Personality Disorders in Older Adults by Rosowsky Erlene. Abrams Robert. Zweig Richard A

Author:Rosowsky, Erlene.,Abrams, Robert.,Zweig, Richard A.
Language: eng
Format: epub
Publisher: Taylor & Francis Ltd
Published: 1999-12-07T16:00:00+00:00

CLINICAL EMERGENCE OF PERSONALITY DISORDER IN THE OLDER ADULT: GENERAL COMMENTS

When older people come to the attention of a mental health professional, it is often because their usual way of being in the world has somehow failed. The diagnostic requirement for a PD is that the individual experiences impairment in social or occupational functioning and/or experiences subjective distress. Older adults with PD often “emerge” as a result of a comorbid condition or in response to an imperative for change with which they cannot cope. With regard to comorbidity, it is known that PD patients treated for an Axis I condition do more poorly in treatment and at follow-up then those without a PD diagnosis (Howard, Bandyopadhyay, & Cook, 1992). The inclusion of cultural considerations among DSM–IV Axis II criteria acknowledges the role of group identity in contributing to diagnostic labeling. It is also recognized that PD may be differentially diagnosed according to gender (Bornstein, 1997). Such considerations and assumptions, although they are not without merit, may contribute to the PD being underdiagnosed, untreated, and not considered in treatment planning (George, 1990).

The need to change often becomes a catalyst for the reemergence of PD after a quiescent phase during midlife, often following the loss of a significant relationship. This relationship is one that had previously served as a buffer between the patient and the world, to bind the expression of PD symptoms, or to bolster the more adaptive behaviors of the individual while reciprocally inhibiting maladaptive ones. Additionally, the loss of a role that had once served to contain the expression of pathology, or to support the individual by providing a “domain of success” (to be discussed later), may also be a catalyst. PD can also appear selectively in different contexts. For example, an individual whose life revolves around her home might be able to function adequately. This same person, needing to make independent decisions in a fast-paced work setting may become increasingly symptomatic and interpersonally disordered (see chap. 16 in this volume). It is not unusual for an older adult to become identified as “difficult” following the death of a spouse, a move to a new housing setting, or identified as a “resistant” patient while being treated for an Axis I or Axis III (medical) disorder. In addition, with regard to the presentation of serious character pathology in old age, certain criteria for clinical diagnosis appear to be altered with age. Conversely, some presumed expressions may be state dependent and may be confused with an “enduring” disposition. Some of the more florid cases of PD (greater PDism) may exhibit selective mortality, thus leaving the lesser ones to define the disorder in old age. This may be especially true for the Cluster B PDs, as a group highly impulsive and risk taking (Cohen et al., 1994). Other ways to understand the presumed reduced prevalence of PD in old age (Fogel & Westlake, 1990) may include physiological changes, specifically changes in brain neurochemistry (see chap. 1 in this volume) or the manifestation

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