7
COMMENTARY 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 [email protected]. © 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

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Page 1: Personality Disorders in Adolescence: Label or Opportunity?

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

[email protected].

© 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

Page 2: Personality Disorders in Adolescence: Label or Opportunity?

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

Page 3: Personality Disorders in Adolescence: Label or Opportunity?

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

Page 4: Personality Disorders in Adolescence: Label or Opportunity?

(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

Page 5: Personality Disorders in Adolescence: Label or Opportunity?

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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Received September 17, 2013; accepted September 30, 2013.

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