CHAPTER 38—PERSONALITY AND SOMATOFORM DISORDERS
Personality disorders are defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) by the presence of chronic and pervasive patterns of inflexible and maladaptive inner experiences and behaviors. These patterns lead to significant disruptions in several spheres of function, including cognitive perception and interpretation, affective expression, interpersonal relations, and impulse control. People with personality disorders are often distinguished by repeated episodes of disruptive or noxious behaviors, and as a result they often receive pejorative labels, depending on their form. Descriptive terms often applied to those with personality disorders include “difficult,” “dramatic,” and “overbearing,” to name just a few. The developmental roots of personality disorders are believed to lie in childhood and adolescence, but their features can present clinically at any age. These features represent the influence of both genetic and environmental factors.
The DSM-IV-TR describes ten personality disorders, grouped into three broad clusters that are based on common phenomenology. Depressive and passive-aggressive personality disorders are two additional categories, but they are considered provisional since they appear to lack the empirical support of the other ten diagnoses. Brief definitions and late-life features of all twelve personality disorders are provided in Table 38.1. Mixed diagnoses and those that do not fit into any existing category are labeled “personality disorder, not otherwise specified” (NOS).
Many older persons with personality disorders can easily become overwhelmed by age-associated losses and stresses, largely because they lack appropriate coping skills and the personal, social, or financial resources to buffer their losses. In particular, admission to a hospital or long-term-care setting poses a unique stress on all persons with personality disorders in late life. The loss of a familiar environment, personal items, privacy, and the control over one’s schedule can lead to a sense of disorganization and displacement. Conflict in an institutional setting begins when patients with personality disorders try to cope with the stresses from their new environment by exaggerating their maladaptive behaviors. An obsessive-compulsive person may attempt to maintain a sense of control by demanding rigid adherence to schedules and rules of hygiene. Dependent persons may feel helpless and panicked without enough attention to their needs, and they respond with clinging behaviors and excessive questions or requests for assistance. Paranoid, antisocial, and borderline patients may refuse to cooperate with treatment plans or institutional rules.
Prevalence rates of late-life personality disorders in the community range from 5% to 10%, which is a slightly lower range than the 10% to 18% prevalence estimates for persons of all ages in the community. Prevalence rates in inpatient settings and with comorbid depression are much higher, ranging from 10% to over 50%, depending on the method of diagnosis. The most common personality disorders in late life are dependent, obsessive-compulsive, paranoid, and NOS. Although most research has demonstrated fewer diagnoses in older age groups, it is unclear whether this represents an actual difference in prevalence or merely reflects the fact that it is more difficult to make a diagnosis in late life. Some researchers have suggested that prevalence rates may be influenced by increased mortality among those with personality traits that are associated with higher rates of reckless, impulsive, and self-injurious behaviors. Other research exploring the neural substrates of emotion has demonstrated an attenuation of emotional reactivity in late life across a number of physiologic and behavioral parameters. These findings may partially explain the reduction in prevalence of the more impulsive and emotionally reactive personality features, such as those associated with borderline personality disorder.
Establishing a diagnosis of personality disorder in the older patient can be especially challenging because it requires a detailed, longitudinal psychiatric and psychosocial history. Elderly patients and their informants are not always able to provide sufficient history, especially when it may span 50 years or more. The history may be distorted by recall bias (the tendency to present more socially desirable traits) or memory impairment. Furthermore, schizotypal and paranoid persons may be reluctant to engage in clinical interviews and share personal history, and antisocial and narcissistic persons who lack insight into their problems may refuse to divulge relevant experiences. Records often do not provide sufficient information to determine prior personality dynamics. Remote diagnoses from previous decades cannot be easily correlated with current ones because the diagnostic criteria for personality disorders have changed significantly in the past 50 years. As a result of all of these limitations, clinicians often are reluctant to make a diagnosis or to make judgments that are based on insufficient information.
A further diagnostic challenge for clinicians is the need to isolate lifelong personality characteristics from a multitude of comorbid problems. Acute and chronic episodes of major depression, psychosis, and other major psychiatric disorders can distort personality features considerably. Even the current diagnostic nomenclature might serve to handicap late-life diagnosis since it is not age adjusted, and many criteria fail to apply in late life. A final barrier to diagnosis may be present if the clinician erroneously considers all older patients to have disruptive personality features as a normal function of age.
In clinical settings, it is important to remember that not every older person with prominent or troubling personality features has a personality disorder. Those who demonstrate rigid and maladaptive personality traits but without the pervasiveness or severity as represented by DSM-IV-TR criteria are better described as suffering from personality dysfunction or an adjustment disorder. An adjustment disorder might best characterize previously healthy and well-adjusted persons who demonstrate acute changes in personality as a result of severe stresses. For example, physical pain and disability can lead to dependent or avoidant behaviors that resemble those seen in personality disorders, but without the pervasive pattern and degree of maladaptiveness. There is also considerable overlap between symptoms of major psychiatric disorders and those of personality disorders, and without longitudinal history it can be difficult to distinguish between them. For example, the odd thinking and unusual perceptual experiences seen in psychotic disorders may resemble behaviors seen in schizotypal personality disorder. The emotional lability of bipolar states can mimic behaviors of borderline and histrionic diagnoses, and depressive symptoms from dysthymic and depressive disorders can be almost indistinguishable from depressive personality traits. Diagnosis of a personality disorder becomes more certain when seemingly acute behaviors emerge as enduring and pervasive personality traits. This process depends on the opportunity to observe a person over time and in multiple settings or situations.
Personality disorders as described in DSM-IV-TR must also be differentiated from the diagnosis of personality change due to a specific medical condition. When personality change is a direct result of brain damage, it has classically been described within the context of an “organic” personality disorder, although this term is no longer used in DSM nomenclature. Most often, personality changes with an “organic” source involve impairments in executive functioning, consisting of poor impulse control, poor planning, and greater vulnerability to irritability or agitation. Along these lines, Alzheimer’s disease and other dementias are often associated with personality changes, including apathy, egocentricity, and impulsivity. Frontal lobe injury may result in a disinhibited impulsive syndrome, or conversely, an apathetic, avolitional syndrome may result. Frontotemporal dementia has been associated with distinct personality changes characterized by odd social interactions and compulsive behaviors such as hoarding. (See Dementia.) Temporal lobe epilepsy has been associated with personality change, including emotional deepening, verbosity, hypergraphia, hypersexuality, and preoccupation with religious, moral, and cosmic issues.
Personality disorders may follow one of four possible courses: they persist unchanged, evolve into a different form or major psychiatric disorder (eg, depression), improve, or remit. Few disorders have actually been studied over time, and rarely into late life. Several studies have suggested that personality disorders may enter a period of relative quiescence in middle age, with fewer and less intense symptoms and increased adaptation. However, this period may precede their reemergence in late life. Other researchers have proposed that personality disorders characterized by emotional and behavioral lability, including antisocial, borderline, histrionic, narcissistic, and dependent, tend to improve over time, although patients remain vulnerable to depression. Personality disorders characterized by an overcontrol of affect and impulses, including paranoid, schizoid, schizotypal, and obsessive-compulsive personality disorders, are thought to either remain stable or to worsen in late life.
Only antisocial and borderline personality disorders have been looked at longitudinally, and both have shown symptom improvement and even remittance into middle and later life for a significant percentage of patients. At the same time, there can be persistent psychopathology that is not recognized within the context of existing antisocial or borderline diagnostic criteria. In other words, longstanding personality dynamics may manifest in new behaviors. For example, those with antisocial personality disorders demonstrate less aggressiveness, violence, and criminal acts as they age, but they still have antisocial tendencies expressed through substance abuse, disregard for safety, and noncompliance with institutional rules. Elderly borderline patients display less impulsivity, self-mutilation, and risk-taking, but more age-appropriate symptoms, such as the use of multiple medications and nonadherence with treatment.
The treatment of personality disorders in late life is complicated and often has limited success. Given the chronic and pervasive nature of personality disorders, the overall goal of treatment in late life is not to cure the disorder, but to decrease the frequency and intensity of disruptive behaviors. The first step should always be to clarify the diagnosis and then to identify recent stressors that may account for the current presentation. The resultant formulation will guide the selection of realistic target symptoms and therapeutic approaches and will allow a treatment team to anticipate future stressors. Treatment of personality disorders in late life uses the same basic approaches as with younger patients, but clinicians must incorporate a much broader understanding of the impact of age-related stressors and comorbid disorders. All forms of psychotherapy have been used to treat personality disorders in older adults, ranging from intensive and long-term insight-oriented approaches to equally intensive but more focused cognitive-behavioral models. In late life, however, there may be more limitations on time and intensity of therapy, and as a result treatment must focus more on short-term, cognitive-behavioral, and pharmacologic approaches. Studies in adults generally find that comorbid personality disorders complicate the treatment of psychiatric illness, but that with consistent treatment, the prognosis is often favorable. The prognosis in late life is more guarded, especially for persons with comorbid major depression. One study of elderly persons with major depression found that those with a concomitant personality disorder were less likely to benefit from psychotherapy.
In outpatient settings, clinicians have limited control over a patient’s environment and must therefore rely on one-to-one interventions if the patient is willing to cooperate with treatment. With some patients, it may be necessary to convey a basic formulation of their behaviors, along with suggested approaches, to caregivers and affiliated health care professionals, such as internists, social workers, and visiting nurses. This communication is important when patients are vulnerable to self-harm or likely to cause significant disruptions in other settings when they are not understood and approached in a therapeutic manner. Table 38.2 suggests therapeutic approaches that clinicians can employ with various personality disorders.
Long-term-care settings allow more opportunities for intervention. A staff meeting or case conference often provides the best forum to discuss disruptive persons and to coordinate a consistent treatment plan. Disruptive behaviors can sometimes be traced to particular activities or staff interactions, which can be adapted as part of an overall treatment strategy. Sometimes, disengagement from patients will reduce the intensity of disruptive interactions. In other situations, the continuity of staffing and of daily schedules is critical. In all situations, a treatment plan should be well documented and conveyed to the patient, as well as all involved staff and caregivers. All plans must provide appropriate limits to ensure the safety of patients and staff. A written contract, signed by all parties, may be needed with nonadherent persons in order to eliminate ambiguity. Although it is important to involve family members in the treatment plan, clinicians must recognize that patients with personality disorders often have conflictual relationships with them. Attention should also be given to individual staff members who must work with difficult patients. They need opportunities to vent feelings of anxiety and frustration, and to feel acknowledged and supported by administrative and clinical staff.
There have been no studies looking specifically at pharmacologic strategies for personality disorders in late life, so clinicians must instead extrapolate from guidelines used for younger persons. Psychotropic medications can be targeted at a particular personality disorder, specific symptoms or symptom clusters, or comorbid depression, anxiety, or psychosis. The goal is not to cure the disorder, but to reduce the frequency and intensity of targeted symptoms. Antidepressant medication may be helpful for the target symptoms of depression and anxiety found in most personality disorders. Mood stabilizers (eg, lithium carbonateOL and divalproex sodiumOL) and antipsychotic medications have been found to reduce mood lability and impulsivity in borderline patients, and they may be useful with similar symptoms in antisocial personality disorder. Antianxiety agents are commonly used for transient agitation seen in borderline, antisocial, narcissistic, and paranoid disorders, and they may reduce social anxiety and panic in avoidant and dependent patients. Antidepressants are used commonly to treat obsessive-compulsive personality symptoms, although efficacy has not been established for the treatment of these symptoms as opposed to obsessive-compulsive disorder. Antipsychotic agents can treat the transient psychosis, agitation, and impulsivity seen in dramatic cluster and paranoid disorders, as well as the borderline psychosis and paranoia seen in odd cluster disorders.
For personality disorders, psychotropic medications are best used as adjuncts to psychotherapy. In older persons, multiple medications should be avoided in general, and particularly when there is a history of nonadherence, confusion, or impulsivity. Attention must be given to potential interactions with multiple other medications used to treat medical disorders. It is important to obtain and document informed consent (or consent of family members or guardians) for the use of psychotropics when there is a history of dementia, recent delirium, paranoia, or conflictual doctor-patient relationships.
Finally, clinicians must recognize that in some cases it is best not to prescribe a psychotropic medication. Such cases include older persons with personality disorders and comorbid substance abuse, chronic nonadherence, or a history of or potential for abusive or self-injurious use of medications. Antisocial and borderline persons often demonstrate such behaviors. Dependent patients may insist upon medications as a means of fostering dependency on the clinician, and obsessive-compulsive patients may perpetuate a maladaptive relationship with the clinician through detailed and controlling discussions of medication management. In each example, medication management is corrupted by dysfunctional interpersonal behaviors that lie at the heart of personality disorders.
Somatoform disorders encompass a heterogeneous group of seven diagnoses that have in common the presence of physical symptoms or complaints without objective organic causes, and that are strongly associated with psychologic factors. Clinical characteristics of each diagnosis are summarized in Table 38.3. These disorders are especially relevant to geriatric care because affected older persons are seen in all health care settings, and they tend to overutilize medical services. Somatoform disorders in late life have not been well studied, and existing research has usually focused on select diagnoses, such as hypochondriasis, in limited or biased samples. Research also has looked at somatic symptom reporting rather than at specific diagnoses. Prevalence rates in middle and late life have been found to be less than 1%, except for one study, which found a prevalence rate of more than 36% for somatization disorder in women over 55 years old seen in health care clinics. The presence of these disorders has not been found to be strongly associated with age, although there is weak evidence for a slight increase in hypochondriasis with age. Increased somatic preoccupation and symptoms are, however, associated with depression in late life, and older age of onset for depression may be most predictive. In addition to depression, increased somatic preoccupation is associated with the presence of the personality trait of neuroticism, in which a person displays a tendency to experience more negative emotions. Somatoform disorders are found more commonly in women and in lower socioeconomic groups. Late onset of a somatoform disorder may suggest associated neurologic illness.
It is important to recognize that somatoform disorders do not represent intentional, conscious attempts by older patients to present factitious physical symptoms. Somatoform symptoms are experienced by the affected person as real physical pain and discomfort, usually without insight into associated psychologic factors. Somatoform disorders do not represent delusional thinking as found in psychotic states (although body dysmorphic disorder can be associated with beliefs of delusional quality), and they are different from psychosomatic disorders, which are characterized by actual disease states with presumed psychologic triggers. Rather, somatoform disorders represent a complex interaction between mind and brain in which an affected person is unknowingly expressing psychologic stress or conflict through the body. It is not surprising, then, that depression and anxiety are associated with increased somatic expressions. In late life, somatoform disorders, in particular hypochondriasis, may be a way for a person to express anxiety and attempt to cope with accumulating fears and losses. These may include fears of abandonment by family and caregivers, loss of beauty and strength, financial setbacks, loss of independence, loss of social role (eg, through retirement, loss of spouse, occupational disability), and loneliness. The psychologic distress and anxiety over such losses may be less threatening and more controllable when shifted to somatic complaints or symptoms. In turn, the adoption of a sick role might be reinforced by increased social contacts and support.
The causes of somatoform disorders are usually multifactorial, and often they are rooted in early developmental experiences and personality traits. Psychodynamic approaches suggest that these disorders result from unconscious conflict in which intolerable impulses or affects are expressed through more tolerable somatic symptoms or complaints. One reason for this may be the presence of alexithymia, in which a person is unable to identify and express emotional states, so that the body becomes the available mode of expression.
Although psychodynamic explanations can apply across the life span, these conflicts often begin early in life, perhaps accounting for the relatively young age of onset for most somatoform disorders. In late life, psychologic conflict that results in significant depression and anxiety are for the most part the same conflicts that can lead to somatization. In addition, the presence of so many comorbid medical problems and the use of multiple medications may provide readily available somatic symptoms around which psychologic conflict can center. In long-term care, older persons are faced with many overwhelming losses, and their own bodies often serve as the last bastion of control. Somatic preoccupation thus serves as a means of coping with stress, even though it is maladaptive and can result in excessive and unnecessary disability.
Persons with somatoform disorder do not usually present as such; by their definition they present to clinicians with what appear to be legitimate somatic complaints with an unknown physical cause. It is only after repeated but fruitless work-ups, multiple and persistent complaints and requests, and sometimes angry and inappropriate reactions to treatment that clinicians begin to suspect a somatoform disorder. In some cases the manner of presentation and symptom complex is more immediately suggestive of a particular somatoform disorder. In any event, it is important for the clinician to remember that from the perspective of the patient, the symptoms and complaints are quite real and disturbing. It is never wise to challenge the patient or to suggest that the symptoms are “all in your mind,” even after work-up has made it obvious that psychologic factors are involved. The typical response to such advice is for the patient to seek additional opinions and medical tests, which in turn can perpetuate a cycle of somatization that never addresses the underlying issues.
Instead, the physician should attempt to foster an ongoing, supportive, consistent, and professional relationship with the affected person. Such a relationship will serve to provide reassurance as well as to protect the patient from excessive and unnecessary medical visits and procedures. The physician should focus on responding to individual complaints, perhaps with periodic but regularly scheduled appointments, and to set limits on work-up and treatment in a firm but empathetic manner. This can be difficult to do when patients become demanding and attempt to consume excessive clinic time, but the physician must endeavor to remain professional and not to personalize the situation or to feel that he or she is failing the patient. Overall, the role of the physician is to focus on symptom reduction and rehabilitation, and not to attempt to force the patient to have insight into the potential psychologic nature of his or her symptoms. It would be hazardous to prematurely diagnose a somatoform disorder when there might actually be an underlying medical problem that has eluded diagnosis. For example, disorders such as multiple sclerosis, systemic lupus erythematosus, and acute intermittent porphyria commonly have complex presentations that elude initial diagnostic work-up. Moreover, many somatoform disorders coexist with actual disease states; for example, many persons with pseudoseizures also have an actual seizure disorder. At the same time, it is important for the physician to set limits on what he or she can offer, and to make appropriate referrals to specialists and mental health clinicians.
The mental health clinician will play a more active role in addressing the somatoform disorder. Unfortunately, no particular treatment for any somatoform disorder has been found to have good efficacy, and most disorders tend to be lifelong. As a result, the goal of treatment is not to cure, but to control symptoms. The physician first forms a therapeutic alliance based on empathetic listening and acknowledgment of physical discomfort, without trivializing the somatic complaints. Sometimes an offer to review all available medical records can be a tangible way of conveying one’s seriousness to the patient. Underlying anxiety and depression must be identified and treated with psychotherapy and, when necessary, antidepressant or antianxiety medications, or both. Cognitive-behavioral therapy focuses on identifying distorted thought patterns and anxious triggers, and replacing them with more realistic and adaptive strategies. A mental health professional may assist in determining whether cognitive-behavioral therapy may be of benefit. In many cases, however, the supportive nature of regular visits to a primary care provider may be sufficient to meet the needs of persons with somatoform disorders as well as other personality disorders.
■ Agronin ME. Somatoform disorders. In: Blazer DG, Steffens DC, Busse EW, eds. Textbook of Geriatric Psychiatry. 3rd ed. Washington, DC: American Psychiatric Press; 2004:295–302.
This chapter provides a comprehensive, up-to-date review of somatoform disorders in late life, including specific features and treatment strategies for each diagnosis. The chapter emphasizes the heterogeneity of both clinical presentation and treatment for these varied disorders, which are placed under a common diagnostic heading.
■ Agronin ME, Maletta G. Personality disorders in late life: understanding and overcoming the gap in research. Am J Geriatric Psychiatry. 2000;8(1):4–18.
This review article provides a comprehensive discussion of diagnostic limitations for personality disorders in late life and of the implications for research. This is a helpful guide to the evolution of diagnostic categories over the successive nosologies in the Diagnostic and Statistical Manual of Mental Disorders. The discussion addresses a number of ways in which late-life diagnosis could be improved.
■ Rabinowitz T, Hirdes JP, Desjardins I. Somatoform disorders. In: Agronin ME, Maletta GJ, eds. Principles and Practice of Geriatric Psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2006:489–504.
This unique chapter weaves together a review of somatoform disorders in late life along with illuminating data from the author’s own research to underscore many points. Keeping with the focus of the comprehensive textbook in which this chapter appears, there is a particular focus on clinical diagnosis and management.
■ Zweig RA, Agronin ME. Personality disorders. In: Agronin ME, Maletta GJ, eds. Principles and Practice of Geriatric Psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2006: 449–470.
This chapter presents a comprehensive review of personality disorders in late life, with a specific focus on clinical diagnosis and management. Both psychotherapeutic and psychopharmacologic approaches are described in detail and supplemented with a practical table.
Marc Edward Agronin, MD