model for PDs, criterion A, and integrates life course information, distinguishing between chronic PD, re-emergent PD, late-onset PD, and past PD.

CONCLUSION

The findings suggest that international experts support the implementation of a CS model for PDs in older adults, considering both the severity of personality functioning and the retrospective life course of PD expression.

Antisuicidal effect of lithum in bipolar disorder: is there an age-specific effect?

OBJECTIVE

Our group reported previously a comparable overall antisuicidal effect of lithium and valproate in bipolar patients. We investigated factors associated with higher antisuicidal efficacy of lithium in older individuals.

METHODS

The age-related antisuicidal effect of lithium and valproate was compared in ninety-four (n = 94) high-risk bipolar suicide attempters who participated in a 2.5-year randomized, double-blind trial.

RESULTS

Age significantly moderated the effect of lithium vs. valproate on the risk of suicide event during the study (z = -1.98, p = 0.049). We found that those who were 42 years or older (above the 75th percentile), and on lithium had significantly lower risk of suicidal behavior than older patients on valproate (>42y) or younger (<42 y) patients on either medication (interaction HR = 0.09, 95%CI: 0.01-0.89, z = -2.07, p = 0.039). This difference in risk differences was not explained away by age-related differences in the proportion of participants with bipolar II disorder (Fisher's test p = 0.020) or higher lethality of past suicide attempts in younger participants (Wilcoxon test p = 0.024); neither was there any correlation with age in the longitudinally measured blood lithium levels (t = 1.04, df = 36, p = 0.307) or valproate levels (t = -0.50, df = 41, p = 0.621).

LIMITATIONS

Besides the fact that this is a secondary analysis, a limitation is that the study is not powered to detect suicide deaths or suicide attempts.

CONCLUSION

Bipolar patients randomized to lithium and older than 42 years had less suicidal behavior compared to same aged patients on valproate or younger patients (<42 y) on either medication. This effect was independent of clinical and sociodemographic characteristics.

The stability of personality disorders and personality disorder criteria: A systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to investigate the diagnostic, the dimensional mean-level, and rank-order stability of personality disorders (PDs) and PD criteria over time. EMBASE, PsycInfo, PubMed, and Web of Science were searched for peer-reviewed studies published in either English, German, or French between the first publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 and December 20, 2022. Inclusion criteria were a prospective longitudinal study design, assessing the stability of PDs or PD criteria over at least two measurement occasions at least one month apart, and using the same assessment at baseline and follow-up. Effect sizes included proportion of enduring cases (i.e., diagnostic stability), test-retest correlations (i.e., dimensional rank-order stability), and within-group standardized mean differences (i.e., dimensional mean-level stability), based on the first and last available measurement occasion. From an initial pool of 1473 studies, 40 were included in our analyses, covering 38,432 participants. 56.7% maintained the diagnosis of any PD, and 45.2% maintained the diagnosis of borderline PD over time. Findings on the dimensional mean-level stability indicate that most PD criteria significantly decreased from baseline to follow-up, except for antisocial, obsessive-compulsive, and schizoid PD criteria. Findings on the dimensional rank-order stability suggested moderate estimates, except for antisocial PD criteria, which were found to be high. Findings indicated that both PDs and PD criteria were only moderately stable, although between study heterogeneity was high, and stability itself depended on several methodological factors.

Psychometric evaluation of the Estonian version of the Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1)

BACKGROUND

The DSM-5 Alternative Model for Personality Disorders introduced a dimensional perspective on personality disorders. The model assesses functioning in four domains: Identity, Self-Direction, Empathy, and Intimacy. This study evaluates the psychometric properties of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) in Estonian.

METHOD

The sample consists of 131 participants: 58 from the general population and 73 from a mixed clinical sample that is further divided into a mood and anxiety disorder sample and personality disorder sample. All participants completed the STiP-5.1 interview and the Level of Personality Functioning Scale-Brief Form (LPFS-BF 2.0).

RESULTS

The Estonian STiP-5.1 interview has good internal consistency (McDonald's ω between .94-.98) and high convergent validity (correlations with LPFS-BF 2.0 above .7). Interview scores successfully differentiated the general population from the mixed clinical sample (Cohen's d = 2.68), as well as patients with personality disorder from those without (Cohen's d = 1.76). The LPFS-BF 2.0 total score differentiates the general population sample from the mixed clinical sample (Cohen's d = 1.99) but not the personality disorder sample from other clinical sample participants.

CONCLUSIONS

The properties of the Estonian STiP-5.1 replicate those of other languages, and empirically support a unified personality functioning dimension that can be meaningfully thought of as reflecting impairments in self and interpersonal functioning. Findings of this study will be discussed in the light of the ongoing debate on the dimensionality of personality pathology and the use of self-report versus interview measures for assessing personality pathology.

A meta-structure for DSM-5 and ICD-11 pathological traits and the differentiation of personality functioning at different trait levels in older adults

OBJECTIVES

Categorical criteria are not well suited to inform personality disorder (PD) diagnoses in older adults. More promising are the ICD-11 and DSM-5 alternative models. Both conceptualize PD by level of severity and maladaptive traits. Severity is conditional for making a PD diagnosis. Trait levels portray stylistic differences in PD expression. Yet, in older adults the hierarchical trait structure is unknown. Neither is the differentiation of the severity criterion from maladaptive traits confirmed.

METHODS

A series of exploratory factor analyses with progressively greater numbers of factors were conducted to examine the hierarchical trait structure in 293 community dwelling older adults. The on average differentiation of a single higher order personality functioning factor from trait factors at succeeding levels of the hierarchy was estimated with Cohen q effect size.

RESULTS

Six meaningful trait levels were identified. From the fourth trait level on the general personality functioning factor shared less than 15% variance on average with the trait factors. Trait factors at the sixth level corresponded to both DSM-5 and ICD-11 pathological traits.

CONCLUSION

A future nosology integrating DSM-5 and ICD-11 trait proposals would be applicable in older adults. Personality functioning can be differentiated from traits, so separate assessment of traits and severity is worthwhile.

Impact of personality functioning and pathological traits on mental wellbeing of older patients with personality disorders

BACKGROUND

Although personality disorders are common and consequential, they are largely ignored in geriatric mental healthcare. We examined the relative contributions of different aspects of personality disorders and comorbid mental disorders to the impairment of mental wellbeing in older adults.

METHODS

Baseline data were used of 138 patients who participated in a randomized controlled trial on schema therapy for geriatric mental health outpatients with a full or subthreshold cluster B or C personality disorder. Personality was assessed according to both the categorical and dimensional model of DSM-5. Aspects of mental wellbeing assessed were; psychological distress, positive mental health, subjective health, and life satisfaction. The current study uses baseline data of the RCT to examine the associations between different aspects of personality pathology and mental wellbeing by multivariate regression analysis, controlling for age, sex, level of education, and number of chronic somatic illnesses.

RESULTS

The vast majority of patients (79.0%) had one or more mental disorders in addition to personality disorder. Personality pathology was responsible for the core of the mental health burden experienced by patients, and negated the influence of co-occurring mental disorders when entered subsequently in multivariate analysis. Personality dimensions proved to be highly predictive of mental wellbeing, and this contrasted with absence of influence of personality disorder diagnosis. Although the personality functioning dimensions - and in particular Identity integration (large effect size with partial eta-squared = 0.36) - were the primary predictors of mental wellbeing, personality trait dimensions added significant predictive value to that (Disinhibition 0.25 and Negative affect 0.24).

CONCLUSIONS

Personality disorders seriously affect the mental wellbeing of patients, and this overshadows the impact of comorbid mental disorders. In particular personality functioning and pathological traits of the Alternative Model of Personality Disorders (AMPD) of DSM-5 contribute to this impact on mental wellbeing. Alertness for and treatment of personality disorders in geriatric mental healthcare seems warranted.

Clinical Staging as a Novel Approach for Selecting Psychological Treatment Levels for Older Adults with Borderline Personality Disorder

OBJECTIVES

In this paper, a novel approach is presented for selecting psychological treatment levels for older adults with borderline personality disorder (BPD). BPD tends to be a lifelong disorder persisting into old age, with a specific presentation of BPD symptoms in later life, which is illustrated by three different clinical cases.

METHODS

Recently, a clinical staging and health management model for BPD was presented to assist in selecting appropriate treatment approaches.

RESULTS

We combined this clinical staging model for BPD across the lifespan with psychotherapeutic treatment levels for older adults with personality disorders.

CONCLUSIONS

This may allow for a more accurate treatment selection for older adults with BPD and was applied to the three clinical cases. Finally, implications for research and clinical practice are discussed.

Semi-structured interview for personality functioning DSM-5 (STiP-5.1): Psychometric evaluation of the Czech version

The DSM-5 Alternative Model for Personality Disorders introduced a dimensional perspective on personality disorders and their assessment by measuring personality functioning in the following domains: Identity, Self-Direction, Empathy, and Intimacy. This study provides a replication of the psychometric evaluation of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) within a mixed clinical sample and a community sample. The sample consisted of 188 adults: 86 participants from the general population and 102 people from a mixed clinical sample. All participants completed the STiP-5.1 and Level of Personality Functioning Scale-Brief Form (LPFS-BF 2.0). Results showed good internal consistency (McDonald's ω = 0.89-0.94) and promising convergent validity (correlations with LPFS-BF 2.0 above 0.6) of the STiP-5.1. Its scores differentiated participants within the community sample from those in the mixed clinical sample with large effect sizes (r_rb = 0.77-0.88). Moreover, the impairment in personality functioning was more pronounced in people with personality disorders than in other psychiatric disorders (medium effect size, r_rb = 0.46-0.57), supporting the notion of a continuum of personality functioning impairment. The STiP-5.1 therefore offers an instrument with satisfactory psychometric properties for the assessment of personality functioning both for research and clinical practice.

Late-onset personality disorder: a condition still steeped in ignorance

Personality disorder is likely to be common in late life, but our ignorance is such that, at present, we can only speculate about its frequency and importance. The only firm evidence we have is that antisocial personality features tend to be attenuated in older age and obsessional and detached features accentuated. Differentiating personality change following organic disease from personality disorder requires more attention as it is important for good clinical management.

The General Criteria for Personality Disorders Assessed by Interview: Do They Still Have a Role to Play?

On the path to developing dimensional models of personality disorder (PD), we are at risk of leaving key diagnostic aspects behind. The general criteria for PD may be important ones because they reflect the defining aspects of personality pathology: long duration, independence from psychopathological states, and harmfulness. We assessed these criteria by interview in a sample of 362 psychiatric outpatients after administering the Personality Diagnostic Questionnaire-4+. The result was a 42.5% fall in self-reported endorsements, due to misinterpretations (11.5%), short duration of traits or contamination by state psychopathology (9.8%), and traits being non-harmful (21.2%). However, not all personality traits and disorders underwent correction to the same extent, and ultimately, the interview did not improve the prediction of clinical variables. These findings raise doubts about the practical relevance of the general criteria for PD and support the role of self-report questionnaires for diagnostic purposes.

The effectiveness of individual schema therapy in older adults with borderline personality disorder: Protocol of a multiple-baseline study

BACKGROUND

The treatment of borderline personality disorder (BPD) has been examined extensively in adults up to the age of fifty in the past quarter of a century, but there is still a world to discover in treating BPD in older adults. The aim of the study is to investigate the effectiveness of schema therapy in older adults with BPD.

METHODS/DESIGN

A multiple baseline design is used in which participants are randomly assigned to baseline length. The primary outcome measure is assessed weekly and consists of the credibility of negative core beliefs. Secondary outcome measures are quality of life, psychological distress, early maladaptive schemas, schema modes, severity of BPD symptoms and meeting the criteria for BPD. Ten older adults (age > 60 years) with BPD are treated with schema therapy, with weekly sessions during one year. This treatment phase is preceded by a baseline phase varying from 4 to 8 weeks. After treatment, there is a 6-month follow-up phase with monthly booster sessions.

DISCUSSION

To our knowledge, this is the first empirical study of the effectiveness of psychotherapeutic treatment for BPD in older adults. Because of the different manifestation of BPD in later life, besides section II DSM-5 criteria, the alternative, dimensional model for personality disorders of DSM-5 is used to assess BPD in older adults.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR7107. Registered 11 March 2018.

A Life Span Perspective on Borderline Personality Disorder

PURPOSE OF REVIEW

To provide an update of a life span perspective on borderline personality disorder (BPD). We address the life span course of BPD, and discuss possible implications for assessment, treatment, and research.

RECENT FINDINGS

BPD first manifests itself in adolescence and can be distinguished reliably from normal adolescent development. The course of BPD from adolescence to late life is characterized by a symptomatic switch from affective dysregulation, impulsivity, and suicidality to maladaptive interpersonal functioning and enduring functional impairments, with subsequent remission and relapse. Dimensional models of BPD appear more age neutral and more useful across the entire life span. There is a need for age-specific interventions across the life span. BPD symptoms and impairments tend to wax and wane from adolescence up to old age, and presentation depends on contextual factors. Our understanding of the onset and early course of BPD is growing, but knowledge of BPD in late life is limited. Although the categorical criteria of DSM allow for reliable diagnosis of BPD in adolescence, dimensional models appear both more age neutral, and useful up to late life. To account for the fluctuating expression of BPD, and to guide development and selection of treatment across the life span, a clinical staging model for BPD holds promise.

Affective instability across the lifespan in borderline personality disorder - a cross-sectional e-diary study

OBJECTIVE

Longitudinal and cross-sectional studies suggest that affective instability is inversely related to greater age in borderline personality disorder (BPD). However, existing studies relied on retrospective self-reports of perceived instability. We examined affective instability in everyday life in patients with BPD and healthy controls (HCs) by age in a cross-sectional e-diary study.

METHODS

Two hundred and sixty female participants between 14 and 53 years of age (130 patients with BPD and 130 HCs) carried an e-diary over 4 days. The e-diaries emitted a prompting signal in approximately hourly intervals asking participants to rate their current affective state, that is valence (ranging from pleasant to unpleasant) and tense arousal (ranging from calm/relaxed to restless/under tension).

RESULTS

Multilevel analyses revealed a significant interaction of age and group predicting affective instability (valence: F_(1,255.6)  = 7.59; P < 0.01; tense arousal: F_(1,252)  = 6.08; P < 0.01), suggesting that affective instability significantly declines with greater age in patients with BPD. Controlling for the number of comorbid disorders and BPD severity did not change the results, illustrating an inverse relationship between age and affective instability in BPD (significant interaction of age*group for valence: F_(1,238.7)  = 5.74; P < 0.02 and tense arousal: F_(1,235.2)  = 5.28; P < 0.02).

CONCLUSION

Affective instability during daily life declines with greater age in BPD. This decline is irrespective of comorbidity and BPD severity.

Missed diagnosis: The emerging crisis of borderline personality disorder in older people

OBJECTIVE

Clinical experience suggests a growing prevalence of borderline personality disorder in aged residential care and psychiatric facilities with attendant difficulties in their management. This paper reviews the literature concerning the prevalence, phenomenology and diagnosis of borderline personality disorder in old age. The aim is to elucidate the phenomenological differences in old age and thus improve identification of the disorder.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE and PsycINFO databases, employing the search terms including 'personality disorder', 'borderline personality disorder', 'aged care', 'gerontology', 'geriatric psychiatry' and 'life span'. The search included articles in English involving participants 65+ years. Long-term prospective studies of borderline personality disorder, long-term follow-up studies and studies involving older adults from 50+ years were also examined.

RESULTS

There is a paucity of literature on borderline personality disorder in the elderly. No diagnostic or rating instruments have been developed for borderline personality disorder in the elderly. The phenomenology of borderline personality disorder in the aged population differs in several respects from that seen in younger adults, causing some of the difficulties in reaching a diagnosis. Escalations of symptoms and maladaptive behaviours usually occur when the diagnosis of borderline personality disorder is either not made or delayed. Improved identification of borderline personality disorder in older patients, together with staff education concerning the phenomenology, aetiology and management of these patients, is urgently needed.

CONCLUSION

Diagnostic instruments for borderline personality disorder in the elderly need to be developed. In the interim, suggestions are offered concerning patient symptoms and behaviours that could trigger psychiatric assessment and advice concerning management. A screening tool is proposed to assist in the timely diagnosis of borderline personality disorder in older people. Timely identification of these patients is needed so that they can receive the skilled help, understanding and treatment needed to alleviate suffering in the twilight of their lives.

Personality Assessment in the Diagnostic Manuals: On Mindfulness, Multiple Methods, and Test Score Discontinuities

Recent controversies have illuminated the strengths and limitations of different frameworks for conceptualizing personality pathology (e.g., trait perspectives, categorical models), and stimulated debate regarding how best to diagnose personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), and in other diagnostic systems (i.e., the International Classification of Diseases, the Psychodynamic Diagnostic Manual). In this article I argue that regardless of how PDs are conceptualized and which diagnostic system is employed, multimethod assessment must play a central role in PD diagnosis. By complementing self-reports with evidence from other domains (e.g., performance-based tests), a broader range of psychological processes are engaged in the patient, and the impact of self-perception and self-presentation biases can be better understood. By providing the assessor with evidence drawn from multiple modalities, some of which provide converging patterns and some of which yield divergent results, a multimethod assessment compels the assessor to engage this evidence more deeply. The mindful processing that ensues can help minimize the deleterious impact of naturally occurring information processing bias and distortion on the part of the clinician (e.g., heuristics, attribution errors), bringing greater clarity to the synthesis and integration of assessment data.

Personality disorder across the life course

The pervasive effect of personality disorder is often overlooked in clinical practice, both as an important moderator of mental state and physical disorders, and as a disorder that should be recognised and managed in its own right. Contemporary research has shown that maladaptive personality (when personality traits are extreme and associated with clinical distress or psychosocial impairment) is common, can be recognised early in life, evolves continuously across the lifespan, and is more plastic than previously believed. These new insights offer opportunities to intervene to support more adaptive development than before, and research shows that such intervention can be effective. Further research is needed to improve classification, assessment, and diagnosis of personality disorder across the lifespan; to understand the complex interplay between changes in personality traits and clinical presentation over time; and to promote more effective intervention at the earliest possible stage of the disorder than is done at present. Recognition of how personality disorder relates to age and developmental stage can improve care of all patients.

Male inmate profiles and their biological correlates

OBJECTIVE

Borderline and antisocial personality disorders (PDs) share common clinical features (impulsivity, aggressiveness, substance use disorders [SUDs], and suicidal behaviours) that are greatly overrepresented in prison populations. These disorders have been associated biologically with testosterone and cortisol levels. However, the associations are ambiguous and the subject of controversy, perhaps because these heterogeneous disorders have been addressed as unitary constructs. A consideration of profiles of people, rather than of exclusive diagnoses, might yield clearer relationships.

METHODS

In our study, multiple correspondence analysis and cluster analysis were employed to identify subgroups among 545 newly convicted inmates. The groups were then compared in terms of clinical features and biological markers, including levels of cortisol, testosterone, estradiol, progesterone, and sulfoconjugated dehydroepiandrosterone (DHEA-S).

RESULTS

Four clusters with differing psychiatric, criminal, and biological profiles emerged. Clinically, one group had intermediate scores for each of the tested clinical features. Another group comprised people with little comorbidity. Two others displayed severe impulsivity, PD, and SUD. Biologically, cortisol levels were lowest in the last 2 groups and highest in the group with less comorbidity. In keeping with previous findings reported in the literature, testosterone was higher in a younger population with severe psychiatric symptoms. However, some apparently comparable behavioural outcomes were found to be related to distinct biological profiles. No differences were observed for estradiol, progesterone, or DHEA-S levels.

CONCLUSIONS

The results not only confirm the importance of biological markers in the study of personality features but also demonstrate the need to consider the role of comorbidities and steroid coregulation.

Aging: empirical contribution. A longitudinal analysis of personality disorder dimensions and personality traits in a community sample of older adults: perspectives from selves and informants

Research has indicated that personality disorders (PDs) and normal-range personality traits generally "get better" with time, as evidenced by mean-level decreases in PD traits and mean-level increases in broad factors such as emotional stability, agreeableness, and conscientiousness. One limitation of many of these studies is their reliance on self reported data. In the current study, the authors analyzed the 2.5-year course of PD dimensions and normal personality traits in a representative sample of adults approaching later life (originally ages 55-65) by using a semistructured diagnostic interview as well as self- and informant-reported data from two personality inventories. Consistent with previous literature, many self-reported PD traits showed mean-level decreases over time, and self-reported normal-range personality traits generally showed positive aging effects (e.g., mean-level increases in emotional stability, agreeableness, and conscientiousness). Surprisingly, however, informant-reported PD traits often demonstrated small but significant increases over time, and informant-reported normal-range personality generally "worsened" with age (e.g., mean-level decreases in extraversion, agreeableness, and conscientiousness). Informant reports may challenge the finding that personality and PDs tend to "improve" over time.

The course of personality pathology

PURPOSE OF REVIEW

Durability has traditionally been considered to be a defining feature of personality disorders, but recent studies have challenged this notion. We review the most recent findings on the stability and course of personality pathology.

RECENT FINDINGS

Personality disorders seem to remit more often and faster than previously thought, and their relapse rate is low. However, the recent optimism regarding these disorders is mitigated by the existence of highly heterogeneous trajectories among patients and traits, the identification of certain methodological shortcomings, and the maintenance of psychosocial impairment long after symptomatic relief. The causes of personality improvement are largely unknown, but involve intermingled genetic and environmental effects.

SUMMARY

Recent follow-up studies of patients with personality pathology are changing orthodox conceptions of their inevitably negative prognosis. The current taxonomies must be reviewed and future research should be integrated with adjacent fields. Treatments need to target the enduring real-life hardships of these patients, apart from their acute symptoms.

The role of identity in the DSM-5 classification of personality disorders

In the revised Diagnostic and Statistical Manual DSM-5 the definition of personality disorder diagnoses has not been changed from that in the DSM-IV-TR. However, an alternative model for diagnosing personality disorders where the construct "identity" has been integrated as a central diagnostic criterion for personality disorders has been placed in section III of the manual. The alternative model's hybrid nature leads to the simultaneous use of diagnoses and the newly developed "Level of Personality Functioning-Scale" (a dimensional tool to define the severity of the disorder). Pathological personality traits are assessed in five broad domains which are divided into 25 trait facets. With this dimensional approach, the new classification system gives, both clinicians and researchers, the opportunity to describe the patient in much more detail than previously possible. The relevance of identity problems in assessing and understanding personality pathology is illustrated using the new classification system applied in two case examples of adolescents with a severe personality disorder.