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C O M M E N T A R Y
Personality Disorders in Adolescence: Label or
Opportunity?
Joost Hutsebaut, MBT Netherlands
Dine J. Feenstra, Viersprong Institute for Studies on
Personality Disorders (VISPD), Department of Medical
Psychology and Psychotherapy, Erasmus Medical Centre
Patrick Luyten, Viersprong Institute for Studies on
Personality Disorders (VISPD), Faculty of Psychology
and Educational Sciences, University of Leuven,
Research Department of Clinical, Educational, and
Health Psychology, University College London
The articles in this special issue testify to the rapidly
growing body of research concerning the assessment
and treatment of personality disorders (PDs) in adoles-
cence. In this commentary, we will first attempt to sum-
marize what we consider to be the overall take-home
messages of the articles in this issue in the context of
current limitations in our knowledge of PDs in adoles-
cence. Further, we comment on the gap between
science and practice in this field, stressing the impor-
tance of diagnosing PDs in adolescence. We close with
some thoughts and recommendations concerning the
future of research on PDs in adolescence.
Key words: adolescents, personality disorder, per-
sonality pathology, treatment. [Clin Psychol Sci Prac 20:
445–451, 2013]
The overall take-home messages from this special
issue can perhaps be summarized as follows. First, per-
sonality disorder (PD) diagnoses are as reliable and valid
in adolescents as they are in adults (Courtney-Seidler,
Klein, & Miller, 2013; DeFife, Malone, DiLallo, &
Westen, 2013; Shiner & Allen, 2013; Tackett, Herz-
hoff, Reardon, Smack, & Kushner, 2013). PDs in
adolescents show more similarities than differences with
PDs in adults, and any differences may be explained by
the principle of heterotypic continuity, that is, that
similar underlying traits are developmentally deter-
mined and can differ across age ranges (Courtney-
Seidler et al., 2013). Second, PDs and borderline PD
(BPD) specifically peak in middle to late adolescence,
but symptoms may come and go as they seem to be
greatly influenced by contextual factors and develop-
mental tasks (Shiner & Allen, 2013). Nonetheless, PDs
are relatively stable in adolescence (Courtney-Seidler
et al., 2013; Shiner & Allen, 2013). Some PDs, like
schizotypal, might even be more stable in adolescents
than in adults (Ryan, Macdonald, & Walker, 2013) and
are highly predictive of future personality functioning,
a range of symptoms and PDs in adulthood, and devel-
opmental arrest more generally, including problems in
areas such as school, work, and peer and romantic rela-
tionships (Courtney-Seidler et al., 2013; DeFife et al.,
2013; Ryan et al., 2013; Shiner & Allen, 2013). Third,
a dimensional approach that focuses not only on acute
symptoms, but also on underlying personality patterns,
may lead to a more developmentally sensitive assess-
ment of PDs (Courtney-Seidler et al., 2013; DeFife
et al., 2013) and at the same time may identify impor-
tant targets for treatment (Shiner & Allen, 2013).
Address correspondence to Dine J. Feenstra, Viersprong Insti-
tute for Studies on Personality Disorders (VISPD), PO Box
7, 4660 AA, Halsteren, The Netherlands. E-mail: dineke
© 2013 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.All rights reserved. For permissions, please email: [email protected]. 445
Fourth, there is increasing evidence that early expres-
sions of PD symptoms in adolescence, including BPD
features, can be effectively treated by even relatively
short interventions (Courtney-Seidler et al., 2013).
Nonsuicidal self-injury or attempted suicide may
perhaps be important markers in this context and may
guide decisions concerning referral to early specialized
intervention to prevent the development of BPD and a
range of comorbid conditions, such as substance abuse
disorders.
At the same time, however, the articles in this spe-
cial issue also point to important limitations in our
knowledge of PDs in adolescence: (a) Although PDs in
adolescence and adulthood share many features, the need
to develop adolescent-sensitive assessment instruments
for both research and clinical purposes remains (DeFife
et al., 2013; Shiner & Allen, 2013; Tackett et al.,
2013). (b) Outcome studies of treatment models for
personality-disordered adolescents do exist and include
cognitive analytic therapy (Chanen et al., 2008), men-
talization-based treatment (Rossouw & Fonagy, 2012),
and emotion regulation training (Courtney-Seidler
et al., 2013; Schuppert et al., 2012). However, the
inclusion of adolescents who only exhibit symptoms of
PDs but not full-blown PDs renders it difficult to gen-
eralize these findings to more severely disturbed adoles-
cents, not to mention the almost complete lack of
research on the treatment of other PDs in adolescents
besides borderline PD. (c) The limited number of stud-
ies on the outcome of treatments for adolescents with
PDs makes it difficult to develop general guidelines for
the treatment of adolescent PDs (Courtney-Seidler
et al., 2013). It remains unclear whether existing evi-
dence-based treatments for personality-disordered adults
need to be adapted for this group of adolescents, and if
so, what adaptations are needed. For example, do we
need to involve parents and other family members in
these treatments? Finally, the long-term effects of these
relatively short interventions remain unclear.
SCIENCE VERSUS CLINICAL PRACTICE
Several authors in this issue (Courtney-Seidler et al.,
2013; Shiner & Allen, 2013) recognize the still exist-
ing gap between research (with few researchers
currently denying the possibility that PDs can be
diagnosed in adolescents) and clinical practice. This is
also evidenced by the extreme reluctance among
many professionals to diagnose PDs in adolescents, as
was recently shown in a study in the Netherlands
(Laurenssen, Hutsebaut, Feenstra, Busschbach, & Luyten,
2013). The integration of research findings in clinical
practice is further hindered by a relatively sharp dis-
tinction between mental health services for adults and
adolescents in most countries. Specialist services for
the treatment of PD are often the domain of psychia-
trists and psychologists specializing in the treatment of
adults. As a result, the real tragedy is, as Courtney-
Seidler et al. (2013) argue in this issue, that adoles-
cents will go undiagnosed or misdiagnosed and there-
fore fail to receive proper treatment. In our
experience, this is unfortunately everyday practice.
One of us (DF) recently was contacted by a 17-year-
old girl whom we will call Amy. Amy had already
been in and out of treatment for more than
five years. She had been previously diagnosed with
ADHD, conduct disorder, depression, and autism, and
according to the referral letter, she had been consid-
ered to “show a complete lack of motivation,”
constantly “externalizing” her symptoms and “not yet
ready for treatment.” Stated otherwise: “It’s her own
fault that she didn’t receive proper treatment.” And
indeed, responses such as these are to a certain extent
understandable: She had a history of not showing up
for appointments and if she did, she was “difficult,”
“distrustful,” or “verbally aggressive.” She was even
“punished” by her previous therapist who terminated
the treatment after an aggressive assault. To cut a
long story short, she is considered to be a burden for
her teachers, parents, and therapists. Over the last
year, she has been admitted to crisis services twice
after she threatened to commit suicide. With every
treatment failure, her despair and powerlessness
increased. She dropped out from school for almost
two years now, and the only contacts with other
peers are through mental health services, and thus
with other patients.
Adolescents like Amy probably suffer from the
“diagnosis that dare not speak its name” (Chanen &
McCutcheon, 2008). Her case illustrates much of the
tragedies that characterize these adolescents and their
families. In our opinion, there are at least five reasons
why the identification of PDs in adolescents and their
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE � V20 N4, DECEMBER 2013 446
families could help prevent such tragedies. First, as
evidenced by Amy’s case, not identifying PDs often
leads mental health professionals to focus on only one
aspect of the problem, leading to a fragmented
approach in adolescents who already feel fragmented.
For instance, internalizing problems that are part of a
broader picture of developmental personality issues are
diagnosed as reflecting a mood or anxiety disorder,
while externalizing problems are considered to reflect
ADHD or a conduct disorder. The fact that some of
these adolescents withdraw from social contacts is
sometimes interpreted as reflecting an autism spectrum
disorder. Bateman and Krawitz (2013) have quite
appropriately referred to the metaphor of the blind
men and the elephant in this context: Any number of
blind people touching an elephant in different places
will inevitably describe it in a completely different
way. The same is true for PDs. Particularly if we lack a
comprehensive conceptual framework, we risk ignoring
the broader picture and the complex intertwining of
problems in different areas.
Second, these isolated problems that are part of a
broader personality problem are often treated with
treatment protocols for symptom disorders, although
we now know that these are often less effective in
these patients, particularly in more severe cases (Oleski,
Cox, Robinson, & Grant, 2012; Reich & Vasile,
1993). Given the problems with the dissemination and
implementation of evidence-based treatments for PDs
in adolescence, there is a risk that therapists feel unable
to cope with inevitable crises and apply ineffective and
potentially damaging interventions, such as repeated
crisis admissions and the prescription of increasing
dosages of medication. This is only likely to add to the
feelings of despair of adolescents with PDs and their
families.
Third, congruent with the DSM PDs Work Group
(Bender, Morey, & Skodol, 2011), we believe that a
focus on personality issues in adolescents necessarily
entails a focus on impairments in self and interpersonal
functioning, a focus that immediately provides impor-
tant targets for treatment (Luyten & Blatt, 2013). This
approach is also particularly helpful in identifying the
many problems these adolescents often have to
establish a treatment alliance in the first place: difficul-
ties of adolescents to commit themselves to treatment,
to reflect upon and discuss their problems, to engage
in a constructive therapeutic alliance, and to be able
to tolerate frustrations encountered in treatment. All
these issues reflect impairments in self-definition and
interpersonal relatedness; they are not simply the
reflection of a lack of motivation or an unwillingness
to accept help. We therefore fully agree with Shiner
and Allen (2013) that the newly proposed dimensional
model in Section 3 of DSM-5 (American Psychiatric
Association, 2013) could help to identify important
targets for treatment and furthermore bridge the gap
between research and clinical practice in this field.
Fourth, there is good evidence to suggest that PDs
in adolescence are associated with a greater psychoso-
cial or economic burden than in any other life phase.
Adolescents experience more painful affects (Bradley,
Zittel Conklin, & Westen, 2005), and they engage
more often in self-destructive and suicidal behavior
(Claes & Vandereycken, 2007; Lewinsohn, Rohde, &
Seeley, 1996) compared to adults. This puts a heavy
burden upon parents and other family members, often
leading to parental dilemmas so well described by
Miller, Rathus, and Linehan (2007). It also puts pres-
sure on clinicians to control these frequent crises, often
through the use of medication and crisis admissions,
leading to high medical costs. Cailhol et al. (2012), for
instance, found that BPD in adolescence, just as in
adulthood, was associated with greater use of mental
health care services. Elsewhere, we (Feenstra et al.,
2012) reported that PDs in adolescence are associated
with a high burden for society. For example, we found
that the complete cost of an adolescent with a PD, in
the Netherlands, equalled €14,032 (approximately
$18,500) per year, which is mainly caused by direct
medical costs, like unhelpful treatments, crisis admis-
sions, and high levels of medication use. Remarkably,
costs associated with PDs in adolescents are even
higher than those typically found in adults with PDs
(€7,398 per patient, approximately $9,700; Soeteman,
Hakkaart-van Roijen, Verheul, & Busschbach, 2008).
The economic burden in adolescents with PDs is
also substantially higher than the burden associated
with other child or adolescent conditions, such as
conduct disorder (Harrington et al., 2000; Romeo,
Knapp, & Scott, 2006), depressive disorder (Byford,
Barrett, Roberts, Wilkinson, et al., 2007), or ADHD
COMMENTARY ON THE SPECIAL SERIES 447
(Swensen et al., 2003), but lower than for adolescents
with anorexia nervosa (Byford, Barrett, Roberts,
Clark, et al., 2007), adolescents admitted to an inpa-
tient treatment (Green et al., 2007), or young offend-
ers (Barrett, Byford, Chitsabesan, & Kenning, 2006).
Yet, the quality of life of adolescents with PDs is very
low, comparable to the quality of life found in adoles-
cents with major depressive disorder (Byford, Barrett,
Roberts, Wilkinson, et al., 2007) and to adults with
PDs (Soeteman, Verheul, & Busschbach, 2008). Fur-
ther, these adolescents also increase the economic bur-
den of their families as well as decrease the quality of
life of their siblings and parents (Romeo, Byford, &
Knapp, 2005). Although no data exist on the burden
on families of adolescents with PDs, it is likely to be
quite substantial.
Finally, we agree with Chanen’s plea for early
detection and intervention of PDs (Chanen &
McCutcheon, 2013). Personality in adolescence lacks
the typical rigidity that is characteristic of PD features
in adults. Adolescence therefore may be a key develop-
mental phase for interventions to target. On the other
hand, adolescents go through a series of important
biological, cognitive, social, and emotional changes
(Slot, 1994) that may limit the effectiveness of inter-
ventions. Neurodevelopmental changes in this life
phase in particular often make it difficult, even for nor-
mal adolescents, to understand the perspective of others
(Blakemore, 2008; Bleiberg, Rossouw, & Fonagy,
2012; Fonagy & Luyten, 2011; Sharp et al., 2011).
Yet, there is much at stake here, given the major
developmental challenges of adolescence, such as the
consolidation of feelings of self, identity and autonomy,
the development of increasingly differentiated and
mature interpersonal relationships, including romantic
relationships, and career development (Erikson, 1963;
Luyten, Vliegen, Van Houdenhove, & Blatt, 2008).
Developmental research suggests that it is very hard
to catch up with developmental delays as a result of
psychological problems in adolescence, particularly if
these problems are associated with extended inpatient
treatment and the development of negative expecta-
tions about oneself and the future as a result of drop-
ping out of school, treatment failures, and being
stigmatized. As Chanen and McCutcheon (2013)
point out, after all, we are not treating these adoles-
cents to prevent diagnostic categories, but to enable
them to develop a more promising life with more
possibilities.
CONCLUSIONS
But there is also good news, as there are a growing
number of studies demonstrating that personality
pathology in adolescents can be effectively treated.
Currently, four randomized controlled trials (RCTs;
Chanen et al., 2008; Mehlum et al., n.d.; Rossouw &
Fonagy, 2012; Schuppert et al., 2012) and a number of
naturalistic studies (for an overview, see Feenstra, Lau-
renssen, Hutsebaut, Verheul, & Busschbach, 2013) are
available. What is perhaps most remarkable about these
studies is that in both the RCTs of Chanen et al.
(2008) and Rossouw and Fonagy (2012), a relatively
small number of sessions were associated with clinically
significant changes in adolescents with BPD traits. The
average number of (psychotherapy) sessions in both
studies was 13 (although, of course, these interventions
also included family work, case management, and/or
psychiatric review sessions). This is far fewer than the
number of sessions in evidence-based treatments for
BPD in adults. At the very least, this provides some
hope that the typical negatively spiral associated with
BPD in adolescence may be relatively easily turned
into a more positive one, at least in a considerable
number of these adolescents.
To summarize, this special issue demonstrates the
growing interest and evidence base concerning PDs in
adolescents. At the same time, however, it also illus-
trates the great challenges we face as a field. It is clear
that future research should focus on adolescent-specific
assessments of personality pathology in adolescents.
Furthermore, the development and empirical testing of
treatment models for more severely disturbed adoles-
cents is needed. The (cost-)effectiveness of these treat-
ment models deserves specific attention given the high
psychosocial and economic burden associated with PDs
in adolescence. Finally, more knowledge of the neuro-
biology and genetics of PDs in adolescence is needed,
which promises to considerably increase our insights
into the intergenerational transmission of personality
pathology and may provide important targets for
interventions as well (Fonagy & Luyten, 2009; Lagioia
et al., 2011).
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE � V20 N4, DECEMBER 2013 448
This special issue will likely lead to an increased
awareness among both researchers and clinicians of the
need to acknowledge the importance of PDs in adoles-
cents. Only then individuals like Amy may face a
brighter future.
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