Personality Disorders in Adolescence: Introduction to the Special Issue

In honor and memory of Theodore Millon (1928 – 2014)

We are delighted to introduce this special issue of SJCAPP, which addresses personality disorders (PDs) in adolescence; financed through a generous grant from the Institute of Personality Theory and Psychopathology (IPTP) in Denmark.

The International Society for the Study of Personality Disorders (ISSPD) was founded in 1988 via the initiative of Theodore Millon, as we have described elsewhere (1). The purposes of the ISSPD were to establish international connections among people involved in the study of PDs and to foster collaboration for related research and education. The Danish IPTP served as the organizer of the first and founding ISSPD International Congress on the Study of Disorders of Personality, which was held in Copenhagen, Denmark, in 1988. The ISSPD has become the most prominent organization in the field of PD, and there has been rapid growth in research into PDs since its founding; this research has contributed significant findings that have altered our very understanding of the etiology, assessment, treatment, course, and outcome of PDs.

From September 16 through 19, 2013, the XIII^th ISSPD Congress on the Disorders of Personality was organized by the IPTP and once again held in Copenhagen. A major reason for bringing the ISSPD Congress “back home” to Denmark was to celebrate the 25th anniversary of the ISSPD. The Congress had the overall theme of “Bridging Personality and Psychopathology: The Person Behind the Illness.” Ted Millon, the founding father of the ISSPD, served as patron of the Congress (2). The theme was chosen not only for its academic and clinical relevance but also as a salute to Millon, for whom this idea was a common thread throughout his pioneering and impressive career. Millon always insisted that personality, PD, and psychopathology were intermingled. He argued that they should be understood always as part and parcel of a complex and organically interwoven whole: the real person. With a voice that echoed the age-old Grecian thoughts of Hippocrates and later of Sir William Osler, Millon always insisted that we do not treat diagnoses but real people; our diagnostic categories only capture bits of this idea, and they leave out much of what is most important for treatment; namely, the very person behind the illness (3,4). This holistic and humanistic line of thinking advocated by Ted Millon has since been approved by the World Psychiatric Association (WPA) in the WPA Institutional Program on Psychiatry for the Person: From Clinical Care to Public Health in an effort to address the needs of real people and the inadequacies and fragmentation of mental health care and social services (5). This WPA initiative, which is also referred to person-centered psychiatry, affirms that it is the whole person of the patient—within his or her context and at both the individual and community levels—that should be at the center of clinical care and health promotion (6). We should know our patients and take their personalities(-in-context) into account whenever we conduct psychodiagnostic assessment or deliver treatment, whether it is psychosocial, pharmacological, or a mix of both. Knowing the personalities of our patients also means treating them as people, with warmth and respect, and communicating effectively to serve their individual and social needs (7). In this respect, we suggest that knowing the person behind the illness is vital for the art of mental health care. This can be a curative factor in and of itself by fostering a working alliance and catalyzing hope, positive treatment expectations, and treatment adherence (8-11).

Among the many presentations and areas covered by the XIIIth ISSPD Congress (12), deliberate privilege was given to the important issue of personality pathology in adolescence. After the Congress, the IPTP invited the authors of the excellent presentations about PD during adolescence to submit their work as articles for this special issue. We were fortunate to receive the seven scholarly papers that represent important contributions to this field.

PD in adolescence has historically been regarded as controversial within the literature, and psychiatrists and clinical psychologists have been reluctant to diagnose PD during this stage of life. Although such controversy and hesitation were previously justified given the lack of empirical evidence, since the 1990s, research focusing on this subject has been steadily growing. Contrary to expectations, the accumulating empirical studies have converged to underscore the clinical importance and feasibility of detecting, diagnosing, and treating PD during adolescence. Thus, although articles about PD in childhood or adolescence customarily begin with somewhat apologetic, tentative, or defensive statements, we shall refrain from this practice. We agree with Tackett and Sharp (13) that, in light of the available evidence, such statements are no longer needed. PDs are developmental disorders that should accordingly be approached and understood from a lifespan developmental perspective (14,15), and we will expand on this idea in the concluding article for this special issue (16). This developmental conception of PD is also recognized within the official diagnostic systems of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (17) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) (18), which both allow for the diagnosis of PD in individuals who are less than 18 years old (except for antisocial PD, which the DSM-5, Section II, does not allow for diagnosing before the age of 18). The upcoming ICD-11 will in all likelihood continue to endorse this idea by removing any arbitrary age restrictions for PD diagnosis, as was done for the DSM-5 Section III alternative classification of PD.

Another important reason for the increasing interest in PD during adolescence is the likelihood that the earlier the illness starts, the more likely it is to become severe and chronic. Indeed—albeit arguably—we firmly believe that prevention and early intervention lie at the heart of all of the clinical sciences. Given that PDs are developmental disorders that usually emerge during childhood or adolescence, as has been convincingly argued by Chanen and colleagues (19,20), prevention and early intervention for PDs ought to be given high priority in the future. This confers a privileged position to the fields of child and adolescent psychiatry and psychology, in which interventions can be delivered at an early age to target key PD symptoms, perhaps before such symptoms become more entrenched and possibly chronic.

With these reflections in mind, it came as no surprise that the validity of the borderline PD diagnosis was the focus of many of the articles included in this special issue. Fossati (21) tackles this issue head on with his review of the empirical literature regarding the feasibility of diagnosing borderline PD during adolescence. He argues that research in adults with borderline PD has revealed and paved the way for global interest in early identification and intervention. The interrater reliability and internal consistency of the adolescent borderline PD construct seems adequate. Reliable and valid measures of borderline PD during adolescence are also available. Fossati furthermore reports that although no single diagnostic symptom is predictive of future borderline PD diagnosis, combinations of two or more borderline PD symptoms are. Links between borderline PD and disruptive behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) are also discussed. In this SJCAPP special issue, Sharp and Kalpakci (22) also focus on the validity of the borderline PD construct for adolescents by using the five classic validation criteria of Robins and Guze. Like Fossati, these authors conclude that the available evidence supports the construct validity of borderline PD diagnosis during adolescence, although there are problems with the delimitation from other psychiatric disorders. Moreover, they point to the fact that there is only a limited number of family and longitudinal studies. They conclude by suggesting that, in the future, the validity of the borderline PD construct should be investigated with the use of the National Institute of Mental Health developed Research Domain Criteria (RDoC) as a complement, which propagate a dimensional system in response to the flawed categorical system.

Brunner, Henze, Richter, and Kaess (23), in this issue, summarize the neurobiological research on borderline PD in youth. They argue for the importance of this line of research during adolescence, when potential confounding factors are less likely to be present. The authors focus on recent research within the field and review results that pertain to genetics, neuroimaging, neuropsychology, endocrinology, and disturbed pain perception; they then integrate their findings into a developmental psychopathological model. They also underline the need for future longitudinal studies to help determine whether neurobiological factors are a cause, an effect, or an epiphenomenon of borderline PD.

The article by Schlüter-Müller, Goth, Jung, and Schmeck (24) provides yet another perspective on PD in adolescence generally and on borderline PD more specifically by focusing on identity pathology. They describe the psychometric properties of the Assessment of Identity Development in Adolescence (AIDA), a newly developed self-report inventory for the assessment of identity pathology during adolescence. They also outline a treatment model inspired by psychodynamic object relations theory including the Kernberg group’s transference-focused therapy (25,26).

The next two articles in this issue take an alternative approach by focusing on the psychometric evaluation of assessment instruments for maladaptive personality traits in adolescent samples. Tromp and Koot (27) describe the factorial structure, reliability, and validity of the Dimensional Assessment of Personality Pathology – Short Form for Adolescents (DAPP-SF-A), demonstrating its potential utility in both research and applied settings as a brief measure of maladaptive personality traits to enable routine clinical assessments as well as future research into the developmental trajectories of PDs throughout the lifespan. The article by Kongerslev, Bo, Forth, and Simonsen (28) focuses on examining the psychometric properties of the Inventory of Callous-Unemotional Traits (ICU). This study provides preliminary support for the psychometric adequacy of the Danish version of the ICU in a sample of incarcerated adolescent boys, as weel as the construct of callous-unemotional traits strong association with the broader concept of psychopathy. With the inclusion of callous-unemotional traits in the DSM-5 as well as the addition of a “with limited prosocial emotions” specifier for the diagnosis of conduct disorder, we expect that much more research will be generated in the future regarding this maladaptive trait–based subtyping of the heterogenous and behaviorally based construct of conduct disorder.

To conclude this special issue of SJCAPP and to broaden its scope beyond specific PDs and approaches, we—together with Andrew M. Chanen—provide a narrative review of the available research evidence for PDs during childhood and adolescence (16). We are grateful to have Dr. Chanen, who is the current president of the ISSPD and widely regarded as a leading expert on prevention and early intervention for PDs during adolescence, as part of our author team.

With this special issue, we hope to further the research agenda regarding PD in adolescence and to draw clinicians’ attention to the feasibility and importance of diagnosing and treating PD during childhood and adolescence. We want to thank all of the contributing authors for submitting their articles to SJCAPP, and we wholeheartedly dedicate this special issue to Ted Millon, who paved the way.