Review Article

Journal of Geriatric Psychiatry

and Neurology
Antisocial Personality Disorder in Older 1-12
ª The Author(s) 2017
Reprints and permission:
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DOI: 10.1177/0891988717732155
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Katherine J. Holzer, MSW1, and Michael G. Vaughn, PhD1

Abstract
Antisocial personality disorder (ASPD) has enormous negative impacts on the affected individuals, their loved ones, and society.
This burden is intensified by the social and functional changes related to age. The lower prevalence of ASPD in older adults
compared to younger adults is well-documented. This discrepancy, often attributed solely to antisocial “burnout,” contributes to
the lack of attention given to this disorder in older adults and may signify difficulty measuring ASPD in this population. These
measurement issues likely stem from problems with the validity of the diagnostic criteria for older adults which may not effectively
capture changes that occur with age. This review focuses on the current literature surrounding the validity of ASPD criteria with
older adults and relevant concepts, including the connection between criminality and ASPD. Issues with screening tools and the
measurement of ASPD caused by problems with the criteria are also discussed. Finally, recommendations for improvement,
including use of dimensional models of personality disorders, a potential geriatric subclassification of criteria, and modification of
the existing criteria are presented with clinical implications and suggestions for future research.

Keywords
antisocial personality disorder, older adults, personality disorder criteria, criminality, five-factor model

Introduction
Results from a nationally representative survey found that
14.5% of older adults met criteria for at least 1 personality
disorder (PD), higher than rates of past-year anxiety and mood
disorders.1 Despite less attention given to PDs over depression
and dementia in older adults, PDs are associated with signifi-
cant burden, including increased morbidity and mortality rates,
anxiety, depression, social welfare burden, and poor quality of
life with unstable long-term relationships.2-4
In a review of the impact of PDs in later life, Oltmanns and
Balsis5 found that the presence of a PD significantly influenced
individuals’ health, social relationships, marital adjustment,
and experience of life events, including an association with
greater self-reported stressful life events. Additionally, older
adults with PDs present unique challenges to health-care pro-
fessionals and are often treatment resistant.6 The affected indi-
viduals can create conflict among their caregivers and family
members, while also causing disturbances and discord in a
variety of settings, including senior living communities, nur-
sing facilities, and inpatient and outpatient treatment settings.6
It is important to study PDs in older adults to better understand
their effect on the comorbidities that occur more frequently
with age, develop more effective interventions, and advance
a nosology accounting for the functional changes that occur
with age.6,7
Although the prevalence of PDs in older adults is found to
be lower than that for younger adults, the range is quite large,
with studies reporting PDs between 2.8% and 14.5% of older
adults in general1,8 and between 6% and 63% of older adult
patients receiving mental health services.9,10 The range of
prevalence in recent studies of PDs in older adults is presented
in Table 1.
The low prevalence of PDs in older adults may be the result
of problems associated with the diagnostic criteria, assessment,
and diagnosis of the disorders in this population. Although
much of the literature on PDs in older adults has focused on
PDs in general19-21 and borderline PD,22-24 less is known about
antisocial personality disorder (ASPD) in older adults despite
its significant burden on the individual and society. A review of
studies examining the impact of ASPD finds that it is associ-
ated with higher comorbidity of medical and psychiatric ill-
nesses, increase in mortality, and greater utilization of
medical care. 25 Antisocial persons often rely on public
resources and those in correctional facilities require a higher
level of care.26 The difficulties are even more pronounced for
older adults with ASPD who often have the highest rates of
1
School of Social Work, College for Public Health and Social Justice, Saint Louis
University, St Louis, MO, USA
Corresponding Author:
Katherine J. Holzer, School of Social Work, College for Public Health and Social
Justice, Saint Louis University, 3550 Lindell Boulevard, St Louis, MO 63103,
USA.
Email: holzerkj@slu.edu
2 Journal of Geriatric Psychiatry and Neurology XX(X)
Table 1. Prevalence of Personality Disorders in Older Adults.
Overall Prevalence of
Study Prevalence (%) ASPD (%)
Goldstein et al11 NA
Reynolds et al1 14.50
Schuster et al12 8.00
Goldstein et al13 NA
Balsis et al14 14.60
Narrow et al15 NA
Widiger and Seidlitz16 10.00
Kenan et al17 55.40
Molinari and Marmion10 63.00
Molinari et al18 15.50
Mezzich et al9 6.00
Abbreviations: ASPD, antisocial personality disorder; NA, not applicable.
medical comorbidities, increasing the associated burden on
their family and caregivers.27
This review focuses on the history of ASPD criteria with
attention to the validity of their use with older adults. Literature
surrounding current issues with regard to PDs that are specif-
ically relevant to older adults is also examined. Implications
and recommendations for future research are discussed.
The literature search was conducted using the online
search engines EBSCOhost, PubMed, and Google Scholar
with key words antisocial, PD, criteria, and older adults or
geriatric or elderly. Relevant works cited in articles identi-
fied during the initial search were subsequently located
using EBSCOhost. The searches were limited to English-
language texts published after 1950 to include early texts
on the development of ASPD criteria. Results from the lit-
erature search are grouped according to issues surrounding
ASPD in older adults. Many of the studies included in this
review differ in the ages they consider old age, with some
separating individuals aged 50 and older and more recent
studies defining old age as 65 or older. The primary concern
here is with changes in the manifestation of ASPD and their
effect on the applicability of criteria throughout middle and
older adulthood.
Epidemiology of ASPD
Moran28 conducted a review of the literature concerning ASPD
to present the epidemiology of this disorder. Previously labeled
psychopathic personality, the American Psychiatric Associa-
tion (APA) introduced the term ASPD in 1980. Agronin and
Maletta6 illustrate the nosological evolution of Diagnostic and
Statistical Manual of Mental Disorders (DSM) PDs beginning
with the DSM-I published in 1952 with antisocial reaction in
the category labeled sociopathic personality disturbance along
with dissocial reaction, sexual deviation, and addiction. In the
1968 DSM-II, antisocial reaction was changed to antisocial
personality; 1 of 10 PDs. It was not until the DSM-III in
1980 that the PDs were divided into the 3 clusters maintained
in the current DSM, with ASPD in Cluster B along with the
other disorders characterized as dramatic, borderline, histrio-
nic, and narcissistic PDs.
The criteria for ASPD were, in part, derived from a long-
itudinal study of children conducted by Robins,29 including the
1.80 requirement that some of the symptoms must be traced back to
1.60 childhood.30 As such, maladaptive behaviors in childhood are
0.60 risk factors for ASPD, including conduct disorder, childhood
0.40
hyperactivity, delinquency, temperamental deviance, and trau-
0.80
0.00 matic childhood experiences. Robins detailed her comprehen-
NA sive study revealing the epidemiology of ASPD in her 1966
0.00 book, Deviant Children Grown Up. She and her colleagues
1.00 followed 524 individuals referred to a child guidance clinic for
2.00 30 years. Analyses of data obtained from interviews and exten-
0.20 sive records were thought to reveal the natural history of the
disorder. The majority of the patients diagnosed with ASPD
were male with a history of a number of antisocial symptoms
including theft, incorrigibility, running away, truancy, bad
companions, sexual activity and excessive interest, staying out
late, and problems with school discipline. They were primarily
antisocial toward their parents, teachers, and other authority
figures and involved in at least 1 juvenile court case, with
51% sent to correctional institutions. With regard to family
patterns, the majority of the patients with ASPD came from
broken or impoverished homes and had fathers who were either
sociopathic or alcoholic.
Robins29 continued to document the behavior and ASPD
symptoms displayed and reported by her patients into adult-
hood. As adults, the individuals diagnosed with ASPD had poor
work histories, were financially dependent, had problems with
debt, and experienced marital difficulty. They had a history of
multiple arrests, incarceration, and alcohol problems. These
patients were impulsive, sexually promiscuous, vagrant, belli-
gerent, and socially isolated. If they served in the military,
individuals with ASPD were more likely to experience prob-
lems with the armed services. The results suggest that the
degree of juvenile antisocial behavior, as measured by classi-
fication of the behavior, number of episodes, and seriousness of
the behavior (whether it resulted in interaction with the juvenile
court system), was the best predictor of sociopathic personality.
Additional predictors included lack of discipline, being male,
history of theft, antisocial acts against businesses as well as
truancy, and poor school performance. As the study began
when the patients were children and followed them for only
30 years, it did not include data for older adults, and therefore
much of the criteria developed as a result of this study are not
based on research into this population.
The available data for adults were used to determine the
characteristics of individuals whose symptoms improved. With
regard to the course of ASPD into adulthood, Robins found that
39% reported improvement in symptoms with 12% remitting
and 27% improved but not in remission. This improvement
occurred at a median age of 34.5 years with half improving
between the ages of 31 to 40. Of the 22 patients who improved
and agreed to provide an explanation, 41% attributed the
improvement to a general decrease in motivation. Other com-
mon reasons included marriage and fear of future incarceration.
Holzer and Vaughn
Robins29 used these results to refute the notion of the immut-
ability of this disorder. Black et al31 conducted a similar out-
come study with 71 men admitted to a psychiatric hospital and
diagnosed with ASPD. Follow-up data were obtained an aver-
age of 29 years after discharge from interviews and medical
and legal records. Using Robins’ global ratings, 42% of the
patients were unimproved, 31% were improved but not in
remission, and 27% remitted. Black et al31 also found that very
few of those individuals who remitted, however, achieved suc-
cess and were considered middle or upper class with regard to
socioeconomic status.
Later community psychiatric surveys also examined trends
in ASPD and consistent patterns emerged. Moran28 reviewed a
number of these studies and found that the prevalence of ASPD
is higher in males, younger age groups (25-44), and individuals
with lower levels of education. Studies of ASPD in prisons
found that it is common in this population. Results of the stud-
ies reviewed by Moran suggest that ASPD is predictive of
suicidal behavior and death from unnatural causes. It is also
strongly linked to other forms of mental illness including sub-
stance use disorder and the presence of other PDs.
More recently, researchers used data from the National Epi-
demiologic Survey on Alcohol and Related Conditions
(NESARC) to study the prevalence, sociodemographic corre-
lates, psychiatric and medical comorbidities, and disability of
PDs among the 8205 adults aged 65 and older included in the
data.12 Results from this study indicated that approximately 8%
of these older adults have at least 1 PD and that the most
prevalent PD was obsessive–compulsive disorder. Less than
1% of the respondents aged 65 or older met criteria for ASPD.
The only significant sociodemographic correlates found in this
study included that individuals with ASPD were more likely to
be male and live in a rural area. These respondents were also
more likely than individuals with any other PD to have a comor-
bid psychiatric disorder of any kind and substantially more likely
to have a substance use disorder, with the highest percentage of
respondents with ASPD also having an alcohol use disorder
(68%). Further, ASPD was significantly associated with any
mood disorder and any anxiety disorder as well as heart disease
and the highest rate of arthritis compared with all other PDs.
Diagnostic Criteria
The diagnosis of PDs in older adults is challenged by limits to
the applicability of the current DSM (DSM-5) criteria for this
age-group. As Oltmanns and Balsis5 note, inadequate diagnos-
tic criteria create cyclical problems, in that the criteria interfere
with research in this area that results in a shortage of knowl-
edge to inform the development of more valid criteria. In gen-
eral, the DSM-5 defines a PD as “an enduring pattern of inner
experience and behavior that deviates markedly from the
expectations of the individual’s culture”32(p646) manifested in
at least 2 areas including cognition, affectivity, interpersonal
functioning, and/or impulse control. The pattern is inflexible,
pervasive, and leads to clinically significant distress or impair-
ment in functioning.
3
The DSM-5 continues the use of a categorical approach to
PDs found in previous editions and separates 10 PDs into 3
clusters.32 Cluster B includes ASPD, which is defined as “a
pervasive pattern of disregard for and violation of the rights of
others, occurring since age 15 years”.32(p659) Multiple studies
argue that diagnostic criteria for PDs, including ASPD, are not
applicable to older adults.33
As the diagnosis of PDs typically relies on behavioral man-
ifestations,34 it is easily understood how this may lead to diag-
nostic issues in older adults given biological and associated
behavior changes with age. Many of the criteria for ASPD, for
example, require physical activities including illegal behaviors,
aggressiveness, and disregard for safety. The typical decline in
energy and strength that occurs with aging would likely result
in an associated decline in aggressive behaviors.33
Balsis and colleagues14 examined the prevalence of PD fea-
tures across age groups included in the NESARC data and
conducted an analysis of the item-level functioning of DSM-
IV criteria. Results support the existing literature finding that
the prevalence of many PDs is negatively correlated with age,
including ASPD that was present in 4.5% of young adults and
close to 0% of adults aged 65 or older. Participants endorsed
the majority of PD criteria less frequently with age. All criteria
for ASPD were reported less frequently by adults aged 65 and
older compared to those aged 18 to 64, including failure to
conform to norms regarding legal behavior, deceitfulness,
impulsiveness, irritability and aggressiveness, reckless disre-
gard for safety, consistent irresponsibility, and lack of remorse.
The largest decreases between groups 18 to 24 and 65 and older
were observed for impulsiveness, reckless disregard for safety,
lack of remorse, and failure to conform. With regard to the
latter criteria, for example, failure to conform was endorsed
by 11.5% of 18 to 24 year olds, 6.4% of individuals aged 44
to 55 years and close to 0% by those over the age of 75. In their
second analysis, Balsis et al14 conducted an item response the-
ory analysis of the DSM-IV PD criteria from the same data set
to examine which criteria show differential item functioning
(DIF) for older adults compared with younger adults. Their
analysis indicated the presence of DIF for all PD criteria. With
regard to ASPD, they found that older adults with ASPD may
use deception more than their younger counterparts and that
they may be less likely to fail to conform to norms. The dimin-
ished usefulness of aggressive means to accomplish goals in
this population, including physical confrontation, may account
for these differences.
In addition to a lack of face validity of the diagnostic criteria
for PDs in older adults, Oltmanns and Balsis5 contend that the
diagnostic threshold criteria for PDs should depend on age as
they are defined in terms of impairment in social functioning
and subjective distress. They find the current thresholds to be
arbitrary and argue that they should be related to function as
functional outcomes may differ across age groups. For exam-
ple, a young adult with 4 symptoms of ASPD may fare better
than an older adult meeting 2 ASPD criteria, given the comor-
bid health issues and smaller social support system associated
with later life.
4 Journal of Geriatric Psychiatry and Neurology XX(X)
Balsis et al35 also point to research finding that the preva-
lence of ASPD in older adults is extremely low when arguing
that items of the DSM criteria for ASPD lack content validity.
For example, in a study with 8748 adults aged 55 or older,
there were no reports of past year ASPD among this group.15
Although the absence of ASPD may be due to the early deaths
or high rates of incarceration for individuals with this disor-
der, Balsis and colleagues35 posit that these results are likely
due to the inadequate applicability of the DSM criteria to older
adults. They examine the 7 criteria for ASPD, finding that at
least 4 pose issues when applied to older adults, including
failure to conform to norms, impulsivity, irritability and
aggressiveness, and consistent irresponsibility as indicated
by repeated failure to sustain consistent work behavior or
honor financial obligations. If these items contain measure-
ment bias, older adults are less likely to endorse them and will
not receive a diagnosis of ASPD, resulting in a perceived
lower prevalence among this population.
It may also be the case that the severity of symptoms of PDs
lessens with age17 or that the symptoms and behaviors associ-
ated with PDs are manifested differently. This observed change
likely occurs with ASPD, given the reliance of its diagnostic
criteria on behaviors that older adults may be unable to physi-
cally externalize. Van Alphen et al36 noted that symptoms
relying on mobility, social interaction, and energy may be less
evident in older adults with fewer opportunities for expression.
Of note, many of the symptoms of ASPD require these abilities.
These attitudes or behaviors may be manifested through proxy
behaviors such as firing caregivers or shouting at family mem-
bers.36 Further, the manifestation of PDs likely changes with
age as a result of cognitive decline and somatic comorbid-
ities.36 Sadavoy37 conducted a review of the literature on PDs
in old age and whether symptom expression changes over time.
The review found that while some studies suggest a decline in
overt expressions of ASPD symptoms after age 40, the research
is inconsistent and that not all individuals with ASPD “burn
out”—an expression comparing the diminishing of antisocial
behavior observed by researchers to a light bulb burning out.26
These findings suggest that while the etiology of the PD
remains stable, the expression of symptoms changes. There-
fore, researchers suggest that symptoms of PDs rely more heav-
ily on internal psychological factors of PD, such as affective
instability, and less on the behavioral expressions.36
In a study designed to determine whether forensic psychia-
trists and psychologists consider DSM-IV criteria for ASPD
applicable to older adults, Van Alphen and colleagues38 ana-
lyzed data from mini-questionnaires completed by 69 of these
experts. Respondents cited sexual offense, fraud, and assault as
the crimes most frequently committed by older adults with
ASPD. Respondents named the ASPD criteria most applicable
to older adults, including tends to justify behavior, shows no
remorse, persecuted or stolen something from someone and
dishonesty. Lack of empathy, externalization, egocentric beha-
vior, and lying/making threats were behaviors most frequently
labeled as specific to older adults with ASPD. Results showed
that over 30% of respondents observed mellowing of ASPD
with age; however, some respondents stated that this was an
exception. Approximately 46% of respondents indicated that
age did not influence psychopathic behavior, while others
found the idea of mellowing idealistic. Respondents differed
in views of which factors may influence the process of mellow-
ing, with one-third indicating neurological factors, nearly 25%
citing social factors, and about 26% stating that psychological
factors are the most influential.
Onset
The subject of much debate, especially with regard to older
adults, is the criterion that the onset of the pattern of PD
occurs in adolescence or early adulthood.5 This is especially
troubling for the diagnosis of ASPD as the criteria include the
presence of conduct disorder in childhood. This criterion may
also contribute to diagnostic challenges, particularly for older
adults who may not have access to information from child-
hood. Researchers argue that this prohibits the diagnosis of a
late-onset PD. Notably, an analysis of the data from the Duke
Epidemiologic Catchment Area (DECA) study revealed that
over half of individuals reporting at least 4 adult antisocial
behaviors also report onset in adulthood rather than child-
hood.39 This is especially interesting given that these individ-
uals would not have met DSM criteria for ASPD, which is
another indication that prevalence data for this disorder in
adulthood may be inaccurate.
The DECA study results also suggest age differences
between those participants reporting onset in adulthood versus
childhood. Predictably, those reporting childhood onset were
younger. This difference may be a result of older adults repres-
sing or forgetting childhood memories of antisocial behaviors.
If this is the case, there are a number of potential consequences.
Without these childhood memories, older adults who would
otherwise meet criteria for a PD fail to do so without endorsing
the presence of antisocial behaviors earlier in life. Interestingly,
the study notes many similarities between the individuals
reporting adult-onset or childhood-onset, including symptom
and comorbidity patterns as well as severity. This comparison
suggests that the presentation of ASPD does not differ despite
age of onset. Individuals with adult-onset ASPD suffer from the
same symptoms as those who meet full criteria for ASPD with
childhood onset.
Results from a study conducted by Goldstein and Grant25
indicate differences between adults diagnosed with ASPD and
those with adult antisocial behavioral syndrome (AABS).
Adult antisocial behavioral syndrome is a term used for indi-
viduals who present with syndromal antisocial behavior in
adulthood but did not meet the criteria for a conduct disorder
before age 15. It is not a codable disorder in the DSM. The
researchers analyzed data from wave 1 of the NESARC and the
3-year prospective follow-up in wave 2. Analysis of wave 1
data revealed that individuals diagnosed with ASPD were more
likely than those with AABS to be male, younger, Native
American or Hispanic, and reside in the West. Respondents
with ASPD also reported lower past-year income and
Holzer and Vaughn
educational attainment, a higher prevalence of comorbid life-
time disorders, except pathological gambling, and family his-
tory of antisocial behaviors as well as higher counts of total
antisocial symptoms, major violations of rights of others
(MVOR), and violent symptoms since age 15 years. During
follow-up, the majority of respondents with ASPD and AABS
reported no antisocial behaviors; however, respondents with
ASPD did engage in more of these behaviors than those clas-
sified with AABS.
There was a similar finding with regard to MVOR. Specif-
ically, that the majority of respondents reported no MVOR
since the initial study, however, those with ASPD engaged in
significantly more of these behaviors. Also, the majority of
respondents with ASPD and AABS reported no violent symp-
toms since wave 1, though individuals with ASPD were more
likely to report any violent behaviors. After controlling for
sociodemographic characteristics and psychiatric comorbidity;
however, the differences between ASPD and AABS respon-
dents weakened and further adjustment for parallel symptom
counts from age 15 to wave 1 resulted in no significant differ-
ences between the groups. These results suggest that regardless
of whether an antisocial adult was previously diagnosed with a
conduct disorder, they exhibit many of the same symptoms and
should not be overlooked. Researchers recommend modifica-
tion of ASPD criteria in the DSM, including either the elimina-
tion of the conduct disorder requirement or adding AABS in a
separate category. Of note, AABS was more common in adults
aged 65 years or older (4.8%) than ASPD (3.1%), suggesting
that removal of the conduct disorder requirement will result in a
higher rate of ASPD diagnoses in older adults.
Researchers have proposed multiple changes to the DSM
criteria to overcome issues related to the diagnosis of PDs in
older adults including employment of dimensional models
instead of a categorical approach or the addition of geriatric
subclassifications.6,40
Criminality Criteria
Given the close connection between ASPD criteria and crim-
inal behavior, it is important to understand criminality in older
adults to determine whether the criteria are applicable. It is
well established that crime rates decline with age41,42; how-
ever, it is important to note that there is tremendous variability
in the age at which desistance from crime occurs.43 Research
on elderly perpetrators, however, is lacking with the majority
of research concerning crime and old age focusing on the
elderly as victims.44-46
Most important for the study of older adults, Sampson and
Laub47 found significant negative correlations between job
stability and marital attachment to crime and deviance. From
an evolutionary psychological perspective, Kanazawa and
Still48 theorize that crimes occur after puberty as a result of
men competing for women’s reproductive resources and the
decline follows reproduction when the consequences of crime
could potentially harm their children. It is also known that
muscle strength peaks in young adulthood (20-29 years of age),
5
remains stable, and then significantly decreases in older age
groups (60 years and older),49 which may also contribute to a
decline of aggressive crimes with age.
Interestingly, some of the developmental changes associ-
ated with aging conflict with the apparent decline in preva-
lence of antisocial behaviors with age. For example, older
adults, especially males, experience more difficulty recogniz-
ing facial affect compared to younger adults,50 a deficit also
observed in individuals with psychopathic traits,51 especially
those engaging in impulsive and antisocial behaviors. 52
Research indicates that emotion recognition problems can
result in behavioral disinhibition,53 suggesting that older
males, especially those with a history of psychopathic traits,
may be more rather than less likely to engage in impulsive and
norm-violating behaviors, thus meeting some of the current
ASPD criteria.
Black and Larson26 attribute the decrease in criminality of
adults with ASPD to a tightening of their social environment,
such that their behaviors may be less damaging to society as a
whole, but continue to significantly affect their immediate
family members and neighbors. For this reason, they may
escape arrest while causing destruction in other ways such
as domestic violence.
Stability of Personality
Much debate surrounds the stability of personality over time.
Prompted by conflicting results in previous studies displaying
either a plateau of the consistency of personality traits after age
30 or at age 50, Terracciano and colleagues54 examined rank-
order consistency in personality traits for individuals aged 30
and older over intervals up to 42 years. Using results from the
Guilford-Zimmerman Temperament Survey (GZTS) and the
Revised NEO Personality Inventory (NEO-PI-R), the research-
ers confirmed that consistency of personality traits is high.
What was less clear was whether the consistency plateaued
by age 30, with the GZTS data presenting differences in
consistency between the ages of 30 and 50, with lower retest
correlations for the younger respondents. Results from the NEO-
PI-R, however, failed to demonstrate significant differences
related to age. The researchers posit that the observed decrease
in stability of personality traits with time may be the result of
cerebral atrophy or significant changes in a small number of
respondents possibly caused by trauma or a depressive episode.
A review of prevalence studies on PDs found that those
from Clusters A and C may remain more stable than those
from Cluster B which tend to diminish with time.36 This find-
ing supports the categorization of PDs into 2 groups, mature
and immature, with ASPD in the latter, advanced by Tyrer and
Seivewright.55 They contend that immature PDs improve with
time. It is important to note that due to the risky behaviors
associated with these disorders, the increased mortality rates
could decrease the prevalence of older individuals with Clus-
ter B PDs.
Arboleda-Florez and Holley56 explored the concept of anti-
social burnout, which they defined as the theory that the more
6 Journal of Geriatric Psychiatry and Neurology XX(X)
egregious symptoms of ASPD, especially criminality, decrease
after age 30. Prompted by a lack of empirical evidence regard-
ing this phenomenon, they examined conviction data to deter-
mine whether criminality decreases after a certain age. Their
patients included 39 individuals who were admitted to a hos-
pital forensic unit between 1980 and 1989 and diagnosed with
ASPD based on DSM-III criteria. The retrospective design
allowed researchers to collect information on the patients’
criminal careers from age 16 to January 1989 (patients’ ages
ranged from 41-67 years at the time of study). Results indicate
an overall decline in the average number of convictions after
age 27; however, they also reveal 3 peaks across time, suggest-
ing that the pattern of decreased criminality is complicated.
Researchers found peaks in prevalence and average convictions
occurring at ages 24 to 27, 26 to 42, and 50 to 53. Notably, at
least one-third of the patients remained criminally active over
time. Although the use of a relatively small sample and focus
on forensic psychiatric patients may limit the generalizability
of this study, the results do suggest that burnout is not as
straightforward as a continuous decline and that subtypes of
ASPD may exist.
With regard to the burnout effect, researchers posit that
while older adults who are antisocial may cause less trouble,
few of them would be considered model citizens.26 What likely
occurs is that their social circle tightens with age and their
behavior thereby affects a smaller number of people. Black and
Larson26 note that even with the most extreme symptoms sub-
siding, ASPD “remains a lifelong disorder. Many of those who
improve are unable to regain lost opportunities in education,
employment, and domestic life, and for some, remission means
continuing to live on society’s margins” (p. 89).
Debast and colleagues57 conducted a review of longitudinal
and cross-sectional studies concerning the five-factor model
(FFM), a model of normal personality traits, and DSM PDs
since 1980. Research findings suggest that while personality
traits increase in stability with age, they can continue to change
over a person’s lifetime. The reviewed studies suggest that
personality traits, including neuroticism, extroversion, and
openness decline with age and agreeableness and conscien-
tiousness increase with age. The limited DSM studies, which
have primarily focused on Borderline PD and ASPD, reveal
that the way in which individuals express their maladaptive
personality traits changes with age. As the moderate instability
of personality traits over time may affect the validity of
personality measures with older adults, authors recommend
modification of personality assessments and the inclusion of
age-neutral criteria.
Using data from the Nottingham Study of Neurotic Disor-
der, Seivewright and colleagues58 examined changes in PDs in
patients over a period of 12 years. Researchers used the Per-
sonality Assessment Schedule to assess 178 patients at baseline
and then 12 years later. Patients met inclusion criteria with a
diagnosis of dysthymic disorder, generalized anxiety disorder,
or panic disorder using the DSM-III criteria, and were not
taking drugs for treatment. Results indicate changes in person-
ality traits over time. Notably, average scores for 2 Cluster B
disorders, ASPD and Histrionic PD, significantly decreased at
12 years. These changes suggest that traits characterizing Clus-
ter B PDs, which the researchers describe as more flamboyant,
become less pronounced with age while the eccentric traits
characteristic of Cluster A, and the fearful traits characteristic
of Cluster C increase. It is clear that regardless of whether the
underlying personality pathology remains stable over time, the
manifestation of those traits alters as a result of age-related
cognitive and physical changes and shifts in an individual’s
social environment.
Dimensionality of PDs
Extensive literature exists on the concept of the dimensionality
of PDs and whether this approach is superior to the categorical
system.40,57,59-61 Initially, there was extensive support for a
categorical model as it was considered straightforward with
clear boundaries that aligned with the medical model used by
the DSM, offered obvious diagnostic threshold criteria for clin-
icians, and was easily used to generate simple screening
tools.14 However, major shortcomings of a categorical system
are largely based on the observation that they do not reflect
evidence indicating that boundaries between personality dys-
function and normal personality are not clearly defined and that
the categorical structure results in the loss of information
regarding the severity of the disorder, which can lead to over
or underdiagnosis.7,20 Researchers, therefore, suggest comple-
menting the categorical approach with a dimensional model.7
The dimensional system is especially useful for clinicians
working with older adults as it accounts for the heterogeneity
of personality over time.
The most widely studied dimensional approach is based on
the FFM,62 and there has been considerable effort on the part of
researchers for the DSM to adopt this model.40,63-65 The FFM
was developed through empirical methods and consists of 5
domains, extroversion versus introversion, openness versus
closedness to experience, agreeableness versus antagonism,
conscientiousness versus negligence, and neuroticism versus
emotional stability.40,66 Researchers applied the FFM to PDs,
finding that characteristics of the disorders are indeed related to
the maladaptive variants of the FFM. 66 The relationship
between the FFM and PD traits can be seen using the example
of ASPD, which is characterized by low levels of the facets
encompassing the conscientiousness domain (low levels of
competence, order, dutifulness, achievement striving, self-
discipline, and deliberation). Antisocial personality disorder
is also distinguished by low levels of the facets related to
agreeableness, including trust, straightforwardness, altruism,
compliance, modesty, and tender-mindedness.66
In a review of the literature regarding issues with the cate-
gorical model of PDs, Trull,66 identified the primary problems,
including heterogeneity within diagnoses, diagnostic comor-
bidity, inadequate coverage, arbitrary boundaries with normal
functioning, and lack of empirical support. Studies demonstrat-
ing the co-occurrence of PDs further weaken the notion of
distinct boundaries between the disorders. For example, Grant
Holzer and Vaughn
and colleagues67 examined associations between PDs in the
United States using NESARC data from 2001 to 2002. Predic-
tably, results indicated that PDs within the same cluster were
significantly associated, including ASPD and Histrionic PD.
Less expected, however, were the results revealing significant
associations between PDs of different clusters (eg, ASPD and
dependent PD).
Despite the push for a dimensional approach to PDs in the
DSM-5,32 the APA maintained a categorical perspective that
the disorders are individual clinical syndromes. The authors
did, however, include a section describing the dimensional
model and noted that the 3 clusters can be utilized as dimen-
sions. This model consists of 7 criteria for the diagnosis of any
PD including impairments in personality functioning (Criterion
A), pathological personality traits (Criterion B), pervasiveness
and inflexibility of impaired functioning and personality
traits (Criterion C), onset in adolescence or early adulthood
(Criterion D), absence of differential diagnoses, including
alternative mental disorder (Criterion E), substance use or
medical condition (Criterion F), and that the disorder is not
characteristic of a normal developmental stage or sociocultural
environment (Criterion G). Using this approach, the proposed
diagnostic criteria for ASPD would include difficulties in 2 or
more of the following areas, identity, self-direction, empathy,
and intimacy, as well as 6 or more pathological personality
traits including manipulativeness, callousness, deceitfulness,
hostility, risk taking, impulsivity, and irresponsibility.32 Each
of these traits are related to antagonism or disinhibition and
were found to align with the FFM, further supporting the view
that PD traits can be explained as maladaptive variants of
FFM traits.64
Wygant and colleagues68 compared the alternative dimen-
sional approach for ASPD in the DSM-5 to the long-established
categorical model in a correctional sample of 200 inmates from
a Kentucky prison. The participants were interviewed and com-
pleted multiple self-report measures to determine whether the
alternative method was more aligned with the traditional con-
struct of psychopathy than the categorical model. The results
indicated that the dimensional approach more accurately pre-
dicted psychopathy traits than the categorical method, provid-
ing strong support for use of the alternative model for ASPD
diagnostic criteria in the DSM-5.
The emergence of the FFM and its empirical support is
especially important for the study of PDs in older adults as
research indicates assessments aligned with the FFM may
more effectively reveal latent characteristics of PDs in older
adults than the DSM classification.57 Van den Broeck and
colleagues69 sought to measure the validity of the simple FFM
PD count technique to assess personality pathology in adults
ages 50 or older. The actual participants ranged in age from
50 to 88 years. Results supported the validity of the FFM count
techniques in screening older adults when compared with the
assessment of DSM-IV PDs questionnaire.
Interestingly, however, the 5 FFM count techniques evalu-
ated did not work well for ASPD in this population, with higher
correlations between the ASPD count and the Narcissistic scale
7
on the DSM assessment, rather than the ASPD scale. The
authors of this and a comparable study with younger adults
yielding similar results suggest that the reason ASPD presents
more similarly to Narcissistic PD in older adults is that these
individuals engage in more behaviors that are characteristic of
narcissism, namely, manipulation, instead of the aggressive
behaviors characteristic of ASPD.69 Another explanation is that
the diagnosis of ASPD depends more heavily on behaviors,
such as criminal activities, that are not as adequately measured
by the FFM as abstract traits. Therefore, while use of the FFM
or alternative dimensional models may not appropriately cap-
ture ASPD, the FFM screening techniques will potentially still
reveal personality pathology in older adults who meet subthres-
hold DSM criteria, allowing clinicians and individuals to better
understand their behaviors and treatment options.
There are many benefits to a dimensional approach. Clini-
cians and researchers could use it to better understand both
personality strengths and weaknesses in individuals with PDs
and those without.6 The model can include criteria that are
either applicable to all ages or age-adjusted, allowing compar-
isons between younger and older individuals. An individual’s
scores on assessments using the dimensional approach could be
compared across various periods of their life, including during
episodes of other psychiatric disorders. A dimensional model
would also allow for more descriptive clinical reporting of
personality dysfunction.6 More detailed clinical records would
be especially useful for the study of PDs in older adults as
clinicians could compare current and previous notes to high-
light important changes. Less reliance on categorical diagnoses
and associated labels may also help to eliminate the stigma
associated with PDs, especially in older adults who may have
an even more negative perspective on mental illness than
younger generations. Further, the patients would be able to
better understand their difficulties with a more detailed record
of their dysfunction instead of feeling pigeonholed into a diag-
nostic category that masks the complexity of personality.6
Presentation of ASPD in Older Adults
Given the significant consequences of ASPD and difficulty
diagnosing the disorder in later life, it is helpful for clinicians
and researchers to understand the presentation of ASPD in
older adults. The current literature provides a description of
behaviors common to this population. From the perspective
of forensic psychiatrists and psychologists,38 characteristics
of older adults with ASPD include lying/making threats, ego-
centric behaviors, externalization, and lack of empathy. These
clinicians also reported that the ASPD criteria most applicable
to older adults included justifying behavior, lack of remorse,
persecuting or stealing, and dishonesty. With regard to older
adults with Cluster B PDs in general, experts in the PD field
agree that these individuals engage in less aggressive beha-
viors, with an increase in psychosomatic and depressive com-
plaints along with addictive and passive–aggressive
behaviors.20 Further, item response theory analyses revealed
that older adults with ASPD were more likely to endorse
8 Journal of Geriatric Psychiatry and Neurology XX(X)
deceitfulness, including lying and conning others, and less
likely to endorse failure to conform to norms regarding legal
behavior compared to their younger counterparts.14
As previously mentioned, studies evaluating the FFM PD
count technique with older adults find that the FFM ASPD
prototype is more highly correlated with the DSM Narcissistic
PD criteria than ASPD.69,70 These results suggest that as indi-
viduals with ASPD age, they may present with symptoms more
characteristic of Narcissistic PD, including the use of manip-
ulation rather than aggressive behaviors. These characteristics
may also affect how older adults with ASPD respond to assess-
ments, and therefore it is particularly important for clinicians to
recognize and reduce the potential for manipulation and lying.
Case studies of older adult patients illustrate the presenta-
tion of ASPD during later life. Howardet al71 present a 71-year-
old woman whose antisocial/dissocial PD symptoms became
worse with age, exacerbated by the stresses of living alone after
her husband’s death. Oltmanns and Balsis72 describe John, a
78-year-old male, who met several criteria for ASPD as a
younger adult, but whose manifestation of the criteria changed
significantly over time leading to difficulty with the diagnostic
process. For example, instead of engaging in physical fights,
John now expressed his aggression through nonviolent beha-
viors, including letting air out of people’s tires, which likely
does not meet the DSM criterion of engaging in repeated phys-
ical fights or assaults.
Additional research provides an idea of the lifestyle of
older adults with ASPD, including that the rate of ASPD in
this population is higher in rural areas compared to urban
areas. These individuals also have high rates of medical
comorbidities, mood/anxiety disorders, substance use disor-
ders, tobacco dependence, alcohol use disorders, heart
disease, and arthritis.12,31
Recommendations
Geriatric SubClassification
Multiple researchers have recommended the inclusion of a ger-
iatric subclassification as a solution to the diagnostic problems
for older adults with personality dysfunction, an approach com-
monly used in psychiatry for children and adolescents. Agronin
and Maletta6 suggest that the subclassification account for the
difficulty experienced by older adults to provide accurate long-
itudinal histories by possibly removing the requirement that
maladaptive behaviors begin in childhood. This classification
should also include descriptions of the presentation of PDs in
the context of other psychiatric diagnoses, including depression
and anxiety, and physical comorbidities affecting many older
adults, particularly those with PDs. The new category would
need to account for an extensive range of age-related difficul-
ties affecting the manifestation of PD pathology, including
changes in social environment. The consideration of these fac-
tors may warrant the consolidation of PDs and personality-
change disorder into the same diagnostic category to include
stable personality traits and more recent dysfunction.
The development of a subclassification may require long-
itudinal research which the field of PDs lacks.5 Longitudinal
studies would allow researchers to examine the life course of
individuals diagnosed with PDs and the manifestation of cri-
teria over time. These studies, however, are often costly and
time consuming. Longitudinal research has been found to be
especially challenging with individuals diagnosed with PD,
specifically ASPD, as they can be difficult to locate, refuse
to participate, and have high rates of premature death.31 Due
to the high demands of longitudinal research, researchers may
employ alternative methods including, analyzing regression
and using item response theory techniques in a cross-
sectional design to determine which criteria are most applica-
ble to older adults. These latter studies could include samples
of older adults who either meet full criteria for a PD or a lower
diagnostic threshold compared with younger patients with the
same diagnoses.6 The results can also be used to create weight-
ing coefficients for each criterion, a technique proposed by Van
Alphen et al7 to combat the diagnostic issues. This process
involves linking different weighting coefficients to PD criteria
related to different life phases and further linking the weighted
criterion to the amount of time the symptom has occurred.
These coefficients will allow clinicians to describe variable
behaviors throughout a patient’s life. Results from the item
response test of PD criteria can be used to determine which
criteria may need to be substituted for older adults. For exam-
ple, the aggressive behavior characteristic of ASPD may be
replaced by more passive–aggressive behaviors such as conti-
nually disobeying regulations enforced at senior living facili-
ties. Although the development of a subclassification will
depend on an increase in the amount of research into older
adults with PDs, it should also result in increased interest and
research into this population.
Conclusion
The lower prevalence of PDs among older adults compared to
younger adults is well-documented and even more pronounced
for ASPD. Although this decline could be the result of early
mortality associated with ASPD, follow-up studies also demon-
strate that some adults who previously met criteria for ASPD
do not continue to meet the criteria into old age. Is this change
the result of recovery, burnout, or problems with the criteria?
Does ASPD really burn out or does the underlying pathology
remain with a change in the manifestation of the pathology?
Many of the current DSM criteria for ASPD include engage-
ment in behaviors that require a considerable amount of energy,
including frequent assaults on others and engagement in crim-
inal behaviors that warrant arrest. It is documented and recog-
nized that criminal behavior declines with age. Research has
also demonstrated that strength decreases with age, which may
also diminish the impact of aggressive behaviors. Despite the
rising inapplicability of these criteria with age, it is clear that
aggression, impulsivity, and disregard for safety as well as the
less physically demanding criteria can be manifested through
different avenues.
Holzer and Vaughn
Case studies and longitudinal research demonstrate that
individuals diagnosed with ASPD continue to experience dif-
ficulty functioning in a variety of settings and remain a burden
to their loved ones and caregivers. Older adults with ASPD
may also present increased challenges with age due to higher
rates of comorbid physical and psychiatric conditions as well as
cognitive impairment. It is important then to treat the PD likely
causing the harmful behaviors and further exacerbating comor-
bid illnesses instead of focusing treatment entirely on another
psychiatric disorder or physical ailment. Without appropriate
criteria, however, the diagnostic process is problematic. The
reliance on aggressive and violent behaviors may result in older
adults failing to meet the diagnostic threshold for ASPD.
Furthermore, the older patient may not be able to provide a
detailed history to support an enduring pattern of ASPD char-
acteristics or a conduct disorder in adolescence. The clinicians
may then be reluctant to diagnose ASPD or instead focus on
symptoms that suggest an alternative psychiatric disorder.
There has been progress in the field of PDs and older adults,
including the development of a dimensional approach to PDs
that allows for a more comprehensive understanding of person-
ality traits with age. The primary model of this approach, the
FFM, however, has been shown to be less successful with
ASPD in older adults. This inadequacy is likely due to the
reliance of ASPD criteria on aggressive and violent behaviors,
which remain in the FFM construct for ASPD but are less
prominent than in the DSM. Additional advances in this field
include the creation of personality assessments specifically for
the screening of older adults, the most commonly used being
the Gerontological Personality disorder Scale (GPS).7 Still rel-
atively new, further research and possibly modifications are
needed to support its diagnostic accuracy. Furthermore, while
a separate scale for older adults will undoubtedly benefit clin-
icians working with this population, it presents barriers for
researchers comparing the prevalence and presentation of this
construct across different age-groups. An age-neutral assess-
ment is preferred; however, this is difficult to develop without
age-neutral criteria.
There are 2 prominent proposals to alleviate the difficulties
associated with current DSM criteria for ASPD when applied to
older adults, including modification of the existing criteria and
development of a geriatric subclassification. As previously
noted, longitudinal research would be particularly useful in this
situation. The continued study of individuals diagnosed with
ASPD across their lifetime would allow researchers to better
understand how the ASPD pathology changes in presentation
over time. Longitudinal studies, however, are expensive and
time consuming. It has also been noted that recruiting individ-
uals with ASPD and ensuring commitment to follow-up is
exceedingly difficult.31 Cross-sectional analyses of large, rep-
resentative data sets comparing symptoms of ASPD in older
and younger adults require less time and would provide data
from a large sample. Another approach is to test the DIF of the
current ASPD criteria to detect whether individual criteria are
systematically biased for older or younger adults. The results of
these analyses can be used to examine the criteria containing
9
bias and either eliminate or modify them. Researchers can
supplement results from patient studies with information
obtained by interviews with experts who work with older adults
with PDs. They can describe their experience of ASPD in this
population and which criteria they deem applicable. Results of
research mentioned above may indicate that using different
diagnostic thresholds or criteria for various age groups may
be the most effective solution. The current threshold standards
for ASPD can be lowered for older adults such that a diagnosis
requires fulfillment of only the criteria applicable or relevant to
older adults.
The consequences of ASPD are damaging not only to the
affected individuals but also to their loved ones and society as a
whole. The cognitive, physical, and social changes associated
with old age intensify the impact of ASPD in later life. As
poignantly described by Black and Larson,26(p. 89) “antisocials
often spend their last years alone, sometimes plagued by regret
for what they never knew they were missing until it was too
late”. Although it may not be imperative to label a disorder, it
can provide relief for practitioners, patients, and loved ones.
They can use this information to learn more about the disease,
understand their functional difficulties, and seek treatment
interventions. Without applicable criteria, geriatric patients and
their loved ones continue to suffer without an understanding of
their situation and the appropriate treatment.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
References
1. Reynolds K, Pietrzak RH, El-Gabalawy R, Mackenzie CS, Sareen
J. Prevalence of psychiatric disorders in U.S. older adults: find-
ings from a nationally representative survey. World Psychiatry.
2015;14(1):74-81.
2. Moran P, Romaniuk H, Coffey C, et al. The influence of person-
ality disorder on the future mental health and social adjustment
of young adults: a population-based, longitudinal cohort study.
Lancet Psychiatry. 2016;3(7):636-645. doi:10.1016/S2215-
0366(16)30029-3.
3. Tyrer P, Reed GM, Crawford MJ. Classification, assessment, pre-
valence, and effect of personality disorder. Lancet. 2015;
385(9969):717-726. doi:10.1016/S0140-6736(14)61995-4.
4. Vaughn MG, Fu Q, Beaver D, DeLisi M, Perron B, Howard M.
Are personality disorders associated with social welfare burden in
the United States? J Personal Disord. 2010;24(6):709-720. doi:
10.1521/pedi.2010.24.6.709.
5. Oltmanns TF, Balsis S. Personality disorders in later life: ques-
tions about the measurement, course, and impact of disorders.
Annu Rev Clin Psychol. 2011;7:321-349. doi:10.1146/annurev-
clinpsy-090310-120435.
10
6. Agronin ME, Maletta G. Personality disorders in late life: under-
standing and overcoming the gap in research. Am J Geriatr
Psychiatry. 2000;8(1):4-18. doi:10.1097/00019442-200002000-
00002.
7. Van Alphen SPJ, Engelen GJJA, Kuin Y, Derksen JJL. The rele-
vance of a geriatric sub-classification of personality disorders in
the DSM-V. Int J Geriatr Psychiatry. 2006;21(3):205-209. doi:
10.1002/gps.1451.
8. Ames A, Molinari V. Prevalence of personality disorders in
community-living elderly. J Geriatr Psychiatry Neurol. 1994;
7(3):189-194. doi:10.1177/089198879400700311.
9. Mezzich JE, Fabrega H, Jr, Coffman GA, Glavin YW. Compre-
hensively diagnosing geriatric patients. Compr Psychiatry. 1987;
28(1):68-76. doi:10.1016/0010-440X(87)90046-0.
10. Molinari V, Marmion J. Relationship between affective disorders
and axis II diagnoses in geropsychiatric patients. J Geriatr Psychia-
try Neurol. 1995;8(1):61-64. doi:10.1177/089198879500800112
11. Goldstein RB, Chou SP, Saha TD, et al. The epidemiology of
antisocial behavioral syndromes in adulthood: results from the
national epidemiologic survey on alcohol and related condi-
tions-III. J Clin Psychiatry. 2017;78(1):90-98. doi:10.4088/JCP.
15m10358.
12. Schuster J, Hoertel N, Le Strat Y, Manetti A, Limosin F. Person-
ality disorders in older adults: findings from the national epide-
miologic survey on alcohol and related conditions. Am J Geriatr
Psychiatry. 2013;21(8):757-768. doi:10.1016/j.jagp.2013.01.055.
13. Goldstein RB, Dawson DA, Grant BF. Antisocial behavioral syn-
dromes in adulthood and alcohol use disorder treatment over three-
year follow-up: results from wave 2 of the national epidemiologic
survey on alcohol and related conditions. J Am Psychiatr Nurses
Assoc. 2010;16(4):212-226. doi:10.1177/1078390310375846.
14. Balsis S, Gleason MEJ, Woods CM, Oltmanns TF. An item
response theory analysis of DSM-IV personality disorder criteria
across younger and older age groups. Psychol Aging. 2007;22(1):
171-185. doi:10.1037/0882-7974.22.1.171.
15. Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence
estimates of mental disorders in the United States: using a clinical
significance criterion to reconcile 2 surveys’ estimates. Arch Gen
Psychiatry. 2002;59(2):115-128. doi:10.1001/archpsyc.59.2.115.
16. Widiger TA, Seidlitz L. Personality, psychopathology, and
aging. J Res Pers. 2002;36(4):335-362. doi:10.1016/S0092-
6566(02)00013-2.
17. Kenan MM, Kendjelic EM, Molinari VA, Williams W, Norris M,
Kunik ME. Age-related differences in the frequency of personal-
ity disorders among inpatient veterans. Int J Geriatr Psychiatry.
2000;15(9):831-837. doi:10.1002/1099-1166(2000009)15:
9<831:: AID-GPS208>3.0.CO;2-H.
18. Molinari V, Ames A, Essa M. Prevalence of personality disorders
in two geropsychiatric inpatient units. J Geriatr Psychiatry
Neurol. 1994;7(4):209-215. doi:10.1177/089198879400700403.
19. Balsis S, Woods C, Gleason MEJ, Oltmanns TF. Overdiagnosis
and underdiagnosis of personality disorders in older adults. Am J
Geriatr Psychiatry. 2007;15(9):742-753. doi:10.1097/JGP.
0b013e31813c6b4e.
20. Van Alphen SPJ, Bolwerk N, Videler AC, et al. Age-related
aspects and clinical implications of diagnosis and treatment of
Journal of Geriatric Psychiatry and Neurology XX(X)
personality disorders in older adults. Clin Gerontol. 2012;35(1):
27-41. doi:10.1080/07317115.2011.628368.
21. Van Alphen SPJ, Van Dijk SDM, Videler AC, et al. Personality
disorders in older adults: emerging research issues. Curr Psychia-
try Rep. 2015;17(1):538. doi:10.1007/s11920-014-0538-9.
22. Morgan TA, Chelminski I, Young D, Dalrymple K, Zimmerman
M. Differences between older and younger adults with borderline
personality disorder on clinical presentation and impairment.
J Psychiatr Res. 2013;47(10):1507-1513. doi:10.1016/j.jpsy-
chires.2013.06.009.
23. Stevenson J, Meares R, Comerford A. Diminished impulsivity in
older patients with borderline personality disorder. Am J Psychia-
try. 2003;160(1):165-166. doi:10.1176/appi.ajp.160.1.165.
24. Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attain-
ment and stability of sustained symptomatic remission and recov-
ery among patients with borderline personality disorder and axis
II comparison subjects: a 16-year prospective follow-up study.
Am J Psychiatry. 2012;169(5):476-483. doi:10.1176/appi.ajp.
2011.11101550.
25. Goldstein RB, Grant BF. Three-year follow-up of syndromal anti-
social behavior in adults: results from the wave 2 national epide-
miologic survey on alcohol and related conditions. J Clin
Psychiatry. 2009;70(9):1237-1249. doi:10.4088/JCP.08m04545.
26. Black DW, Larson CL. Bad Boys, Bad Men: Confronting Anti-
social Personality Disorder. New York, NY: Oxford University
Press, Inc; 1999.
27. Workman RH Jr. An ethical framework for understanding patients
with antisocial personality disorder who develop dementia: diag-
nosing and managing disorders of autonomy. J Ethics Law Aging.
1997;3(2):79-90.
28. Moran P. The epidemiology of antisocial personality disorder.
Soc Psychiatry Psychiatr Epidemiol. 1999;34(5):231-242. doi:
10.1007/s001270050138.
29. Robins LN.Deviant Children Grown Up: A Sociological and Psy-
chiatric Study of Sociopathic Personality. Baltimore, MD: The
Williams & Wilkins Company; 1966.
30. Campbell ND.The spirit of St. Louis: the contributions of Lee N.
Robins to North American psychiatric epidemiology. Int J Epi-
demiol. 2014;43(1): i19-i28. doi:10.1093/ije/dyt223.
31. Black DW, Baumgard CH, Bell SE. A 16- to 45-year follow up of
71 men with antisocial personality disorder. Compr Psychiatry.
1995;36(2):130-140. doi:10.1016/S0010-440X(95)90108-6.
32. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. Arlington, VA: American
Psychiatric Publishing; 2013.
33. Segal DL, Hersen M, Van Hasselt VB, Smith Silberman C, Roth
L. Diagnosis and assessment of personality disorders in older
adults: a critical review. J Personal Disord. 1996;10(4):
384-399. doi:10.1521/pedi.1996.10.4.384.
34. Kroessler D. Personality disorder in the elderly. Hosp Community
Psychiatry. 1990;41(12):1325-1329. doi:10.1176/ps.41.12.1325.
35. Balsis S, Segal DL, Donahue C. Revising the personality disorder
diagnostic criteria for the Diagnostic and Statistical Manual of
Mental Disorders-Fifth Edition (DSM-V): consider the later life
context. Am J Orthopsychiatry. 2009;79(4):452-460. doi:10.1037/
a0016508.
Holzer and Vaughn
36. Van Alphen SPJ, Derksen JJL, Sadavoy J, Rosowsky E. Editorial:
features and challenges of personality disorders in late life. Aging
Ment Health. 2012;16(7):805-810. doi:10.1080/13607863.2012.
667781.
37. Sadavoy J. Personality disorder in old age: symptom expres-
sion. Clin Gerontol. 1996;16(3):19-36. doi:10.1300/
J018v16n03_04.
38. Van Alphen SPJ, Nijhuis PEP, Oei TI. Antisocial personality
disorder in older adults. A qualitative study of Dutch forensic
psychiatrists and forensic psychologists. Int J Geriatr Psychiatry.
2007;22(8):813-815. doi:10.1002/gps.1758.
39. Tweed JL, George LK, Blazer D, Swartz M, MacMillan J. Adult
onset of severe and pervasive antisocial behavior: a distinct syn-
drome? J Personal Disord. 1994;8(3):192-202. doi:10.1521/pedi.
1994.8.3.192.
40. Trull TJ, Widiger TA. Dimensional models of personality: the
five-factor model and the DSM-5. Dialogues Clin Neurosci.
2013;15(2):135-146.
41. Farrington DP. Age and crime. Crime Justice. 1986;7:189-250.
42. Moberg DO. Old age and crime. J Crim Law Criminol. 1953;
43(6):764-776.
43. McVie S. Patterns of deviance underlying the age-crime curve:
the long term evidence. Br Soc Criminol. 2005;7. http://www.
britsoccrim.org/volume7/007.pdf. Accessed September 5, 2017.
44. Cook FL, Skogan WG, Cook TD, Antunes GE. Criminal victimi-
zation of the elderly: the physical and economic consequences.
Gerontologist. 1978;18(4):338-349. doi:10.1093/geront/18.4.338.
45. Covey HC, Menard S. Trends in elderly criminal victimization
from 1973 to 1984. Res Aging. 1988;10(3):329-341. doi:10.1177/
0164027588103002.
46. Goldsmith J, Tomas NE. Crimes against the elderly—A continu-
ing national crisis. Aging. 1974;236-237:10-13.
47. Sampson RJ, Laub JH. Crime in the Making: Pathways and Turn-
ing Points Through Life. Cambridge, MA: Harvard University
Press; 1993.
48. Kanazawa S, Still MC. Why men commit crimes (And why they
desist). Sociol Theory. 2000;18(3):434-447. doi:10.1111/0735-
2751.00110.
49. Larsson L, Grimby G., Karlsson J. Muscle strength and speed of
movement in relation to age and muscle morphology. J Appl
Physiol Respir Environ Exerc Physiol. 1979;46(3):451-456.
50. Ruffman T, Halberstadt J, Murray J. Recognition of facial,
auditory, and bodily emotions in older adults. J Gerontol B
Psychol Sci Soc Sci. 2009;64(6):696-703. doi:10.1093/geronb/
gbp072.
51. Hastings ME, Tangney JP, Stuewig J. Psychopathy and identifi-
cation of facial expressions of emotion. Pers Individ Dif. 2008;
44(7):1474-1483. doi:10.1016/j.paid.2008.01.004.
52. Sandvik AM, Hansen AL, Johnsen BH, Laberg JC. Psychopathy
and the ability to read the “language of the eyes”: divergence in
the psychopathy construct. Scand J Psychol. 2014;55(6):585-592.
doi:10.1111/sjop.12138.
53. Baskin-Sommers A, Newman JP. Psychopathic and externalizing
offenders display dissociable dysfunctions when responding to
facial affect. Personal Disord. 2014;5(4):369-379. doi:10.1037/
per0000077.
11
54. Terracciano A, Costa PT, Jr, McCrae RR. Personality plasticity
after age 30. Pers Soc Psychol Bull. 2006;32(8):999-1009. doi:10.
1177/0146167206288599.
55. Tyrer P, Seivewright H. Studies of outcome. In: Tyrer P, ed.
Personality Disorders: Diagnosis, Management and Course.
London, UK: Wright; 1988:119-136.
56. Arboleda-Florez J, Holley HL. Antisocial burnout: an exploratory
study. Bull Am Acad Psychiatry Law. 1991;19(2):173-183.
57. Debast I, Van Alphen SPJ, Rossie G, et al. Personality traits and
personality disorders in late middle and old age: do they remain
stable? A literature review. Clin Gerontol. 2014;37(3):253-271.
doi:10.1080/07317115.2014.885917.
58. Seivewright H, Tyrer P, Johnson T. Change in personality
status in neurotic disorders. Lancet. 2002;359(9325):2253-2254.
doi:10.1016/S0140-6736(02)09266-8.
59. Miller J. Five-factor model personality disorder prototypes: a
review of their development, validity, and comparison to alterna-
tive approaches. J Pers. 2012;80(6):1565-1591. doi:10.1111/
j.1467-6494.2012.00773.x.
60. Rottman BM, Kim NS, Ahn WK, Sanislow CA. Can personality
disorder experts recognize DSM-IV personality disorders from
five-factor model descriptions of patient cases? J Clin Psychiatry.
2011;72(5):630-639.doi:10.4088/JCP.09m05534gre.
61. Widiger TA. Dimensional models of personality disorder. World
Psychiatry. 2007;6(2):79-83.
62. Widiger TA, Costa PT, Jr, Gore WL, Crego C. Five factor model
personality disorder research. In: Widiger TA, Costa PT, eds.
Personality Disorders and the Five-Factor Model of Personality.
3 rd ed. Washington DC: American Psychological Association;
2002. Chap 6. doi:10.1016/B978-0-08-097086-8.25065-4.
63. Bagby RM, Costa PT, Jr, Widiger TA, Ryder AG, Marshall
M. DSM-IV personality disorders and the five-factor model of
personality: a multi-method examination of domain-and facet-
level predictions. Eur J Pers. 2005;19(4):307-324. doi:10.1002/
per.563.
64. Gore WL, Widiger TA. The DSM-5 dimensional trait model and
five-factor models of general personality. J Abnorm Psychol.
2013;122(3):816-821. doi:10.1037/a0032822.
65. Limandri BJ. The plight of personality disorders in the DSM-5.
Issues Ment Health Nurs. 2012;33(9):598-604. doi:10.3109/
01612840.2012.704133.
66. Trull TJ. The five-factor model of personality disorder and DSM-
5. J Pers. 2012;80(6):1697-1720. doi:10.1111/j.1467-6494.2012.
00771.x.
67. Grant BF, Stinson FS, Dawson DA, Chou SP, Ruan WJ.
Co-occurrence of DSM-IV personality disorders in the United
States: results from the national epidemiologic survey on
alcohol and related conditions. Compr Psychiatry. 2005;46(1):
1-5. doi:10.1016/j.comppsych.2004.07.019.
68. Wygant DB, Sellbom M, Sleep CE, et al. Examining the DSM-5
alternative personality disorder model operationalization of anti-
social personality disorder and psychopathy in a male correctional
sample. Personal Disord. 2016;7(3):229-239. doi:10.1037/
per0000179.
69. Van den Broeck J, Rossi G, De Clercq B, Dierckx E, Bastiaansen
L. Validation of the FFM PD count technique for screening
12
personality pathology in later middle-aged and older adults. Aging
Ment Health. 2013;17(2):180-188. doi:10.1080/13607863.2012.
717258.
70. Lawton EM, Shields AJ, Oltmanns TF. Five-factor model person-
ality disorder prototypes in a community sample: self- and
informant-reports predicting interview-based DSM diagnoses.
Personal Disord. 2011;2(4):279-292. doi:10.1037/a0022617.
Journal of Geriatric Psychiatry and Neurology XX(X)
71. Howard R, Bandyopadhyay D, Cook M. Dissocial personality
disorder in the elderly: a case history. Int J Geriatr Psychiatry.
1992;7(7):527-532. doi:10.1002/gps.930070712.
72. Oltmanns TF, Balsis S. Assessment of personality disorders in
older adults. In: Lichtenberg PA, ed. Handbook of Assessment
in Clinical Gerontology. 2nd ed. London, UK: Academic Press;
2010:101-122. doi:10.1016/B978-0-12-374961-1.10026-0.