Personality Disorder Symptoms Predict
Declines in Global Functioning and Quality
of Life in Elderly Depressed Patients
Robert C. Abrams, M.D., George S. Alexopoulos, M.D.
Lisa A. Spielman, Ph.D., Ellen Klausner, Ph.D.
Tatsuyuki Kakuma, Ph.D.

The authors evaluated personality disorder symptoms as predictors of change in
global functioning and quality of life among elderly depressed patients. Treated elderly
patients (N‫ )04ס‬who no longer met RDC criteria for major depression were assessed
for personality disorders, depression, global functioning, and quality of life after treatment of the acute episode and at 1-year follow-up. In interaction with persisting or
recurrent depression, Cluster B personality disorder symptoms contributed to declines
in global functioning and quality of life over a 1-year period. Personality disorder
symptoms in elderly patients appear to operate as co-factors that amplify or exacerbate the impact of residual depression on long-term functioning and quality of life.
(Am J Geriatr Psychiatry 2001; 9:67–71)

A

lthough personality disorders appear to be less
prevalent in the general elderly population than in
younger age-groups,1 these conditions have been reported at rates approaching 24% among elderly patients
with major depression.2 Comorbid personality disorders in this population have been associated with clinically important outcomes of depression, including
poor response to psychotherapy3 and completed suicide.4 Recent research suggests that elderly depressed
patients with personality disorders may have reduced
social support,5 and there are some preliminary data
supporting the possibility that the interaction of personality disorder with residual depressive symptoms
contributes to excess disability in the immediate after-

math of the depressive episode.6 However, the possible
contribution of personality disorder comorbidity to
functional and adaptational outcomes of geriatric depression remains essentially unknown.
Moreover, the existing data on the implications of
personality disorder for functioning have mostly been
taken from a single assessment, and it remains to be
clariﬁed whether personality disorder symptoms also
inﬂuence functioning and adaptation over time in elderly depressed patients. To that end, this study evaluated associations among personality disorder symptoms, depression, global functioning, and quality of life
at the completion of acute antidepressant treatment and
again 1 year later. We tested the hypothesis that in el-

Received September 17, 1999; revised March 9, 2000; accepted April 12, 2000. From The New York Hospital-Cornell Medical Center, New York,
NY. Address correspondence to Dr. Abrams, The New York Hospital-Cornell Medical Center Payne Whitney Clinic, Box 140, 525 E. 68th St., New
York, NY 10021. e-mail: rabrams@med.cornell.edu
Copyright ᭧ 2001 American Association for Geriatric Psychiatry

Am J Geriatr Psychiatry 9:1, Winter 2001

67

Personality Disorder and Depression
derly patients with a recent major depressive episode,
symptoms of Cluster B personality disorders interact
with residual or recurrent depressive symptoms to contribute to declines in global functioning and quality of
life over a 1-year period. The rationale for this hypothesis was that symptoms of Cluster B, sometimes referred
to as the “unstable” or “immature” personality disorders, including the borderline, narcissistic, histrionic,
and antisocial personality disorders, tend to focus on
impulsive or erratic behavior, and on this basis might
contribute a destabilizing inﬂuence on functioning and
quality of life even after remission from depression.

METHODS
Forty inpatients and outpatients were recruited from
the geriatric psychiatry services of a university hospital.
Written informed consent was obtained from each subject after the procedures had been explained. For inclusion, potential subjects were required to be between
the ages of 60 and 85; they were also required to have
had an initial diagnosis of major depressive episode, but,
after antidepressant treatment, to no longer meet RDC7
or DSM-III-R criteria, the latter assessed using the Structured Clinical Interview for DSM-III-R (SCID–P).8 Subjects were recruited consecutively from the hospital’s
geriatric inpatient and outpatient services, that is, in the
order in which they met inclusion criteria. Exclusion
criteria were 1) history of Axis I disorder other than
unipolar depression, also obtained using the SCID–P; 2)
acute medical or neurological illness; 3) score of less
than 24 out of 30 on the Mini-Mental State Exam
(MMSE);9 and 4) score greater than 15 on the Cornell
Scale for Depression in Dementia (CSDD).10 Also, subjects were assessed with the Personality Disorder Examination (PDE),11 the Cumulative Illness Rating Scale–
G (CIRS–G),12 the Quality of Life subscales of the Cornell Medical Health Questionnaire (GHQ-QL-12),13 and
the Global Assessment of Functioning Scale (GAF).8
The PDE interview systematically surveys phenomenology and life experiences relevant to the diagnosis
of personality disorders. Each criterion for the Axis II
disorders is assessed by one or more items. After each
item, the examiner can question the subject further until satisﬁed by the completeness of the answer and the
accuracy of the time frame given, the time frame being
of particular interest in a geriatric study. Following the

68

DSM requirement, to count toward a personality disorder diagnosis, the symptom must be present currently
as well as throughout most of adult life. This process
results in a dimensional score or general index of symptomatology for each disorder, whether or not full criteria for an Axis II diagnosis are met.11 PDE interviews
were in all cases conducted by the principal investigator
(RCA) or research associate (LAS).
All of the above instruments were administered in
two steps: ﬁrst, upon entry to the study (i.e., after completion of acute treatment for the index depressive episode), and, secondly, on follow-up 1 year later. Remission from the acute depressive episode was required
before entry. For purposes of the study, remission was
deﬁned as no longer meeting RDC or DSM-III-R (SCID–
P) criteria and having a CSDD score of 15 or below;
thus, the complete absence of depressive symptomatology was not required, provided that subjects no
longer met criteria for persistent major depressive episode. Change scores between entry and follow-up were
calculated for GAF and the Beta subsection of the GHQQL-12 Quality of Life subscale, the latter measuring aspects of quality of life unrelated to health, such as satisfaction with one’s situation and activities.13

RESULTS
The subjects were psychiatric outpatients and inpatients (all outpatients at the time of the second assessment). There were 29 women and 11 men; mean age
was at intake was 73‫ 50.9ע‬years. Mean MMSE mean
scores were 28.51‫ 80.2ע‬at intake and 28.74‫ 11.2ע‬at
follow-up. Mean CSDD scores were 4.98‫( 12.4ע‬range:
0–15) at intake and 3.83‫( 96.3ע‬range: 0–11) at followup. No subjects met either RDC or DSM-III-R criteria for
Major Depression at follow-up.
PDE dimensional scores were used in lieu of personality disorder diagnoses to facilitate data analysis,
consistent with the generally infrequent appearance of
full diagnoses of borderline and other Cluster B personality disorders in elderly subjects.1,2,14
Because there were no signiﬁcant differences in
PDE dimensional scores between the entry and followup administrations of the exam either for the total PDE
score or for the scores for personality disorder clusters,
we used the PDE dimensional scores collected at entry
for calculations. In contrast, CSDD depression scores

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Abrams et al.
taken from the follow-up assessment were used to ensure that effects on outcomes of any new depression
symptoms that had developed by the end of the 1-year
interval would not be overlooked (Figure 1).
We found that Cluster B personality disorder symptoms contributed to changes in global functioning and
quality of life over the period of the study. Lower scores
in the GAF and Quality of Life Beta subscale (GHQ-QL12-Beta), representing declines in global functioning
and perceived quality of life, respectively, were predicted by models that included the total dimensional
score for Cluster B personality disorders and CSDD depression scores; (for decline in GAF, R2‫ 23.0ס‬and overall F[3,31]‫ ;79.4ס‬P‫ ;3600.0ס‬for decline in GHQ-QL-12Beta, R2‫ 53.0ס‬and overall F[1,36]‫ ;35.6ס‬P‫.)2100.0ס‬
However, the interaction between Cluster B and deFIGURE 1.

pression scores was signiﬁcant in predicting declines in
both global functioning and quality of life (PϽ0.02 and
PϽ0.001, respectively). Therefore, it is unclear whether
Cluster B symptoms or depression contributed independently to changes in global functioning and quality of
life. Nevertheless, using least-square means, we observed a pattern in which GAF and GHQ-QL-12-Beta
scores declined most when both CSDD and Cluster B
scores were relatively high; in contrast, the greatest
positive change was associated with low depression and
high Cluster B scores (Figure 1). [Note: Mean GAF
change with CSDD Ͼ3 and Cluster B Ͼ2 was
‫ ,9.8ע29.4מ‬whereas mean GAF change with CSDD Ͻ3
and Cluster B Ͼ2 was 8.5‫( 0.41ע‬t[32]‫ ;81.2ס‬PϽ0.04).
Mean GHQ-QL-12-Beta change was –0.8‫ 6.3ע‬with high
CSDD and high Cluster B, whereas mean GHQ-QL-12-

Change in global functioning (GAF) and quality of life (GHQ-QL-12-Beta) against depression score (CSDD) on 1-year
follow-up in 40 remitted elderly depressed patients with higher (Ͼ2) Cluster B dimensional score.
12

25

10

20

8
15
6
Change Beta Score

Change GAF Score

10

5

0

4

2

0
–5

–2

–10

–4

–15

–6
CSDD<3

CSDD>3

CSDD<3

CSDD>3

Note: GAF‫ס‬Global Assessment of Functioning; GHQ‫ס‬Cornell Medical Health Questionnaire; CSDD‫ס‬Cornell Scale for Depression in
Dementia.

Am J Geriatr Psychiatry 9:1, Winter 2001

69

Personality Disorder and Depression
Beta change was 3.5‫ 2.7ע‬with low CSDD and high
Cluster B (t[37]‫ ;3.2ס‬PϽ0.03.)] Finally, when “robust
analyses,” using empirical bootstrap regression coefﬁcients and mixed-effects models were applied, the interaction between Cluster B and depression showed signiﬁcance at the PϽ0.1 level for declines in both global
functioning and quality of life.
Of a number of other variables with the potential
to contribute to these models, including age, gender,
medical burden (CIRS–G scores) and dementia, only the
MMSE score was signiﬁcant, and then only for GAF;
thus, the ﬁnal model for decline in global functioning
included cognitive status as well as Cluster B and depressive symptoms and explained 52% of the variance,
with overall F[1,28]‫.46.7ס‬

DISCUSSION
The principal ﬁnding of this study is that Cluster B personality disorder symptoms appear to exacerbate the
long-term adverse effects of depression on functioning
and quality of life in elderly patients. One year after remission from the index depressive episode, Cluster B
personality disorder symptoms interacted with residual
depression such that the negative impact of the affective symptoms on functioning was ampliﬁed. In the absence of high levels of Cluster B symptomatology, mild
residual depression was not associated with impaired
functioning or reduction in quality of life.
Overall, these data suggest that Cluster B personality disorder symptoms may operate as co-factors, conferring a destabilizing effect on functioning and quality
of life, worsening them when signiﬁcant depression is
present and possibly fostering comparative improvement when residual depression is minimal. Although
Cluster B personality disorders have been thought to be
especially likely to “age out,” having relatively low prevalences in elderly persons,1,2,14 they may still exert inﬂuences at a subsyndromal level. For example, in a sample of elderly depressed patients, Cluster B dimensional
scores were found to be have stronger correlations with
state-anxiety measures than Cluster A or C scores, suggesting a mechanism whereby Cluster B symptoms may
inﬂuence individuals to be more reactive.15 Also, Cluster B symptoms have been associated with low levels
of social support in elderly depressed patients,5 suggesting that these individuals might be alienating or oth-

70

erwise rejecting those who seek to help them; this situation could indirectly inﬂuence overall functioning
and quality of life. In another scenario, narcissistic individuals may be less tolerant of the loss of power and
relevance associated with retirement or of the loss of
personal attractiveness accompanying aging, and this increased vulnerability might encourage decline in quality
of life in the context of a major depressive episode.
Several cautions apply. First, depression might be
misconstrued as personality disorder. However, at both
entry and follow-up, subjects in this study were assessed
for personality disorder symptoms when depression
was in remission. Individuals interviewed with the PDE
are instructed to exclude periods of illness when describing their long-term behavior, and there is evidence
that they are able to do so; in mixed-age adults, PDE
scores appear to be stable between raters, across time,
and throughout changes in affective state or clinical
acuteness.16 Our experience using the PDE in several
samples of geriatric depressed patients has produced
high overall test–retest reliability over 1-year intervals
(0.84). We have previously reported that at entry, 40%
of the subjects most fully remitted from depression had
total PDE dimensional scores (a measure reﬂecting overall personality psychopathology) that were at or above
the sample median.6 Moreover, the distortion of subjects’ self-evaluation of personality functioning owing
to depressed state has generally been shown to occur
when self-report questionnaires are used, in contrast to
the PDE interview, which was conducted in this study,
as is recommended, by doctoral-level, clinically experienced personnel. Only examiner bias could not be addressed by use of this methodology. However, examiner–observer agreement studies for the DSM-III-R
version of the PDE yielded a median kappa of 0.78.16
An informant version of the instrument, when validated, might help to further address the issue of potential interviewer bias.
The second caution is that depression itself inﬂuences global functioning in elderly subjects,6 a ﬁnding
consistent with these results; indeed, personality disorder symptoms were associated with the greatest decline in functioning when comparatively high levels of
depression were also present. However, the unique
ﬁndings in this study are the interactive effects of Cluster B personality disorder symptoms and low-grade depression. These preliminary data open up the possibility
of a synergistic model to characterize the relationship
between two entities—personality psychopathology

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Abrams et al.
and subsyndromal depression—whose boundaries in
geriatric patients have traditionally been regarded as
ﬂuid.17,18
Most importantly, these ﬁndings identify a population at risk for disability and declining quality of life.
This group is composed of elderly depressed patients
with Cluster B personality dysfunction and history of a
major depressive episode. When even mild depressive
symptoms persist or recur, comorbid Cluster B personality disorder symptoms appear to increase their prognostic value for decline in functioning and quality of life.

For these patients, complete affective remissions are especially desirable, in a sense to mitigate the personality
and environmental factors that favor declines in functioning and quality of life. Also needed are clinical and
social interventions, beyond the basic somatic treatments, that target impediments to functioning in depressed elderly patients.
We received support from a fund established in
The New York Community Trust by DeWitt Wallace
and from NIMH grants K07-MH01025-05; P20MH49762, and R01-MH51842.

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