Debate: It is time to stop turning a blind eye to personality disorder in young people

Prevalence and incidence of personality disorders among children and adolescents in Danish mental health services: a nationwide register study

A few epidemiological studies have examined personality disorders (PDs) among children and adolescents in secondary mental health services. This study aims to describe the prevalence and incidence of PDs among children and adolescents who have attended Danish child and adolescent psychiatric services (CAPS). Using register-based data, we studied all patients under the age of 18 years who were admitted to in- and outpatient CAPS (N = 115,121) in Denmark from 2007 to 2017. A total of 4952 patients were diagnosed with a PD during the study period. The mean prevalence was 859 patients per year, and the mean incidence was 274 patients per year, including an increased incidence and prevalence of borderline, anxious, and unspecified PDs over the decade. The number of patients diagnosed with PDs increased from 700 to 851 per year, but the proportion of patients with PDs compared to all psychiatric diagnoses decreased from 4.2% to 2.8% over the study period. The PD population had an older age (14.8 years vs. 11.3 years; p < 0.001), a higher likelihood of being female (74% vs. 44%; p < 0.001), and four times more contacts with the psychiatric emergency departments than other patients with a psychiatric diagnosis. Future studies should focus on (a) implementing further epidemiological studies in different countries; (b) tracking diagnostic practices to facilitate comparisons and provide feedback for training clinicians and raising awareness; and (c) estimating trajectories of PDs, including costs within the CAPS, to facilitate informed decision-making regarding the future organization and provision of services to these children, adolescents, and their families.

Patient personality and therapist responses in the psychotherapy of adolescents with depressive disorders: toward the Psychodynamic Diagnostic Manual - third edition

Depressive disorders in adolescence pose unique challenges for assessment and treatment, particularly due to their high comorbidity with various personality disorders. Moreover, young depressed patients may elicit very intense and difficult-to-manage emotional responses in therapists (in this context, countertransference). This study aimed at empirically identifying specific personality disorders (or subtypes) among adolescents with depressive pathology and exploring distinct countertransference patterns emerging in their psychotherapy: 100 adolescents (58 with depressive disorders; 42 with other clinical conditions) were assessed by their respective clinicians (n=100) using the psychodiagnostic chart-adolescent of the Psychodynamic Diagnostic Manual (PDM) - second edition, and the therapist response questionnaire for adolescents. Results showed that depressed adolescent patients exhibited marked traits of four personality subtypes (i.e., depressive, anxious-avoidant, narcissistic, and borderline) characterized by different levels of mental functioning and personality organization. These subtypes were predictably related to specific clinicians' emotional responses, even when controlling for the intensity of depressive symptomatology. Patients with depressive or anxious-avoidant personality subtypes evoked more positive countertransference responses, whereas patients with narcissistic or borderline subtypes elicited strong and hard-to-face emotional responses in therapists. Consistent with the next edition of the PDM, the study emphasizes the importance of comprehensive psychodynamic assessment in the developmental age, which frames depressive disorders in the context of accurate emerging personality and mental functioning profiles. This approach, which also relies heavily on the clinician's subjective experience in therapy, provides crucial information on how to specifically tailor interventions that more effectively meet the needs of adolescents with these heterogeneous and complex clinical conditions.

Personality Disorders and Attachment Trauma in Adolescent Patients with Psychiatric Disorders

This study examined how personality disorders (PD) differ with respect to gender, attachment status and traumatic childhood experiences in adolescent psychiatric inpatients. In particular, we investigated attachment-related traumatic material underlying adolescent PD. Our sample consisted of 175 inpatient adolescents aged 14 to 18 years (77% female, Mage = 15.13, SD = 1.35; 23% male, Mage =14.85, SD = 1.41). Thirty-nine patients (22%) fulfilled the diagnostic criteria for a PD according to the SCID-II PD: 51% avoidant, 13% obsessive-compulsive, 13% antisocial, 19% borderline, 2% paranoid and 2% histrionic. In the total sample, eighty-three (47%) of our inpatients were classified with an unresolved attachment status using the Adult Attachment Projective Picture System (AAP). We did not find any significant gender differences for patients with and without a PD. Our results revealed a higher percentage of unresolved attachment status in patients with a PD. The in-depth analysis of the total sample showed that patients with a PD demonstrated more traumatic material in their attachment interviews indicating a greater severity of attachment trauma. Furthermore, patients with a PD reported higher scores on emotional and physical neglect. Intervention strategies targeting traumatic attachment-related themes might be useful to treat adolescents with PD.

Bringing personality disorder in from the cold: Why personality disorder is a fundamental concern for youth mental health

OBJECTIVE

Personality disorder (PD) has its peak incidence between puberty and young adulthood. By any measure, it is among the most severe mental health problems occurring in young people, uniquely predicting debilitating current problems and acting as a 'gateway' to diverse and serious future problems. Yet, PD still struggles for legitimacy and parity of access to services, including early intervention.

CONCLUSION

Addressing PD is fundamental to youth mental health, and early intervention for PD has reached 'proof of concept'. Yet, reform is hindered by bigotry and sectarianism. Successful early intervention calls for a shift in the culture of services, countering damaging myths, addressing bigotry, and fostering hope. Such reforms are well within the reach of youth mental health.

Commentary: Commentary on the Twitter comments evoked by the May 2022 debate on diagnosing personality disorders in adolescents

The debate about the value and utility of personality disorder (PD) diagnosis in adolescence published in the May 2022 issue of CAMH generated fervent Twitter discussion. This commentary addresses some points raised in the Twitter discussion that represent important social and/or cultural beliefs that are often presented in day-to-day practice but are rarely tested in the context of scientific evidence. This includes, in particular, the assertion that symptoms used to diagnose personality disorder are better described as sequelae of trauma, and the assertion that effective treatment for PD is possible without a diagnosis. The call for a fundamental transformation of mental health services that currently do not meet the needs of people with PD and for the involvement of people with lived experience as equal partner in this process is supported by evidence and might represent common ground among those clinician-scientist advocating for early intervention for PD and those expressing their concerns about this issue.

Persönlichkeitsstörung im Jugendalter

Zusammenfassung: Die kategoriale Klassifikation der Persönlichkeitsstörungen (PS) wurde im letzten Jahrzehnt durch eine „Perspektive der Lebensspanne“ mit zunehmend dimensionaler Sichtweise abgelöst. Für den Kinder- und Jugendbereich ist maßgeblich, dass die PS als Ergebnis dieses Prozesses als Erkrankungen angesehen werden, welche die gesamte Lebensspanne betreffen können. Diese Neuerung bereitet den Weg zu einer möglichen Frühbehandlung und ggf. sogar Prävention der PS bei Kindern und Jugendlichen. Im klinischen Alltag jedoch wird die Vergabe von PS in dieser Altersgruppe bis heute oft als kritisch angesehen. Das Themenheft möchte einen Beitrag zur Aufklärung über PS im Jugendalter leisten. Ziel ist es, dass die Vergabe von PS nicht als eine Stigmatisierung junger Menschen angesehen wird, sondern vielmehr als Chance schwerwiegende Entwicklungsverläufe früh zu erkennen und zielgerichtet zu verhindern oder zu behandeln. Der Fokus der Beiträge des Themenheftes liegt dabei auf der Borderline-Persönlichkeitsstörung (BPS) im Jugendalter.