Treatment of Personality disorders in Older Adults

205 Pages·2017·1.51 MB·English

Tilburg University
Treatment of personality disorders in older adults
Videler, Arjan
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Publication date:
2016
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Videler, A. (2016). Treatment of personality disorders in older adults: Beyond therapeutic nihilism Enschede:
Ipskamp
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Download date: 17. okt. 2018
Treatment of
Personality disorders
in Older Adults

Beyond Therapeutic Nihilism

Arjan Videler
The studies presented in this doctoral thesis were conducted in the
context of a joint-doctorate at the Vrije Universiteit Brussel (VUB),
Belgium, and Tilburg University, the Netherlands.

Cover Arjan Videler
Printed by Ipskamp Printing B.V., Enschede, the Netherlands
ISBN 978-94-028-0424-9

© Arjan C. Videler, 2016
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronically, mechanically, by photo-copying, recording or otherwise,
without the prior written permission of the author.

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Vrije Universiteit Brussel (VUB)
Faculty of Psychology and Educational Sciences
Department of Clinical and Lifespan Psychology

Treatment of Personality Disorders in
Older Adults
Beyond Therapeutic Nihilism

Arjan Videler

A dissertation submitted in fulfillment of the requirements for the degree
of Doctor in Psychological Sciences
Joint PhD Vrije Universiteit Brussel – Tilburg University

Brussel, 2 december 2016

Promotors Vrije Universiteit Brussel: Prof. dr. S.P.J. van Alphen
Prof. dr. G. Rossi

Promotor Tilburg University: Prof. dr. C.M. van der
Feltz-Cornelis

Jury Prof. dr. E. Dierckx, Vrije Universiteit Brussel (Chair)
Prof. dr. S. Bogaerts, University of Tilburg
Prof. dr. R.C. Oude Voshaar, Rijksuniversiteit Groningen
Prof. dr. M.J.M. Kardol, Vrije Universiteit Brussel

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Table of contents

Chapter 1 Introduction 7

Chapter 2 Treatment of personality disorders in later life: 27
Conceptual analysis, expert opinion and research
suggestions

Chapter 3 Psychotherapeutic treatment levels of personality 53
disorders in older adults

Chapter 4 Schema group therapy in elderly outpatients: A 79
proof of concept study

Chapter 5 Schema therapy for personality disorders in older 105
adults: A multiple-baseline case series study

Chapter 6 Adapting schema therapy for personality disorders 137
in older adults

Chapter 7 General discussion 167

Acknowledgements 191

Curriculum Vitae & Publications 195

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Chapter 1

Introduction

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Introduction
This dissertation focuses on the treatment of personality disorders (PDs) in older
adults. Throughout this dissertation, older adults are defined by their age, that is
over the age of 65 years old. Of course, in life span theory aging is a much more
complex and heterogeneous concept, defined by many interacting factors,
biological, social, cultural and psychological of nature (Kessler, Kruse, & Wahl,
2014). The general term “older adults” was chosen however for reasons of
readability, although acknowledging the wide diversity and heterogeneity of this
age group.
Our current concept of PD is based on the Diagnostic and Statistical
Manual of Mental Disorders (DSM); its fifth edition (American Psychiatric
Association, 2013) defines a PD as “an enduring pattern of inner experience and
behavior that deviates markedly from the expectations of the individual’s culture”
(p. 646). This implicates a chronic course of maladaptive personality traits
associated with the PD, that may persist into later life after an onset in
adolescence or early adulthood. The diagnosis of a PD requires that the enduring
pattern is pervasive across a range of situations, and leads to distress or
impairment in important areas of functioning. This pattern may not be better
accounted for as a manifestation of another mental disorder, and may not be due
to the direct physiological effects of substance use or medical illness. Besides
these general criteria, DSM-5 lists ten specific PD diagnoses. For individuals who
meet the general criteria but not the required threshold for any specific PD, an
additional category “other specified PD” is available. Because of diagnostic
heterogeneity within the specific PDs and the high degree of comorbidity
between them, a dimensional approach is included in the DSM-5 as an alternative
model (Section III, “Emerging measures and models”). This DSM-5 Section III
PD model contains a conceptualization of personality psychopathology in the
domains of self and interpersonal functioning that distinguishes personality
pathology from health and from other mental disorders, as well as an empirically
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based model of pathological personality traits. Although there are some issues
still to be resolved, like the overlap between functioning and traits, the key
aspects of the model appear to work well (Krueger, Hopwood, Wright, &
Markon, 2014).
However, the suitability of the DSM’s definition and criteria of PDs,
especially that of Section II which is nearly identical to the DSM-IV PD
definition, has a number of limitations when applied to older adults. Often, it is
impossible to trace back the personality functioning of an individual over the
course of many decades (Van Alphen et al., 2015). Furthermore, a number of
DSM criteria (like those related to work and relationships) are not appropriate
for many older adults (Oltmanns & Balsis, 2011). In a large study among people
from 19 to 98 years old in the general population, fewer diagnostic criteria of
DSM-IV PDs were identified in older adults compared to younger persons
(Balsis, Gleason, Woods, & Oltmanns, 2007). Moreover, in older adults
measurement errors were found in nearly a third of the diagnostic criteria of
DSM-IV PDs. Besides this, the temporal stability of both PDs and personality
traits is less than originally thought (Debast et al., 2014). The course of cluster C
PDs (avoidant, dependent and obsessive-compulsive PDs) appears to be more
stable throughout the life span than that of cluster B PDs (Cooper, Balsis, &
Oltmanns, 2014; Gutiérrez et al., 2012). Particularly, the prevalence of cluster B
PDs (borderline, antisocial, narcissistic and histrionic PDs) declines with age
(Debast et al., 2014). Probably, people do not longer meet the threshold for DSM
PDs because of a decrease in expressive, impulsive, and aggressive behavior, and
a shift towards depressive, somatic, and passive-aggressive behaviors with aging
(Van Alphen, Engelen, Kuin, Hoijtink, & Derksen, 2006; Van Alphen, Nijhuis,
& Oei, 2007). Secondly, unhealthy lifestyles, violence, suicides, and accidents
result in a shorter life expectancy among adults with cluster B PDs (Black,
Baumgard, & Bell, 1995).
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