To Diagnose or Not to Diagnose: The Debate on Personality Disorders in Adolescence

The Intersectionality of PD in Adolescence 

The presentation of a personality disorder in adolescence is complicated by the ongoing debate of whether personality disorders should be diagnosed. Some licensed health professionals are hesitant to provide a diagnosis due to the belief that adolescence is a period of changing personality,[1] thus, it is not appropriate to judge if a personality is disordered. However, other health professionals argue for the benefits of early detection and treatment, leading to better health outcomes.[2] The impacts of the home environment, genetics and consequences of a diagnosis further complicate this debate.

Effects of Home Environment 

Childhood maltreatment (e.g., neglect, physical abuse) substantially increases the risk of developing a personality disorder.[3] The Minnesota Project by Sroufe et al. (2005) followed a group of high-risk children into adulthood and found that insecure attachment during childhood is strongly associated with the later development of personality disorders in adolescence.[4] Later studies on Borderline Personality Disorders (BPD) further supported the association of adverse childhood experiences as a risk factor for personality disorders. Marchetti et al. (2022) found that a history of childhood maltreatment was associated with higher levels of BPD in adolescents (average age 16).[5] Furthermore, studies by Xiao et al. (2023) found that adolescents with BPD had higher rates of all the assessed childhood traumas when compared to adolescents with non-disordered personalities; this was especially true for emotional neglect (the most commonly seen childhood trauma).[6]

Effects of Biological Factors

Adolescence is a time of biological change, including those that regulate one’s personality. Throughout adolescence, the brain continues to develop in term of myelination and the formation of synaptic networks; thus, the neural basis for many psychological regulatory systems are still in development.[7] Furthermore, the frontal, temporal and occipital lobes of the brain (which are responsible for response inhibition, emotion regulation, planning and organization) are still developing during adolescence, which may account for the increased impulsivity sometimes seen during this period.[8] The increased levels of sex hormones adolescents are exposed to during puberty also affect mood regulation.[9] Therefore, the developmental changes of adolescence can bring forth impulsivity and mood changes, similar to the changes brought by a personality disorder. 

However, studies by Xiao et al. (2023) have found that there are also biological differences in adolescents with personality disorders compared to non-disordered peers.[10] They found that adolescents with Borderline Personality Disorder showed increased Amplitude Low-Frequency Fluctuations in the limbic system (a measure of spontaneous neuronal activity related to the mood swings associated with BPD).[11] Thus, biological factors can also account for differences in the mood swings of adolescents with disordered personalities compared to non-disordered adolescents.

Arguments in favor of a diagnosis

The argument in favor of a diagnosis appeals to the benefits of early diagnosis, specifically: better health outcomes. Paris et al. (2013) report that conditions such as antisocial personality disorders begin in childhood, and as a result of the early onset, psychopathology is more likely to continue.[12] An analysis of personality trait dimensions also supports the early establishment of personality. Studies by Shiner et al. (2009) suggest a continuity from child to adult personality based on findings that certain personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) in childhood predicted later behaviors.[13] Klimstra et al. (2009) distinguish that personality traits change considerably at the ages of 10-15 years old and then stabilize at the ages of 16-21 years.[14] However, according to Cicchetti et al. (2009), since personality disorders (PD) do not begin in adulthood, early investigation is necessary to develop a lifespan model for treatment.[15] Schmeck (2022) further supports the need for early intervention in personality disorders, arguing that early diagnosis rids the stigma associated with PD and lessens the possibility of long-lasting impairments and disability by facilitating the transition into adulthood.[16] 

These benefits of early diagnosis may have been considered by the Diagnostic and Statistical Manual of Mental Disorders (DSM) since the most recent version of the guide to diagnosing mental disorders has changed its age requirements for diagnosing PD. While earlier versions of the DSM did not allow someone under 18 to be diagnosed, the DSM-5 (the most recent version) allows the diagnosis of a personality disorder in someone under 18 if symptoms are present for at least one year.[17] 

Arguments against diagnosis

A study by Laurenssen et al. (2013) found that 57.8% of psychologists working with adolescents acknowledged the existence of personality disorders in this age group; however, only 8.7% of them actually made formal PD diagnoses in the adolescents.[18] The majority of psychologists are reluctant to diagnose adolescents based on the idea that personality is fluid and still developing.[19] Dijk et al. (2021) argue that while personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) are structurally similar between adolescents and adults, there are developmental differences; for example, adolescents appear to be less conscientious.[20] Some psychologists also argue that an early diagnosis is stigmatizing since personality pathology can often be viewed as being unmodifiable.[21,22] Furthermore, according to Adshead et al. (2012), a misdiagnosis of a personality disorder in adolescence can focus attention away from interventions to improve the caregiving environment, particularly if neglect or abuse are present.[23] Perhaps taking the drawbacks of diagnosis into account, the American Psychiatric Association webpage, as of now, states that diagnosis of personality disorders is only applicable to individuals 18 and older (It is important to note that the American Psychiatric Association oversees the DSM-5).[24]

Treatment of PD in adolescence

Personality disorders vary in the ways they impact an individual’s thoughts and ways of expressing themselves, however, they align in their need for treatment to go away.[25] In adults certain psychotherapies (e.g., Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Group Therapy, Psychoanalytic) have shown to be effective for treating personality disorder.[26] If an adolescent is diagnosed with a personality disorder, their treatment plans may differ slightly from adults. Adolescent treatment plans are complex due to a current need for more evidence if adult interventions also work for adolescents.[27] Furthermore, these treatment plans are unique as they often incorporate the adolescent’s school and parents.[28]

If you believe you or your child may have a personality disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Adshead, G., Brodrick, P., Preston, J., & Deshpande, M. (2012). Personality disorder in adolescence. Advances in Psychiatric Treatment, 18(2), 109-118. doi:10.1192/apt.bp.110.008623

2 Cicchetti, D., & Crick, N. R. (2009). Precursors and diverse pathways to personality disorder in children and adolescents. Development and Psychopathology, 21(3), 683-685. doi:https://doi.org/10.1017/S0954579409000388

3 Adshead et al. (2012)

4 Sroufe, A, Egeland, B, Carlson, E et al (2005) The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. Guilford Press

5 Marchetti, D., Musso, P., Verrocchio, M., Manna, G., Kopala-Sibley, D., De Berardis, D., . . . Falgares, G. (2022). Childhood maltreatment, personality vulnerability profiles, and borderline personality disorder symptoms in adolescents. Development and Psychopathology, 34(3), 1163-1176. doi:10.1017/S0954579420002151

6 Xiao, Q., Yi, X., Fu, Y., Jiang, F., Zhang, Z., Huang, Q., Han, Z., & Chen, B. T. (2023). Altered brain activity and childhood trauma in Chinese adolescents with borderline personality disorder. Journal of affective disorders, 323, 435–443. https://doi.org/10.1016/j.jad.2022.12.003

7 Adshead et al. (2012)

8 Ibid. 

9 Ibid. 

10 Xiao et al. (2023)

11 Ibid. 

12 Paris, Joel. “Personality disorders begin in adolescence.” Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent vol. 22,3 (2013): 195-6. doi:10.1007/s00787-013-0389-7

13 Shiner, R (2009) The development of personality disorders: perspectives from normal development. Development and Psychopathology 4: 715–34

14 Klimstra, TA, Hale, WW, Raaijmoken, QA (2009) Maturation of personality in adolescence. Journal of Personality, Society & Psychology 96: 898–912

15 Cicchetti et al. (2009)

16 Schmeck, K. (2022, March 17). Debate: Should CAMHS professionals be diagnosing ... - wiley online library. ACAMH. https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12553

17 Personality disorders: Diagnosis. CAMH. (n.d.). https://www.camh.ca/en/professionals/treating-conditions-and-disorders/personality-disorders/personality-disorders---diagnosis#:~:text=According%20to%20DSM%2D5%2C%20features,for%20at%20least%20one%20year.

18 Laurenssen, E. M., Hutsebaut, J., Feenstra, D. J., Van Busschbach, J. J., & Luyten, P. (2013). Diagnosis of personality disorders in adolescents: a study among psychologists. Child and adolescent psychiatry and mental health, 7(1), 3. https://doi.org/10.1186/1753-2000-7-3

19 Paris (2013)

20 van Dijk, I., Krueger, R. F., & Laceulle, O. M. (2021). DSM-5 alternative personality disorder model traits as extreme variants of five-factor model traits in adolescents. Personality disorders, 12(1), 59–69. https://doi.org/10.1037/per0000409

21 Cicchetti et al. (2009)

22 Adshead et al. (2012)

23 Ibid. 

24 What are personality disorders?. Psychiatry.org - What are Personality Disorders? (2022, September). https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders#:~:text=Diagnosis%20of%20a%20personality%20disorder,their%20personalities%20are%20still%20developing.

25 Ibid.

26 Ibid.

27 Adshead et al. (2012)

28 Ibid.

When Does Dissociation Become Unhealthy?

Physically I’m Here… Mentally I’m Far, Far Away

Dissociative experiences can be a harmless and even euphoric part of life. This can look like getting lost in your favorite song, watching a beautiful sunset in complete awe or being so engaged in a meditation session that nothing else matters to you in that moment. On the other end of the spectrum, however, maladaptive dissociation can have detrimental impacts on a person’s wellbeing and functionality if left untreated and misunderstood.

Dissociation can severely impair peoples’ ability to effectively integrate their thoughts, memories and emotions with their experience of reality and perception of their identity.[1] The result in such extreme cases is often a highly fragmented sense of life and self-identity that can lead to mental health problems such as depression, anxiety and suicidal thoughts. Understanding the difference between so-called “healthy” and “unhealthy” dissociation is a critical first step for determining whether someone should seek help.

What is “Healthy” Dissociation?

Compared to other psychological defenses, dissociation is unique in that milder versions can be invoked voluntarily. For example, the ability of absorption to be consciously learned and applied combined with its psychological defensive capacity makes it an ideal therapeutic strategy.[2] Absorption consists of disconnecting from one’s current circumstances (both external and psychological) and becoming immersed in another focus. Absorption in music, nature and other positive foci can relieve emotional distress when a person is experiencing emotional or even physical pain.[3] While absorption itself involves some degree of dissociation, it is not indicative of pathological dissociation and can have many advantageous effects. 

In her book, Everyday Music Listening: Absorption, Dissociation and Trancing, Ruth Herbert describes absorption in music as a therapeutic practice that may involve “multi-sensory blending” and “heightened awareness”.[4] She argues that everyday listening can be not only pleasurable or relaxing, but transcendent in a way that is comparable to religious rituals and mindfulness meditation — all of which frequently prompt a state of dissociation. The multitude of ways in which individuals can remold, reinterpret or redirect their own consciousness through absorption in positive foci certainly exemplifies the human brain as a powerful tool in constructing our reality. Healthy dissociation — that is, when one can control it and choose when to do it — has incredible promise in both therapeutic approaches and consciousness research more broadly. So… How can dissociation become a chronic or even debilitating problem, characteristic of the dissociative disorders?

A Very Fine Line

Milder forms of dissociation often provide a defensive function which dislocates affect from ideas, diminishing the impact of disturbing emotional states.[5] For example, a dissociative episode may help foster a state of indifference or neutrality towards a stressful situation. Up to 75% of people experience at least one depersonalization/derealization episode in their lives, with only 2% meeting the full criteria for chronic episodes.[6] Yet, most clinically-noted dissociative episodes typically involve severely dysfunctional behavior, perpetuating the notion that dissociation is not applicable to the overall population.[7]

Upon examining typical manifestations of dissociation as defense mechanisms conducive to survival, we see that dissociation is the “freeze” part of the flight, fight and freeze emergency systems. Taken alone, this is a completely natural mental response to discomfort, stress and adversity. However, the tendency to rely on this “freeze” reaction can be the birthplace of dissociative disorders. Once individuals have learned to use dissociation to cope with an aversive event, dissociation can presumably become automatized and invoked on a habitual basis in response to even minor stressors.[8] Thus, even seemingly isolated experiences of dissociation can become chronic manifestations characteristic of dissociative disorders. It is therefore important that researchers and therapists take note of this link as to not overlook acute, nonpathological episodes in a clinical framework.

The Trauma-Dissociation Link

At some point in life, most people will endure some degree of heartbreak and loss. However, to live through true trauma is a completely different experience. The physical and mental shock of trauma elicits the brain’s immediate survival instincts — one of which being dissociation.[9] The vast majority of people who develop dissociative disorders have experienced repetitive, overwhelming trauma in childhood. Those who have experienced physical and sexual abuse in childhood are at increased risk of dissociative identity disorder (DID). Among people with dissociative identity disorder in the United States, Canada and Europe, roughly 90 percent had been the victims of childhood abuse and neglect.[10] 

Severely dissociative symptoms are manifestations of an automatic defense mechanism that serves to mitigate the impact of highly aversive or traumatic events. The idea of dissociation serving a defensive function can be traced back to Pierre Janet’s 1889 pioneering investigations of dissociative phenomena.[11] In the context of trauma, dissociation can be one of the ways your brain protects us in the face of adversity – both in the present moment and for the future. In a traumatic situation where someone might need to react quickly and instinctively to escape danger, dissociation serves as a way to mentally “check out” so that stress and fear does not overwhelm their mind. Also taking preventative measures, our brains do not want us to relive the shock of a traumatic experience, so it leaps into survival mode, taking steps to conceal or numb what happened. But… If dissociation is a natural response meant to protect us from trauma, how does it become something disordered that requires treatment?

Trapped in Limbo Between Past and Present

Binks & Ferguson (2013) note that while at the moment of the traumatic event dissociation is highly adaptive and protects the psyche from pain and feelings of helplessness and humiliation, individuals who cope with trauma by dissociating are vulnerable to using this method to cope with future stressors.[12] This becomes especially problematic in cases of childhood/adolescent trauma, as these time periods are integral junctures in the development of more persistent personality pathology.[13] Exposure to trauma during these critical periods exacerbates the likelihood of establishing dissociation as a habitual coping mechanism for the rest of life.

Dissociation is paradoxical in that it can relieve trauma survivors of the immediate pain they are in, but can also become a danger in, and of, itself. In the long-run, habitual dissociation established as a standardized defense mechanism early in life produces detrimental consequences. An account of dissociation from the perspective of a childhood trauma survivor illustrates why: “Dissociation makes surviving the abuse much easier… But it also makes living as an adult so much harder.”[14] Contorting the timeline of when trauma is experienced, dissociation keeps someone trapped in a sort of limbo between past and present. It challenges their ability to fully heal and transcend childhood levels of emotional maturity. In turn, dissociation threatens the agency a person has over their own life and, ultimately, the beauty of actually living as opposed to merely surviving.

The Double-Edged Sword

There are many promising avenues for future research in the realm of therapeutic dissociation, keeping in mind that dissociation in the context of mindfulness is vastly different from habitual dissociation evoked as the primary response to trauma. This distinction lies in the agency we have over the dissociation – that is, choosing to dissociate to enhance the experience of living vs. dissociating merely to survive. In this way, dissociation is a double-edged sword, possessing a great potential in encouraging wellbeing when we can control it, but perhaps an even greater potential for danger when it controls us.

If you feel you may be dissociating at unhealthy levels and/or in a way that is interfering with fully living your life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) to discuss possible therapeutic options and treatment modalities. Cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) are both common forms of psychotherapeutic treatment for all dissociative disorders.[15] To learn more about types of dissociative disorders and effective treatments, feel free to refer to our encyclopedia entry on dissociation.

Contributed by: Sara Wilson

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 American Psychiatric Association. (2022, October). What are Dissociative Disorders? Psychiatry.org. Retrieved 27 May, 2023, from https://www.psychiatry.org/patients-families/dissociative-disorders/what-are-dissociative-disorders. 

2  Bowins, B. E. (2012). Therapeutic Dissociation: Compartmentalization and Absorption. Counseling Psychology Quarterly, 25(3), 307-317.

3 Ibid.

4  Becker, J. (2014). [Review of Everyday Music Listening: Absorption, Dissociation and Trancing, by R. Herbert]. Ethnomusicology Forum, 23(2), 266–268. http://www.jstor.org/stable/43297432.

5  Bowins (2012)

6  National Alliance on Mental Illness. (2023). Dissociative Disorders. Retrieved 27 May 2023, from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Dissociative-Disorders.

7  Bowins (2012)

8  Giesbrecht, T., Lynn, S. J., Lilienfeld, S. O., & Merckelbach, H. (2008). Cognitive Processes in Dissociation: An Analysis of Core Theoretical Assumptions. Psychological Bulletin, 134(5), 617-647. https://doi.org/10.1037/0033-2909.134.5.617.

9  Gillette, H. (2021, August 3). Trauma-Related Dissociation: Symptoms, Treatment, Coping, and More. Psych Central. https://psychcentral.com/pro/coping-with-trauma-through-dissociation.

10  American Psychiatric Association.

11  Giesbrecht et. al., (2008)

12  Binks, E., & Ferguson, N. (2013). Religion, trauma and non-pathological dissociation in northern ireland. Mental Health, Religion & Culture, 16(2), 200-209. https://doi.org/10.1080/13674676.2012.659241.

13 Shiner, R. (2023, April 4). Emergence of Personality Disorder in Adolescence: New Findings and Their Implications for Treatment. YouTube. https://www.youtube.com/watch?v=K00Xdcjd7_E&t=416s.

14 Beauty After Bruises. (2023, April 21). Dissociation and Survival vs. Living: A Survivor’s Story. Beauty After Bruises. https://www.beautyafterbruises.org/blog/survivorstory.

15  Cleveland Clinic. (2022, October 24). Dissociative Disorders: Causes, Symptoms, Types & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/17749-dissociative-disorders.