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Editorial                                                                                                                                               Open Access

## Personality Disorders in Adolescence: Introduction to the Special Issue

Erik Simonsen 1,2 & Mickey Kongerslev 1,3

1 Psychiatric Research Unit, Region Zealand, Denmark 2 Institute of Clinical Medicine, University of Copenhagen, Denmark 3 Psychiatric Clinic Roskilde, Region Zealand, Denmark

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 patientwithin 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(-incontext) 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  attentiondeficit/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 transferencefocused 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 callousunemotional  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.

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