Why should you pay attention to personality pathology in geriatric psychiatry? To what extent is mental well-being determined by this? How does that relate to the influence of mental disorders? Does the Alternative Dimensional Model of Personality pathology (AMPD) as proposed by the DSM-5 provide more insight into this than the DSM-IV and DSM-5 categorical diagnoses of personality disorders?

These questions were examined in baseline data of 145 patients included in our randomized controlled trial (RCT) into group Schema therapy enriched with psychomotor therapy in older patients with a personality disorder (see Oude Voshaar in this symposium). Mental well-being was measured by a combination of psychological distress (53-item Brief Symptom Inventory), positive mental health (Warwick-Edinburgh Mental Well-being Scale), assessment of own health (RAND-36), and satisfaction with life (Cantrill’s ladder). Personality pathology was assessed according to the categorical personality model using the Structured Clincal Interview for Personality Disorder (SCID-II) as well as the AMDP DSM-5 model using the Severity Indices of Personality Problems (SIPP-short form) and the Personality Iventory for DSM-5 (PID-25). The relationship between personality pathology and mental well-being was investigated using multivariate regression analysis.

Three quarters of the included people with a personality disorder also had another psychiatric disorder (beyond personality pathology). However, personality pathology was found to be responsible for the bulk of the mental health burden and outweighed the influence of these psychiatric disorders. Personality dimensions were highly predictive of mental well-being. This contrasted with the absence of any influence from categorical personality disorders. Although dimensions of personality functioning – and in particular Identity Integration – were the primary predictors of mental well-being, pathological traits added significant predictive value (particularly Disinhibition and Negative Affectivity).

Personality pathology seriously affects the mental well-being of patients and exceeds the impact of comorbid psychiatric disorders. Contrary to the assumption in the alternative DSM-5 and ICD-10 model, both personality functioning and pathological traits contribute to this impact on mental well-being. Screening and systematic assessment of personality pathology in geriatric psychiatry seems warranted.

Different types of psychotherapy have been shown to be successful in treating personality disorders in younger age groups. Nevertheless, well-powered, randomized controlled trials evaluating effectiveness of these therapies in older are lacking. That is why we set up the first randomized controlled trial worldwide into the effect and cost-effectiveness of psychotherapy in older patients with a personality disorder.

We randomized 145 patients (mean age 68 years, range 60 – 80, 65% females) with a cluster B and/or C personality disorder to either group schema therapy enriched with psychomotor therapy (GST+PMT) or to usual care (UC) in specialized geriatric mental health care. The effects were measured after 6 months (end of therapy) and 12 and 18 months (one-year follow-up). Primary outcome measure was psychological distress, as measured with the 53-item Brief Symptom Inventory (BSI-53). Secondary outcome measures were mental well-being, assessed with the Warwick-Edinburgh Mental Well-being Scale, and personality functioning assessed with the Severity Indices of Personality Problems – Short Form (SIPP-SF). Intention to treat analyses using linear mixed models were applied to compare GST+PMT with UC.

Group schema therapy significantly outperformed usual care with an medium effect-size of 0.4 post-treatment, which faded out to a small effect-size of 0.2 at the end of follow-up on the primary outcome parameter. Interestingly, the lower effect-size during follow-up could be explained by a slower treatment response in the usual care condition as post-treatment results of schema therapy were fully maintained during follow-up. Similar results were found with respect to improvement of mental well-being and improvement of personality functioning, although effect-sizes of the latter were a little bit smaller. Age, sex, level of education, and/or cognitive functioning had no impact of these outcomes.

Schema therapy enriched with psychomotor therapy is more effective for the treatment of personality disorder in later life than usual care (which often consists of drug treatment combined with supportive nurse-led care and/or individual psychotherapy).

Personality dysfunction has been postulated as the most clinically salient problem of persons suffering from medically unexplained symptoms (MUS) but empirical studies are scarce. This study aims to compare the personality profile of older patients suffering from MUS with two comparison groups and a control group.

Ninety-six older patients with MUS were compared with 153 frequent attenders in primary care suffering from medically explained symptoms (MES), 255 patients with a past-month depressive disorder (DSM-IV-TR), and a control group of 125 older persons. The Big Five personality domains (NEO-Five-Factor Inventory) were compared between groups by multiple ANCOVAs adjusted for age, sex, education, partner status and cognitive functioning. Linear regression analyses were applied to examine the association between health anxiety (Whitley Index) and somatization (Brief Symptom Inventory).

The four groups differed with respect to neuroticism (P < 0.001), extraversion (P < 0.001), and agreeableness (P = 0.045). Post hoc analyses, showed that MUS patients compared to controls scored higher on neuroticism and agreeableness, and compared to depressed patients lower on neuroticism and higher on extraversion as well agreeableness. Interestingly, MUS and MES patients had a similar personality profile. Health anxiety and somatization were associated with a higher level of neuroticism and a lower level of extraversion and conscientiousness, irrespective whether the physical symptom was explained or not.

Older patients with MUS have a specific personality profile, comparable to MES patients. Health anxiety and somatization may be better indicators of psychopathology than whether a physical symptom is medically explained or not.