Psychological treatment of personality disorders (PDs) in older adults: adapting protocols and clinical staging

On one hand research demonstrated PDs benefit from treatment and that different psychotherapy approaches have comparable effectiveness (Kramer, 2018) on the other hand age groups addressed in these studies were largely limited to patients up to forty years old (Videler, 2016). Some authors even advocated that changing maladaptive personality aspects is not feasible in older age (Segal et al., 2006). Slowly the field is moving beyond this therapeutic nihilism. Recently, two studies (Lynch et al., 2016; Videler et al., 2014) also demonstrated that a cognitive behavioral approach holds promise in the treatment of PDs and comorbid mood disorders in older adults and one study (Videler et al., 2018) showed that schema therapy is effective in older adults with cluster C PDs applying a multiple baseline design in 8 patients. Feasible and effective treatments for PDs in older adults now need to be further developed. A first step is adapting treatment protocols for older adults by integrating age-specific process factors for enhancing the outcome of psychotherapy for PDs in later life. Possible enhancing process factors have been suggested, like integration of wisdom enhancement, positive schemas and negative attitudes to aging (Videler et al., 2017), but there is a need for empirical research. Clinical trials for adapted treatment protocols need to be set up at different treatment levels to assess their feasibility and efficacy. Treatment levels were identified as relevant for PDs in later life by experts for selecting adequate treatment goals: personality-changing treatment, adaptation enhancing treatment, and supportive structuring treatment (Videler et al., 2017, 2018). Personality-changing treatment focuses on changing pathological aspects of personality. Adaptation enhancing treatment aims at helping the motivated patient yet limited in his ability to change (by for example poor introspection), to adapt to a changing environment and age-specific problems. A supportive structuring treatment is aimed at stabilizing the patient’s current mental and social situation and can also include psycho-education of the of care providers and context of care. Furthermùore we will address the clinical research gap on treatment options and prognosis, by examining the added value of a clinical staging model for PDs in older adults. A clinical staging model distinguishes stages that reflect a specific level in the disease progression according to either their risk profile or phenotypical expression ((Hutsebaut, Videler, Verheul & van Alphen, 2019).

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Segal, D.L., Coolidge, F.L., & Rosowsky, E. (2006). Personality disorders and older adults: Diagnosis, assessment, and treatment. New York: Guilford Press.

Videler, A. (2016). Treatment of Personality Disorder in Older Adults: Beyond Therapeutic Nihilism (Doctoral Dissertation). Enschede, The Netherlands: Ipskamp printing.

Videler, A.C., Rossi, G., Schoevaars, M., Van der Feltz-Cornelis, C.M., & Van Alphen, S.P.J. (2014). Effects of schema group therapy in older outpatients: a proof of concept study. International Psychogeriatrics, 26, 1709-1717.

Videler, A.C., Van Alphen, S.P.J., Rossi, G., Van der Feltz-Cornelis, C.M., Van Royen, R.J.J., & A. Arntz. (2018). Schema therapy in older adults: a multiple baseline case series. Aging and Mental Health, 22, 738-747.

Videler, A. C., Van Royen, R. J.J., Heijnen-Kohl, S. M., Rossi, G., Van Alphen, S. P., & Van der Feltz-Cornelis, C. M. (2017). Adapting schema therapy for personality disorders in older adults. International Journal of Cognitive Therapy, 10(1), 62-78.

Note: This project may be co-supervised by Prof. Dr. S.P.J. (Bas) van Alphen (VUB, Tilburg University & ‘Mondriaan’, Clinical Center of Excellence for Personality Disorders in Older Adults)

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