Although there is a considerable body of evidence supporting the efficacy of psychotherapy for personality disorders (PD), as yet, effect studies focusing on treatment of PD in older adults are lacking. In a literature search (1980–2011) with Pubmed Medline and PsycINFO with the terms “personality disorders,” “psychotherapy,” “treatment,” “elderly,” and “older adults,” it appeared that no randomized and controlled effect studies have been conducted on the treatment of PD in later life. Just one study examined the efficacy of dialectical behavior therapy (DBT) in a small randomized clinical trial among older people with comorbid depression and PD (N = 35; Lynch et al., Reference Lynch, Cheavens, Cukrowicz, Thorp, Bronner and Beyer2007). However, it is surprising that the number of PD in remission (in total 16 out of 35) was almost the same with medication treatment alone (n = 7) compared to combined treatment of medication and DBT (n = 9). Moreover, this study was not exclusively focused on the treatment of PD.
A recent Delphi-study has led to the consensus among Dutch and Belgian experts that existing therapies for PD in younger adults are applicable with older cohorts, such as schema therapy (van Alphen et al., Reference van Alphen2012). However, it is recommended that age-specific aspects are integrated.
Age-specific therapeutic aspects
The efficacy of schema therapy for older adults can probably be improved by integrating several gerontologic aspects into the treatment protocol. First, the changing life perspective can cause an actualization of dysfunctional schemata as one is reviewing one's life; the process of life review can lead to evaluating certain aspects of one's own life (extremely) negatively.
A second gerontologic aspect is formed by the beliefs about – and consequences of – somatic ailments. For example, the core belief of an older dependent woman that she “would not make it on her own” can be actualized by macular degeneration; the prospect of waning eyesight causes her to see the future as threatening. A disturbing consequence of a somatic ailment is when a narcissistic older man becomes immobile because of peripheral vascular disease, which causes him to give up his appraisal-generating role as president of a senior organization.
Third, cohort beliefs and the sociocultural context can be integrated into schema therapy of PD. Cohort beliefs are beliefs held by groups of people born in similar time periods, which tend to have a significant impact on the therapeutic alliance, especially as they combine with dysfunctional core beliefs. The sociocultural context refers to peoples' attitudes to their own aging and can include internalized negative stereotypes about growing old.
A fourth important gerontologic aspect to be considered in therapy is change in role investment. This concerns the extent to which an older adult remains involved in personally meaningful activities and interests. Especially, elderly with PD are less able to adapt to new roles.
Finally, intergenerational linkages, in interaction with dysfunctional cohort beliefs, can cause tensions in intergenerational relationships. Older adults consider continuity and the transmission of values to younger generations as important, whereas younger adults view independency and autonomy as more important. This can cause disagreement between older parents and their children on, for instance, notions of caregiving.
Possibly, integrating worth-enhancing beliefs (James, Reference James, Laidlaw and Knight2008), which have been suggested to provide useful gerontologic targets in the treatment of depression and anxiety, may also have a positive effect on the treatment of PD in the elderly with schema therapy.
Call for evidence
As evidence on treatment of PD in later life is lacking, we recommend conducting explorative research with a series of case studies in which schema therapy is applied to older adults with a PD. This can shed light on relevant age-specific aspects that can be used to adapt schema therapy to a treatment protocol that is molded for older cohorts. A study could focus on cluster C PD to account for the increasing inter-individual variability and multiple morbidity as people age, as this cluster is the most stable across the life span. Furthermore, it is possible to conduct a meta-analysis with a number of studies, which have been conducted in a similar way, using a multiple baseline case series design (Ferron and Scott, Reference Ferron, Scott, Everitt and Howell2005). Because the inter-individual variance in this design is smaller, the same power can be reached with this type of research. Such a design yields findings especially pertinent on how therapeutic change unfolds individually (Borckardt et al., Reference Borckardt, Nash, Murphy, Moore, Shaw and O'Neill2008). In addition, a semi-structured interview is applied to participants to explore possible modifications for older adults. This adapted treatment protocol can then be studied for its efficacy with older adults in a randomized controlled trial.
We are aiming to start a study on schema therapy for older adults with PD using the case series design in 2011 in Breburg Hospital, Tilburg, and Mondriaan Hospital, Heerlen, both in the Netherlands. This study investigates the efficacy of schema therapy in older adults and also explores qualitatively which relevant age-specific aspects can be used to adapt schema therapy to a treatment protocol that is molded for older cohorts. This is a unique study in that it aims to answer the need for evidence of treatment of PD in older adults.
