Personality Disorders Can Be Diagnosed in Adolescents

Laurie Barclay, MD

May 13, 2003

May 13, 2003 — Personality disorders exist and can be diagnosed in adolescents, according to the results of a study published in the May issue of the American Journal of Psychiatry. The investigators suggest that the system developed for adults may not be optimal, and that perhaps a new system based on adolescent samples should be developed.

"The study of personality pathology in adolescence is in its infancy," write Drew Westen, PhD, and colleagues from Emory University School of Medicine in Atlanta, Georgia. "Existing data suggest that despite substantial developmental changes in adolescence, enduring maladaptive personality characteristics can be assessed in the teen years, are not reducible to axis I disorders, and show predictive value above and beyond axis I diagnoses."

Using axis II ratings scales and the Shedler-Westen Assessment Procedure-200 for Adolescents (SWAP-200-A), 296 randomly selected clinicians described a patient aged 14 to 18 years in treatment for maladaptive personality patterns.

For the most part, axis II diagnoses in adolescents resembled those in adults. However, application of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria appeared to overdiagnose antisocial and avoidant personality disorder in adolescents.

Q analysis with the SWAP-200-A identified five personality disorders (antisocial-psychopathic, emotionally dysregulated, avoidant-constricted, narcissistic, and histrionic) and one personality style. For each diagnostic prototype, dimensional scores were predictably correlated with ratings of current axis II disorders, measures of adaptive functioning, and symptoms assessed with the Child Behavior Checklist.

"With some exceptions, personality pathology in adolescence resembles that in adults and is diagnosable in adolescents ages 14-18," the authors write. "Categories and criteria developed for adults may not be the optimal way of diagnosing adolescents. Data from samples of adolescents may prove useful in developing an empirically and clinically grounded classification of personality pathology in adolescents."

Problems with applying axis II to adolescents include high rates of comorbidity and the high percentage of patients diagnosed with antisocial and avoidant personality disorders (more than 30% each).

"Although this could reflect characteristics of the sample or an accurate portrait of adolescent personality pathology, a more likely explanation is that axis II criteria overpathologize adolescent acting out and place depressed or anxious adolescents in an overinclusive avoidant category," the authors write.

Am J Psychiatry. 2003;160:952-966

Reviewed by Gary D. Vogin, MD

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