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

Summary

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 article by Bangash (2020, this issue) shines a torch into a dark cavern; we know very little about personality disorder in later life and need to be better informed. Currently, the subject of personality disorders and what happens to these conditions as people get older is often discussed in old age psychiatry, but almost always in the absence of empirical evidence. The reason is not too far to find. Personality disorder has always had to struggle to get noticed in psychiatry. For most of the past 50 years our classification systems have described the condition as ‘deeply ingrained maladaptive patterns of behaviour generally recognisable by the time of adolescence and continuing throughout most of adult life, although often becoming less obvious in middle or old age’ (World Health Organization 1979). This definition was stated without any real evidence beyond expert opinion, but naturally led to the view that if no personality disorder was apparent by later life it could be safely ignored and that personality disorder apparent in earlier adult life would likely have mellowed or burnt out as the patient entered old age.

What we can state with a degree of confidence is that most of the antisocial aspects of personality disorder are reduced in older people compared with younger ones, and that the traits of detachment and obsessionality are increased (Seivewright 2002; Morse 2004; Gutierrez 2012; Newton-Howes 2015). There is also evidence that borderline personality features are less prominent in older people (Gunderson 2011).

Age at onset

In the new ICD-11 classification of personality disorders there is no age limit in making the diagnosis (Tyrer 2019). The only criterion is that the manifestations of the condition should have been present continuously for at least 2 years. Preliminary evidence suggests that this is likely to raise the prevalence level of personality disorder a little, from about 10% of the population to 12% (Tyrer 2014), but will encourage use of the diagnosis in later life.

Variation in expression of personality disorder over time

One of the common misconceptions about personality disorder is that, once established, it is persistent and continues at least until old age. This is completely false. Personality disorder is one of the least stable diagnoses in psychiatry (Baca-Garcia 2007), because its expression depends so much on circumstances and the presence or absence of comorbid stresses and other disorders. The concepts of bolstering, buffering and binding described in Bangash's article illustrate this well. Personality disorder can appear to come and go depending on the social and environmental setting, and so positive planned environmental manipulation may be successful management in the form of nidotherapy (Mordekar 2008).

Personality change may be independent of personality disorder

Bangash points to a difficult clinical problem in deciding whether an apparent personality disorder is a consequence of change in mental state rather than the exposure of a previously hidden personality disorder. It has been recognised for many years that personality change can occur after major life events, but the diagnosis of enduring personality change after catastrophic experience (F62.0) in ICD-10 (World Health Organization 1992) was hardly ever used in practice. From the only study carried out in this population, the change in personality structure is such that it is appropriate to regard such people as having a personality disorder and they should be managed accordingly (Munjiza 2019).

But there is no doubt that organic brain changes can alter personality, one of the most obvious being frontotemporal dementia, and if personality change occurs without any apparent reason in later life an organic cause must be ruled out carefully before deciding that personality disorder is being manifest.

Conclusions and recommendations

Personality disorder is a proper subject of study in old age and needs to be more widely embraced in clinical practice. There is a dearth of empirical studies and widely held beliefs are no substitute for these. With a new classification in the offing, coupled with its relative simplicity, the diagnosis of personality disorder should be more widely used and empirical research carried out to assess helpful interventions.