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 Am J Geriatr Psychiatry 9:1, Winter 2001 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 Am J Geriatr Psychiatry 9:1, Winter 2001 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. References 1. Ames A, Molinari V: Prevalence of personality disorders in community-living elderly. J Geriatr Psychiatry Neurol 1994; 7:189– 194 2. Abrams RC, Horowitz SV: Personality disorders after age 50: a meta-analysis. J Personal Disord 1996; 10:271–281 3. Thompson LW, Gallagher D, Czirr R: Personality disorder and outcome in the treatment of late-life depression. J Geriatr Psychiatry 1988; 21:133–146 4. Loebel JP: Completed suicide in the elderly, in Abstracts of the Third Annual Meeting, San Diego, CA, American Association for Geriatric Psychiatry, 1990 5. Abrams RC, Horowitz SV, Alexopoulos GS: Personality disorders and social support in old depressives. Washington, DC, American Psychiatric Association. New Research Abstracts of the Annual Meeting of the American Psychiatric Association, Miami, FL; 1995b 6. Abrams RC, Spielman L, Alexopoulos G, et al: Personality disorder symptoms and functioning in elderly depressed patients. Am J Geriatr Psychiatry 1998; 6:24–30 7. Spitzer RL, Endicott J, Robins E: Research Diagnostic Criteria: rationale and reliability. Arch Gen Psychiatry 1978; 35:773–782 8. Spitzer RL, Williams JBW, Gibbon M, et al: Structured Clinical Interview for DSM-III-R–Patient Edition. Washington, DC, American Psychiatric Press, Inc., 1990 9. Folstein MF, Folstein SE, McHugh PR: Mini-Mental State: a prac- Am J Geriatr Psychiatry 9:1, Winter 2001 tical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198 10. Alexopoulos GS, Abrams RC, Young RC, et al: Cornell Scale for Depression in Dementia. Biol Psychiatry 1988a; 23:271–284 11. Loranger AW: Personality Disorder Examination (PDE) Manual. Yonkers, New York, DV Communications, 1988 12. Miller MD, Towers A: A Manual of Guidelines for Scoring the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Pittsburgh, PA, University of Pittsburgh School of Medicine, Department of Geriatric Psychiatry, 1991 13. Bech P: Rating Scales for Psychopathology, Health Status, and Quality of Life. New York, Springer-Verlag, 1993 14. Kunik ME, Mulsant BH, Rifai AH, et al: Diagnostic rate of comorbid personality disorder in elderly psychiatric inpatients. Am J Psychiatry 1994; 151:603–605 15. Abrams RC, Alexopoulos G, Spielman L: Personality disorder and anxiety symptoms in treated elderly depressives: where are the boundaries? Abstracts, 11th Annual Meeting and Symposium of the American Association for Geriatric Psychiatry, San Diego, CA, 1998 16. Loranger AW, Lenzenweger MF, Gartner AF, et al: Trait–state artifacts and the diagnosis of personality disorders. Arch Gen Psychiatry 1991; 48:720–728 17. Lesse S: The multivariant masks of depression. Am J Psychiatry 1968; 124(suppl1):35–40 18. Post F: The management and nature of depressive illness in late life: a follow-through study. Br J Psychiatry 1972; 121:393–404 71