Introduction
Little is known about psychotherapy in older adults with personality disorders. There is a lack of effect studies focusing on the treatment of personality pathology in the elderly.
In a recent Delphi study, Dutch and Begian experts agreed that various interventions in personality disorders in older adults can be placed on a continuum. At one end of the continuum are treatment modules aimed at supportive intervention rather than intrapsychic changes in the patient, such as psychoeducation and specific advice. At the other end are forms of psychotherapy requiring substantial patient cooperation that are aimed at changing pathological aspects of the patient's personality (e.g. schema therapy, dialectical behavior therapy, mentalization-based therapy). In between the ends are adaptation-focused forms of therapy and supportive structuring interventions (van Alphen et al., Reference van Alphen2010).
Adaptation-focused therapy is focused on older adults who are motivated for treatment but are limited in their ability to change, for example, because of poor introspection and empathy. This therapy focuses on influencing critical aspects of the patient's adaptation to his or her environment, particularly to age-specific problems, such as loss of health, loss of significant others, or loss of independance. Treatments in this category include interpersonal psychotherapy, social skills training, or a brief form of psychotherapy dealing with the interpersonal functioning of the patient or cognitive behavioral treatment (CBT). Usually the course of treatment is brief, fewer than 30 sessions.
This case report illustrates a form of adaptation-focused psychotherapy in an older adult who has given written informed consent to the publication of his case in this journal.
Case report
Following the sudden death of his wife, the patient (aged 70 years) no longer enjoys anything. He has problems sleeping through the night and has expressed a passive death wish. It seems that previously all household and administration matters had been dealt with by his wife and the patient now feels at a loss about how to approach these new tasks. He is known to suffer from type II diabetes mellitus and hypertension. He has shown no indications of intoxication, cognitive disorders or psychiatric history. He has a limited social network and only marginal contact with his two sons and his brother. The situation is complicated by the fact that the patient asserts that his gentle golden retriever, Tiësto, cannot be left alone at home. He has noticed that when they are out on a walk his four-legged companion determines the route they take. Tiësto decides whether they turn left or right even if the patient would rather go in another direction. He is registered with the Dutch mental health care service because his GP was concerned about the patient's limited ability to cope in the grieving process. The patient acquiesced to his registration without complaint.
The patient said that he had had a secure childhood and progressed normally through primary school, followed by technical high school. Striking, however, was his inhibition around fellow classmates due to feelings of inferiority. He has worked in a number of jobs, such as roof-layer, bench fitter and freight truck driver. He drove a freight truck for 25 years and enjoyed it as the solitary nature of his range of duties suited him perfectly. He avoided gatherings wherever possible, was wary of his colleagues and avoided conflict for fear of being criticized or rejected. He describes his marriage as having been “good” and can be characterized as a complementary relationship. The relationship with his two sons is less than ideal as the patient has adopted a noticeably reserved attitude towards them.
The patient's wife died suddenly due to a major brainstem infarction. Besides experiencing emotional loss, the patient has also lost his “daily structure and direction”. He does not wish to bother his sons with his grief, stating that “they have enough on their minds”. He tends to decline appointments with others, saying that he cannot leave his dog alone at home as an excuse. The patient describes himself as sensitive, quiet, closed off and evasive and states that he needs contact with others but is afraid of being rejected.
Additional psychological testing resulted in no abnormal scores on the Mini-mental State Examination (MMSE; Folstein et al., Reference Folstein, Folstein and McHugh1975). Intelligence assessment with Raven's Progressive Matrices (Reference Raven1936) demonstrated an average performance level. However, scores on the Gerontological Personality Disorders Scale (GPS; van Alphen et al., Reference van Alphen, Engelen, Kuin, Hoijtink and Derksen2006) indicate the likelihood of personality pathology. Three self-reporting personality questionnaires were taken, namely the shortened (verkorte) Dutch translation of the Temperament and Character Inventory (VTCI; Duijssens and Spinhoven, Reference Duijssens and Spinhoven2001), NEO Five-Factor Inventory (NEO-FFI; Hoekstra et al., Reference Hoekstra, De Fruyt and Ormel2003) and the Coping Inventory for Stressful Situations (CISS; de Ridder and van Heck, Reference de Ridder and van Heck1997). On the VTCI, the traits of harm avoidance in combination with limited self-directedness were observed, while a high level of neuroticism coupled with a very low level of extroversion were noted on the NEO-FFI. The CISS indicated an “avoidance coping” style (seeking distraction by surfing the internet or watching television). The Hetero-Anamnestic Personality (HAP) questionnaire, completed by one son, indicated an avoidant-dependent profile with high scores on “socially aloof behavior”, “uncertain behavior” and “vulnerable in contact with others”, while low scores were shown for “self-centered behavior” and “fitful and impulsive behavior”.
Diagnostic considerations
The sustained pattern of inhibition in the company of others, feelings of inferiority and preoccupation with thoughts of being criticized or rejected in social situations establishes the existence of an avoidant personality disorder on the basis of the axis-II criteria of DSM-IV-TR (American Psychiatric Association, 2000). There are also indications of dependent tendencies. The generally intra-psychological conflicts are complicated by the patient's grief response to the sudden death of his wife. This loss has caused further imbalance in his psychological functioning and has resulted in the current (initial) referral to mental health care.
Schizoid traits were ruled out as the patient has experienced considerable need for and enjoyment from close relationships. He is not indifferent to praise or criticism from others and his mood is not emotionally impassive or diminished. Social-phobic issues are usually considered when making a differential diagnosis. It may well be the case, however, that social phobia and avoidant personality disorder are two different concepts of what is in fact the same psychological condition. The existence of an autism spectrum disorder may also be considered for this patient when making a differential diagnosis due to the limitations of his social interaction. Nevertheless, the patient has demonstrated social and emotional reciprocity. There are few indications of repetitive and stereotypical patterns in behavior, interests or activities. Eye contact and facial expressions have not proven to be unusual.
Referral to mental health care took place within two months of the death of this wife. The patient's depressive traits of anhedonia, sleeping difficulties and passive death wish are considered aspects of the resulting grief response; no other symptoms of depression were observed.
Treatment
The choice of treatment type depends on a patient's help requirements as well as the nature and severity of the personality disorder. Functional limitations due to somatic comorbidity play a significant role in the treatment assessment, particularly in the elderly (>65 years). A patient's ability to self-reflect, empathize and control impulses plays a crucial role in reaching a treatment assessment that is geared towards the patient. In addition, the treatment of avoidant personality pathology assumes a certain degree of motivation and cooperation on the part of the patient. Indeed, in the case of personality pathology, the manner in which the patient begins the treatment relationship is partly determined by his or her personality and the complicated interactional or intra-psychological problems that arise from that (van Alphen et al., submitted).
In this case, the patient's requirements in terms of help are twofold, namely, he needs support in the grieving process as well as pointers to gaining more control over his dog. The underlying avoidant personality pathology, characterized by such traits as sub-assertiveness and limited autonomy, was not an explicitly stated treatment objective for this patient; this is most likely to result from the patient's egosyntonic perception of his own symptoms. Patients' preferences are often the deciding factor in whether treatment is successful. A therapist would do well to identify and take account of these preferences when making a treatment assessment and assigning care.
The patient's help requirements are being met by counseling during the grieving process. Part of the focus lies on training in social skills and communication provided by a psychotherapist. This allows the patient to practice adopting a new, assertive attitude towards his dog to bring about changes in interaction patterns. It should be noted that interpersonal psychotherapy is deemed appropriate for depression that has developed due to experiencing loss.
At the patient's request, he is also receiving help in gaining authority over his dog from a nurse in geriatric psychiatry who is also a canine behavior therapist. The patient's core problems of sub-assertiveness and limited autonomy are being further addressed by the canine behavior therapist through training and exercises in operant conditioning techniques that will enable the patient to take on the role of “shepherd” to his golden retriever. In short, the patient is being approached through his dog in order to work on critical aspects of his personality. Following ten sessions of interpersonal-CBT (support in the grieving process, learning social skills and challenging negative thoughts) and five sessions on how to handle his dog, the patient has remarked that he can influence and control his surroundings, in particular Tiësto. The dog is responding to retraining and meanwhile the patient is becoming more self- assured, confident and autonomous and less avoidant (e.g. he has initiated several activities with his sons). The patient's dysfunctional cognitions of submission have been rejected in several areas of his life.
This case illustrates a form of treatment encouraging adaptation that is geared towards a personality pathology in patients who, though motivated to receive treatment, are limited in their ability to change due to their reduced capacity for introspection and empathy. The course of treatment chosen for the patient was geared towards critical aspects that had a direct influence on adapting to his environment (lack of assertiveness and limited autonomy), which were worsened by an issue typical of his phase of life (death of spouse).
Conclusion
First, this case illustrates that treatment of personality problems in the elderly is possible in mental health care. Secondly, it demonstrates that multiple stand-alone treatment modules can form part of a single course of adaptation-focused treatment of personality disorders. Thirdly, it shows that an interpersonal approach, in this case for the patient and his dog, forms an important starting point in tackling the typical interpersonal difficulties that occur in axis-II disorders. The patient's dysfunctional cognitions of submission were influenced through “treating” his dog and the patient learned to respond to his environment in a functionally assertive way. Further empirical evidence is required to support these qualitative findings.
Conflict of interest
None.
