Can personality disorder be accurately assessed in older age? A differential item functioning analysis of ICD-11 inventories.

OBJECTIVES: The contested categorical personality disorder (PD) criteria are not well suited to inform PD diagnoses in older adults. Yet, the classification of PDs is undergoing a critical transition phase with a paradigm shift to a dimensional approach for diagnosing PDs. No special attention was given to the expression of PDs in older age when the dimensional ICD-11 model was developed. Given that PDs are highly prevalent in older adults, there is an urgent need to examine if ICD-11 related instruments are able to adequately assess for PDs in older adults. METHODS: The age-neutrality of ICD-11 measures was examined in a sample of 208 Dutch community-dwelling adults (N = 208, M age = 54.96, SD = 21.65), matched on sex into 104 younger (age range 18-64) and 104 older (age range 65-93) adults. An instrument is considered not to be age-neutral if a collective large level of differential item functioning (DIF) exists in a group of items of an instrument (i.e., 25% or more with DIF). We therefore set out to detect possible DIF in the following ICD-11 self-report measures: the Standardized Assessment of Severity of Personality Disorder (SASPD), the Personality Inventory for ICD-11 (PiCD), and the Borderline Pattern Scale (BPS). RESULTS: DIF analyses using a non-parametric odds ratio approach demonstrated that SASPD, PiCD, and BPS were age-neutral with less than 25% of items showing DIF. Yet, impact of DIF at scale level, examined by way of differential test functioning (DTF), indicated a DTF effect on the SASPD total score. CONCLUSIONS: These results of age-neutrality of the PiCD and BPS are promising for measuring ICD-11 traits and the borderline pattern. Yet, the age-neutral measurement of PD severity requires further research. With a rapidly aging population, its accurate assessment across the entire adult life span, including older age, is a prerequisite for an adequate detection of PDs.

Association of parental mental illness with anxiety and depression in adulthood: The role of potentially contributing factors.

OBJECTIVE: Children of parents with a mental illness (COPMI) are at risk of developing mental disorders in adulthood, especially anxiety disorders and depression. The role of the family environment and demographic factors as related to adult anxiety and depression is insufficiently understood. We examined potentially contributing factors in the associations between a COPMI background with anxiety and depressive symptoms in adulthood. METHOD: Cross-sectional general population-based study. Instruments were the General Anxiety Disorder scale (GAD-7), Patient Health Questionnaire (PHQ-9) and a questionnaire to evaluate self-reported history of a COPMI background and family-related experiences (CEPMIF). Multiple regression analyses were used to examine the role of demographic and family-related factors in the association of a self-reported COPMI background with the level of anxiety and depressive symptoms. RESULTS: Of the 942 participants (mean age 48.1 (SD = 16.2) years; 53.7 % women), 116 (12.3 %) had a COPMI background. A COPMI background was associated with higher levels of anxiety and depressive symptoms. Within individuals with a COPMI background, relationship problems within the family were associated with elevated levels of anxiety and depression. LIMITATIONS: The cross-sectional design does not allow for causal inferences, COPMI background was based on participant's self-report, and the type of parental mental disorder was not considered. CONCLUSIONS: Adults with a COPMI background have higher levels of anxiety and depressive symptoms. Dysfunctional family relationships during childhood were associated with the severity of mental health problems of adults who grew up with a mentally ill parent. There is a need for targeted interventions for adult COPMI.

First things first: An exploration of the effects of psychoeducation for older autistic adults.

LAY ABSTRACT: After receiving an autism diagnosis, psychoeducation (i.e. information regarding autism) is a first intervention. We adjusted a psychoeducation program that was originally developed by the Dutch Association for Autism for older adults to enhance its feasibility and efficacy in later life. We expected that participants would report an increase in knowledge and acceptance of the diagnosis and that people close to them would also observe this. Indeed, we found this and participants and those close to them agreed on this. Furthermore, we found some evidence that older autistic adults were better at coping with their autism. We found no positive intervention effects on psychological distress. The feedback of participants and informants about the psychoeducation program was largely positive. In future research, we advise using larger group samples and larger time scales and we also advise to further adjust the program to the needs and requirements of older adults, and to help older autistic adults to construct a new narrative of themselves, and the life they have lived, in the light of the recent autism diagnosis.

The effectiveness of individual schema therapy in older adults with borderline personality disorder: A multiple-baseline case series design.

OBJECTIVE: The aim of this study was to explore the effectiveness of schema therapy (ST) in older adults with borderline personality disorder (BPD). METHODS: Multiple baseline case series design with five BPD patients, with a mean age of 66. After a baseline phase with random length, patients received weekly ST sessions for a year, followed by follow-up sessions during 6 months. Participants rated the credibility of negative core beliefs weekly; various secondary outcome measures were assessed every 6 months (severity of BPD, early maladaptive schemas, schema modes, personality functioning, maladaptive personality traits, psychological distress and quality of life), and BPD diagnosis was assessed before baseline and after follow-up. Data were analysed with mixed regression analyses and paired t-tests. RESULTS: Results revealed that ST led to a significant decrease in credibility of negative core beliefs, with high effect sizes. All participants remitted from their BPD diagnosis. CONCLUSION: This is the first study exploring the effectiveness of ST for BPD in older adults, and it suggests that ST can be a powerful intervention for this group of patients.

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.

Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment program for patients with borderline personality disorder (BPD). The program was intended to be highly accessible, both for patients and therapists. During STEPPS, patients are taught emotion regulation and behavior management skills. This systematic review synthesizes the current empirical status of STEPPS, focusing on research designs, quality of studies, target groups, protocols, and outcome. We selected 20 studies, with three randomized controlled trials. Patients with BPD, subthreshold BPD, and patients with BPD and comorbid antisocial personality disorder were investigated. One study was conducted in adolescents. There were no studies in older adults. Results demonstrated STEPPS to be associated with reduced BPD symptoms, improved quality of life, decreased depressive symptoms, and decreased negative affectivity. Mixed results were found for impulsivity and suicidal behaviors. STEPPS has both been studied as an add-on therapy to patients' ongoing treatment, and, with the addition of individual STEPPS sessions, as a stand-alone treatment. High attrition rates were found in patients attending STEPPS, complicating the generalizability of the results. Although the evidence for STEPPS is promising, further research is needed before firm conclusions can be drawn. Recommendations for future research are discussed.

Systems training for emotional predictability and problem solving in older adults with personality disorders: a pilot study.

BACKGROUND: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a cognitive behavioural therapy-based group treatment programme for patients with borderline personality disorder (BPD). STEPPS has demonstrated its effectiveness for (younger) adults. However, there are no studies into the effects of STEPPS for older adults. AIM: The aim was to explore the outcome of STEPPS in older adults with personality disorders. METHOD: In this naturalistic pre- vs post-treatment study, older patients with a personality disorder, reporting emotion regulation difficulties, were included. The primary outcome was BPD symptoms. Secondary outcomes included psychological distress and maladaptive personality functioning. RESULTS: Twenty-four patients, with a mean age of 63.9 years (SD=4.6), completed the 19-week programme. Nine patients (23.1%) did not complete the treatment. There were no significant differences in age, gender or global severity between completers and patients dropping out. There was a significant pre- vs post-treatment decrease of BPD symptoms, with a large effect size (Cohen's d=1.577). Self-control improved significantly and demonstrated a large effect size (r=.576). Furthermore, identity integration improved significantly, with a medium effect size (Cohen's d=.509). No significant differences were reported for most domains of psychological distress and maladaptive interpersonal personality functioning. CONCLUSIONS: The findings in this pilot study suggest STEPPS is a feasible treatment programme for older adults with personality disorders and emotion regulation difficulties. Adaptations to the program, for a better fit for older adults, however, might be needed.

Personality traits related to cognitive functioning in patients with functional neurological disorder.

Cognitive symptoms are prevalent in patients with functional neurological disorder (FND). Several studies have suggested that personality traits such as neuroticism may play a pivotal role in the development of FND. FND has also been associated with alexithymia: patients with FND report difficulties in identifying, analyzing, and verbalizing emotions. Whether or not alexithymia and other personality traits are associated with cognitive symptomatology in patients with FND is unknown. In the current study, we explored whether the Big Five personality model factors (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and alexithymia were associated with cognitive functioning in FND. Twenty-three patients with FND were assessed using a neuropsychological assessment and questionnaire assessment to explore personality traits (Neuroticism-Extraversion-Openness Five-Factor Inventory) and alexithymia (Bermond-Vorst Alexithymia Questionnaire). The results indicated that high conscientiousness was associated with lower planning scores (ρ = -0.52, p = .012) and high scores on alexithymia were associated with lower scores on verbal memory scores (ρ = -0.46, p = .032) and lower sustained attention scores (ρ = -0.45, p = .046). The results did not remain significant after controlling for multiple testing. The preliminary results of our study suggest that personality and cognitive symptomatology in patients with FND are topics that should be further explored in future studies, as cognitive symptomology can affect treatment results.

Psychological and physical wellbeing in adults who grew up with a mentally ill parent: A systematic mixed-studies review.

OBJECTIVE: Genetic vulnerability factors and adverse childhood experiences (ACE) are associated with an increased risk of psychopathology and other adverse health outcomes across the lifespan. However, less is known about how childhood experiences of parental mental illness affect psychological and physical wellbeing in adulthood. This review synthesizes research on the consequences of growing up as a child of a parent with mental illness (COPMI) for adult psychological and physical wellbeing. METHODS: A systematic review was conducted following PRISMA guidelines using a mixed-method-studies approach to enable evaluation of the broad array of research designs (Prospero registration #CRD42020221983). RESULTS: Qualitative studies (k = 10; N = 361) revealed that a COPMI background is associated with substantial psychological challenges in adulthood. Quantitative studies (k = 21; N = 865.402) suggested that COPMI are at increased risk of adult psychopathology, including anxiety and depressive disorders, suicidality, somatoform disorders, substance abuse, but also general medical morbidity and mortality. CONCLUSIONS: Growing up with a mentally ill parent is associated with adverse psychological and physical outcomes in adulthood, but the evidence-base is limited. Longitudinal studies are needed that go beyond establishing genetic and environmental risk factors to further evaluate how a COPMI background influences wellbeing in adulthood and which targeted clinical interventions could be developed.

Personality factors and cognitive functioning in patients with somatic symptom and related disorders.

OBJECTIVE: Somatic symptom and related disorders (SSRD) are often complicated by cognitive symptoms, including reduced information processing speed, memory, and planning. Depression has been related to poor cognitive functioning in SSRD, but the role of underlying personality factors is poorly understood. This study investigates the association between personality factors (neuroticism, extraversion, openness, agreeableness, and conscientiousness) with cognitive functioning in patients with SSRD. METHODS: Data from 366 patients with SSRD from a tertiary care expert center (mean age = 42.1 years (SD = 13.4), 59.6% women) were analyzed using a cross-sectional design. Neuropsychological assessments included measures of information processing speed, memory, attention, and executive function. Personality factors were assessed using the NEO-FFI and depressive symptoms using the PHQ-9. RESULTS: Regression analyses showed associations between neuroticism with poorer performance on visual memory (B = -0.09, SE = 0.04, ß = -0.14, p = .019), and planning (B = -0.09. SE = 0.02, ß = -0.23, p < .001). Extraversion was also inversely associated with visual memory (B = -0.13, SE = 0.05, ß = -0.18, p = .011) and planning (B = -0.07, SE = 0.03, ß = -0.17, p = .021) and openness was associated with better visual memory (B = 0.17, SE = 0.05, ß = 0.19, p = .002). These associations were attenuated but remained significant after adjusting for depressive symptoms. CONCLUSION: Neuroticism, extraversion, and low openness were associated with lower cognitive functioning (particularly planning and visual memory) in patients with SSRD, which remained significant after taking depressive symptoms into account.

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.

Feasibility of the Cognitive Model for Behavioral Interventions in Older Adults with Behavioral and Psychological Symptoms of Dementia.

Objectives: The purpose of this study was to develop an individually tailored, non-pharmacological treatment model, the Cognitive Model for Behavioral Interventions (CoMBI), for patients with Behavioral and Psychological Symptoms of Dementia (BPSD) and comorbid maladaptive personality traits (CMPT), and to explore its feasibility and effectiveness.Methods: CoMBI was developed and implemented in two geriatric psychiatric inpatient wards in the Netherlands. In this single-group pretest-posttest, feasibility study, 40 patients with BPSD and CMPT (M = 73.8, SD = 8.5) were treated with CoMBI. BPSD and CMPT were assessed using informant-based questionnaires. Wilcoxon signed-rank tests and effect size calculations were conducted to determine differences.Results: Wilcoxon signed-rank tests demonstrated a significant decrease of BPSD with medium (r = 0.45) to large (r = 0.56) effect sizes. CoMBI demonstrated high acceptability and compliance by health-care professionals and family members.Conclusions: CoMBI is a feasible treatment model for challenging behavior in patients with BPSD and CMPT. CoMBI is associated with a significant decrease in challenging behaviors regardless of etiology.Clinical implications: Focusing on personality and associated core needs could have a key role in the non-pharmacological treatment of the elderly with BPSD.

Severity Indices of Personality Problems-Short Form in Old-Age Psychiatry: Reliability and Validity.

The Severity Indices of Personality Problems (SIPP; Verheul et al., 2008) is a popular self-report questionnaire that measures severity of maladaptive personality functioning. Two studies demonstrated the utility of the short form (SIPP-SF) among older adults but validation in clinical settings is lacking. Therefore, we examined the psychometric properties of the SIPP-SF in a large sample of older adult Dutch outpatients (N = 124; age range = 60-85 years, M = 69.8, SD = 5.3). The SIPP-SF domains showed good to excellent internal reliability (Cronbach's α = .75-.91) and effectively discriminated between participants with and without a personality disorder, as assessed with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Convergent validity of the SIPP-SF was examined with instruments for measuring personality pathology among older adults (Informant Personality questionnaire [HAP]; Gerontological Personality Disorders Scale [GPS]). The GPS generally correlated with the SIPP-SF domains in expected directions, with small to large effect sizes. For the HAP, only 1 scale correlated with all SIPP-SF domains. No associations were found between the SIPP-SF and psychiatric symptomatology as measured by the Brief Symptom Inventory (BSI). The SIPP-SF appears to be a promising instrument for assessing maladaptive personality functioning among older adult outpatients.

[Differential diagnosis personality disorder versus autism spectrum disorder in older adults]. / Differentiële diag­nostiek van persoonlijk­heids­stoornissen en autisme­spectrum­stoornis bij ouderen.

Scientific knowledge of autism spectrum disorders (ASD) in older adults is still scarce. Differential diagnosis of ASD and personality disorders is complicated, especially in later life. There is overlap between ASD and personality disorders, both conceptually and descriptively. The manifestation of both disorders is heterogeneous, influenced by age specific factors and characterised by similar behavioural symptoms and the lack of a sound developmental history. In both disorders, age specific changes can exceed adaptive abilities of patients, so ASD and personality disorders may become manifest for the first time in old age. More research is needed to fully understand the relationship between ASD and personality development across the life span. Also, there is a need for assessment instruments for both adults and older people with comorbid mental disorders and personality disorders in particular. As comorbidity of ASD and personality disorders appears to be common, more research should be done into treatment of comorbid personality disorders, also in later life.

[Psychological treatment of personality disorders in older adults: a review]. / Psychologische behandeling van persoonlijk­heids­stoor­nis­sen bij ouderen: stand van zaken en suggesties voor onderzoek.

Despite a still reigning therapeutic nihilism, attention for the psychological treatment of personality disorders in older adults has been growing recently. The first empirical studies have been conducted, but their number is still limited, and varies from expert consensus to the first tests of effectiveness of schema therapy and dialectical behavior therapy. Therefore, there is an urgent need for further empirical studies into psychological treatments that have been optimized for older adults on all three treatment levels.

[The Cognitive Model for Behavioural Interventions for older adults with neurocognitive disorders and co-morbid maladaptive personality traits]. / Mediatieve behandeling bij mensen met zowel neuro­cognitieve stoornissen als persoonlijkheids­problematiek.

The starting point of this study is that comorbid maladaptive personality traits (CMPT) influence behavioral and psychological symptoms of dementia (BPSD). The purpose of this study was to develop and investigate the feasibility of the Cognitive Model for Behavioral Interventions (CoMBI). Forty patients with BPSD and CMPT from two geriatric psychiatric departments were treated with CoMBI. Feasibility was assessed through patient flow, compliance to, and acceptability of the treatment for family members and psychiatric nurses. CMPT was assessed using informant-based questionnaires. Change in BPSD was assessed using pre- and posttests. To determine differences in BPSD, Wilcoxon signed rank tests were conducted and effect sizes were computed. Of 312 patients admitted to the geriatric psychiatric wards, 138 patients were found eligible. 64 (46.4%) patients were discharged from the wards before or shortly after the pretest, in 28 (20.3%) cases CoMBI could not be not applied. Eventually, forty (29.0%) patients were included for analysis. Wilcoxon signed rank tests demonstrated a significant decrease of BPSD with medium (r=0.45) to large (r=0.56) effect sizes. CoMBI is highly feasible for treating challenging behavior in patients with BPSD and CMPT. CoMBI is associated with a significant decrease of challenging behaviors regardless of etiology.

Development of a tool to detect older adults with severe personality disorders for highly specialized care.

OBJECTIVES: Current guidelines recommend highly specialized care for patients with severe personality disorders (PDs). However, there is little knowledge about how to detect older patients with severe PDs. The aim of the current study was to develop an age-specific tool to detect older adults with severe PDs for highly specialized mental health care. DESIGN: In a Delphi study, a tool to detect adults with severe PDs for highly specialized mental health care was adjusted for older adults based on expert opinion. Subsequently, the psychometric properties of the age-specific tool were evaluated. SETTING: The psychometric part of the study was performed in two Dutch highly specialized centers for PDs in older adults. PARTICIPANTS: Patients (N = 90) from two highly specialized centers on PDs in older adults were enrolled. MEASUREMENTS: The age-specific tool was evaluated using clinical judgment as the gold standard. RESULTS: The Delphi study resulted in an age-specific tool, consisting of seven items to detect older adults with severe PDs for highly specialized mental health care. Psychometric properties of this tool were evaluated. Receiver operating curve analysis showed that the questionnaire was characterized by sufficient diagnostic accuracy. Internal consistency of the tool was sufficient and inter-rater reliability was moderate. CONCLUSIONS: An age-specific tool to detect older adults with severe PDs was developed based on expert opinion. Psychometric properties were evaluated showing sufficient diagnostic accuracy. The tool may preliminarily be used in mental health care to detect older adults with severe PDs to refer them to highly specialized care in an early phase.

Positive schemas in schema therapy with older adults: clinical implications and research suggestions.

BACKGROUND: Schema therapy is an effective treatment for borderline personality disorder and other complex disorders. Schema therapy is feasible in older adults, and the first empirical support for its effectiveness in later life was provided in older patients with a cluster C personality disorder. The central concept of the schema therapy model is the early maladaptive schema (EMS). Early adaptive schemas (EAS) give rise to adaptive behaviour, and they also emerge during childhood, when core emotional needs are adequately met by primary caregivers. AIMS: To examine the concept of EAS and its application in schema therapy with older adults. METHOD: Literature review and case example: the role of EAS in schema therapy with older adults is discussed and suggestions for integrating EAS in schema therapy in later life are proposed. RESULTS: Directing attention in therapy to EAS may help strengthen the healthy adult mode, and it might also help change a negative life review. Working with positive schemas may be an important avenue for re-awakening positive aspects of patients, reinforcing the therapeutic relationship, creating a positive working atmosphere, and also for facilitating the introduction of experiential schema therapy techniques. CONCLUSIONS: This review suggests that positive schemas may be important vehicles of therapeutic change when working with older people. There is a need for validating the Young Positive Schema Questionnaire (YPSQ) in older adults, and for examining whether integrating EAS in schema therapy with older adults indeed has a positive effect on therapy outcome.