Mohammed T. Abou-Saleh

594 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYcategories. The mature disorders include obsessive–compulsive,schizotypal, schizoid and paranoid; these personality disordersshow more stability and less variation with age than others.Schizotypal personality disorder, for example, would be expectedto behave more like schizophrenia from the longitudinalperspective because of its spectrum and genetic relationships tothe Axis I disorder 5–8 . The immature or flamboyant personalitydisorders include the borderline, antisocial, narcissistic, histrionicand passive–aggressive categories; these personality disorders maybe more evident in younger individuals and may have earlier onsetthan mature personality disorders. In this scheme, maturepersonality disorders consist primarily of the Cluster A (odd–eccentric) disorders plus obsessive–compulsive disorder fromCluster C (anxious–fearful); immature personality disordersconsist primarily of Cluster B (dramatic–emotional) disorders,plus passive–aggressive disorder from Cluster C.Other authors, notably McGlashan 5 and Stone 6 , have commented,on the basis of follow-up data, that the florid borderlinesymptomatology seen at index admissions substantially declinesby the second decade of follow-up. Both male and female patientsappear to advance occupationally and globally, as well assymptomatically, with time 5 . Tyrer 18 also reviewed data suggestingthat patients with personality disorders have higher mortalityby suicide than other psychiatric patients for a period of 5 yearsfrom diagnosis, after which differences in suicide rates betweenpersonality disorders and other psychiatric patients becomenegligible. These mortality data have been interpreted by Tyrerto support a maturation hypothesis, especially for antisocial andother immature personality disorders, in which impulsiveness andsuicide become less likely over time. There are also suggestionsthat mature personality disorders are more frequent in thegeriatric population than immature disorders 19,20 .Thus, it is possible to speculate about a ‘‘flattening’’ over timeof at least some specific types of personality disorder symptomatology,which might explain why geriatric patients seem to havediffuse Axis II symptomatology, with relatively fewer fulldiagnoses of personality disorder 19,20 . In the case of borderlinepersonality disorder, the assumption that symptoms are enduringand inflexible has been challenged; this disorder might now beviewed as a state of delayed maturation that improves with time,rather than as a set of chronic defects. However, even inborderline personality disorder, the improvement may not beuniform across different spheres of functioning. McGlashan 5 hassuggested that borderline patients may improve considerably inoccupational or instrumental functioning, yet never developsatisfactory personal relationships.Moreover, aging does not necessarily imply linear reduction inseverity of the immature personality disorders. An epidemiologicalstudy of personality disorders conducted by Reich et al. 21found the dramatic cluster to be described by a reverse J-shapedcurve, in which core traits decline to age 60, then take a slightupturn. Geriatric clinical experience also suggests that there aresome individuals who have relatively mild personality dysfunctionin young and middle adulthood, but in old age develop a markedand persistent worsening of these trends 22 . Thus, late-onset oremergent personality disorders are possible. Alternatively, individualswith lifelong personality dysfunction can have an affectivedenouement; they may be more likely to develop depression in oldage, as some data suggest 19,20 .A recent body of contributions from psychoanalytic theoristsand clinicians has been leading to a developmental theory ofthe second half of life 23 . Freud’s early ideas about the decliningplasticity of the personality 24 , based on experience in clinicalpsychoanalysis, have given way to the notion that psychosocialdevelopment is continuous throughout life. Successful disengagementfrom active working and parental roles, andacceptance of the inevitability of death, are several of theproposed developmental tasks of aging. For example, awarenessof one’s eventual death has been thought to be marked byuniversal apprehension and, in some individuals, by phobias,paranoia and fear of sleep, attributed to a hypothesized ‘‘deathanxiety’’ 25 . Jacques 26 has proposed that characterologicallyhealthier individuals have mastered the anxiety associated withawareness of death at a relatively earlier age than those withpersonality dysfunction, who might be blocked from acknowledgingthe inevitability of death until overwhelmed by it.Recently, there has been a renewed interest in psychotherapeuticwork with the elderly, most proponents of which argue thatchange and growth is possible 25–27 . In the view of Neugarten 28and Costa 29,30 , personality is the critical factor in adaptation toold age.ASSESSING THE AGING PERSONALITYOverview of Methodological IssuesAssessing personality in the elderly is a daunting task. Each ofthe three basic approaches cited above carries not only its ownset of assumptions but its own limitations as well. Thedimensional scales have restricted clinical relevance and yieldabstract, somewhat reductionistic information about the individual.On the other hand, categorical diagnoses have beencriticized as culture-bound and arbitrary 3 , failing to ‘‘cut natureat its joints’’. DSM criteria, in particular, may be age-biased.Axis II criteria frequently appear to be addressing the concerns ofa modal young adult, one who is expected to be establishingcareer and life-partner choices. If personality disorders ‘‘becomeless obvious in middle or old age’’, this may occur because AxisII does not relevantly assess the present-day experiences andbehaviors of aging persons. Age bias could easily result in anunderestimation of pathology, whereby symptoms are dismissedas ‘‘normative’’ for age. Overestimation of pathology is alsopossible, for example with dependency phenomena, where therealistic needs of an older person might be inappropriatelyviewed as symptomatic.Psychoanalytic approaches have contributed to the study ofpersonality and aging by encouraging the formulation ofdevelopmental theories for the second half of life. However,personality investigation of this type is focused on the individualpatient, and its validity is ultimately predicated on a thoroughknowledge of a few individuals; McHugh and Slavney havetermed this ‘‘meaningful construct’’ validity 31 . While such modelsmay explain how a patient’s unique vulnerabilities and lifecircumstances interact to produce symptoms, large-scale empiricalreplication is impossible.State–Trait Problems and Co-morbidityWhichever theoretical–methodological model is used, the findingof age effects in personality study is frequently subject to thesuspicion that they are not in fact true age effects, but ratherreflect dysthymic, post-depressive or organic contaminants. Thisis the state–trait confound, a term that usually refers to theexaggerated self-report of some personality traits owing to thedepressed state 32,33 . For example, recovered elderly depressiveshave been found to have more lifetime personality dysfunctionthan other elderly subjects 19 , and in another study, twice asmany recovered elderly depressives met full criteria for DSM-III-Rpersonality diagnoses than did normal controls 20 . While recoveryfrom depression in these studies was carefully documented, andno personality testing was carried out during symptomaticperiods, it is impossible to completely rule out depressive