Identity development in adolescents with mental problems

The DSM-IV includes identity disturbance as a criterion of borderline personality disorder and defines it as “markedly and persistently unstable self-image or sense of self” [17], p. 654. In the revision from DSM-IV to DSM-5[18, 19], the concept of identity is a central part of a new conceptualization of personality disorders in the alternative approach to the diagnosis of personality disorders in Section III of DSM-5 (see Schmeck et al. in this issue). The core criteria of personality disorders are composed of impairments in personality functioning in the two domains of self-functioning (self-direction and identity) and interpersonal functioning (empathy and intimacy). Identity is defined as the “experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience” [20]. The new model is placed in Section III of DSM-5 to stimulate further research in this field.

Research of the last 15 years reveals increasing evidence that personality disorders are a prominent form of psychopathology in adolescence [21‐24]. Personality disorders prior to age of 18 years can be reliably diagnosed [25, 26]. They have a good concurrent [24, 27] and predictive validity [22] with adequate internal consistency [28] and similar stability to personality disorders in adulthood [27, 29, 30]. Thus, symptoms of personality disorders in adolescence can be diagnosed and targeted for treatment [11, 31, 32]. Paulina Kernberg [10] described a model for understanding the impact of identity diffusion as a pathogenic mechanism in developing a personality disorder in adolescence and stressed the need to differentiate between normal identity crisis and pathological identity diffusion for a targeted therapeutic intervention. These ideas lead to the development of the psychodynamic treatment approach “Adolescent Identity Treatment” (AIT) [33]. This treatment focuses on identity diffusion in adolescence and is designed to help young patients to establish satisfying relationships, gain self-esteem and clarify aims in life.

Our research group developed the questionnaire AIDA - Assessment of Identity Development in Adolescence[16] to assess pathology-related identity development in healthy and disturbed adolescents aged 12 to 18 years in self-report for diagnostic and prognostic issues. Thus, AIDA is predestinated to be used as a research tool to evaluate therapy efficacy of AIT as well as of every therapy addressing improvement in self-related personality functioning related to constructs described below.

Discourses about identity are heterogeneous [12]. With respect to a broad range of theoretical descriptions about identity development, two domains have been distinguished for constructing the AIDA. In line with the constructs’ dichotomy in social-cognitive psychology as well as in the psychopathology-oriented psychodynamic descriptions the AIDA model distinguishes between the two dimensions “Continuity” and “Coherence”, serving as a well elaborated theoretical framework to find a meaningful and distinct substructure of the higher order construct “identity integration vs. identity diffusion” (for a detailed description see [16]). Following strict rules of deductive test construction and focusing on clear-cut constructs, we integrated aspects of operationalizations of identity diffusion by other authors like Kernberg [34], Westen [35] and Akhtar & Samuel [36] and additionally differentiated the aspects of psychosocial functioning “self-related“, “social-related“, and “related to mental representations / ability” following e.g. Fonagy (emotional and cognitive self-reflection is viewed as an elementary basis for identity development [37]) in order to substructure the construct along its hypothesized constituents (see Table 1).

The construct “Continuity” represents the vital experience of “I” and subjective emotional self-sameness with an inner stable time line. High “Continuity” is associated with the stability of identity-giving goals, talents, commitments, roles, and relationships, and a good and stable access to emotions as well as the trust in the stability of them. A lack of Continuity (i.e. high “Discontinuity”) is associated with a missing self-related perspective, no feeling of belonging and affiliation, and a lack of access to emotional levels of reality and trust in the durability of positive emotions.

The construct “Coherence” stands for clarity of self-definition as a result of self-reflective awareness and elaboration of the “ME”, accompanied by consistency in self-images, autonomy and Ego-strength, and differentiated mental representations. A lack of Coherence (i.e. high “Incoherence”) is associated with being contradictory or ambivalent, suggestible and over-matching, and having poor access to cognitions and motives, accompanied by superficial and diffuse mental representations. The scales are coded towards psychopathology. High scores in the AIDA scales “Discontinuity” and “Incoherence” are indicators of an identity diffusion.

The current study contrasts the identity development of personality disordered adolescents with the identity development of adolescents suffering from internalizing or externalizing disorders. In child and adolescent psychiatric research a procedure like this is often used to clarify the question if discrepancies from a normal sample are specific for a special diagnostic group or if they are a characteristic of mental disorders in general. As outlined above, identity problems are one of the core criteria of personality disorders so that we hypothesize adolescents with personality disorders reaching significantly higher scores in identity diffusion in comparison to other clinical groups. Up to now there are no studies about systematic differences in the level of identity problems in non-PD adolescent patients so that our second hypothesis is based on clinical experience. Patients with severe anxiety disorders and major depression experience a substantially reduced self-esteem which could have an impact on identity development. In contrast, patients with externalizing disorders boost their self-esteem by externalizing their problems. Based on these observations we hypothesize elevated scores of identity diffusion in patients with internalizing disorders in comparison with patients with externalizing disorders.

Participants were 86 inpatients and outpatients of a child and adolescent psychiatric university hospital (N= 75) and a child and adolescent psychiatric practice (N=11). Inclusion criteria were age 12–18 years, sufficient linguistic and cognitive skills to master the written task and no current psychotic episode. The sample consisted of 30 boys (34.9%) and 56 girls (65.1%) in the age range from 12–18 years (mean age 15.24, SD 1.77). The study was approved by the local ethics committee and written informed consent was given. Taking into account the results of the diagnostic interviews K-DIPS (Children – Diagnostic Interview for Psychiatric Diseases) [38] and SCID-II (The Structured Clinical Interview for DSM-IV, Axis II) [39] (see below) and of a classification conference, the patients were assigned to one of the three diagnostic groups “personality disorder (PD)”, “internalizing disorder (internal)”, or “externalizing disorder (external)” (see Table 2). Patients who clearly fulfilled the DSM-IV criteria of a personality disorder were allocated to the PD-group independently of axis I comorbidities like anxiety or depression. Patients with internal or external problems were attributed to the correspondent groups, if the diagnoses were unambiguous and no comorbidities were detected. We excluded patients from further analysis if they showed comorbid internalizing and externalizing problems or other psychiatric disorders like psychoses or pervasive developmental disorders.

From the 86 patients,

In this process we took especially care to create “pure” diagnostic groups to enable valid interpretations of differences between these types of psychiatric disorders in terms of differences in identity development.

We used the Statistical Package for the Social Sciences (SPSS 19 for Windows) for data analyses. Differences between the three groups of psychiatric disorders in AIDA scores were analyzed by multivariate analysis of variance MANOVA with the factor “pathology” (PD, internal, external). The factor “sex” was integrated as a covariate since systematic differences had been detected between boys and girls in the validation sample and different population norms had been suggested [16]. Effect size f is supposed to be big with >.40 but should be at least medium with >.25 to avoid overinterpretation of significant group differences. The sample size is sufficient to test for big effect sizes with significance level p<.05.

The criteria for assignment to the three diagnostic groups were strict in order to build homogenous groups. In a classification conference, where we took the results of the diagnostic interviews and clinical experience into account, heterogeneity and comorbidity could be decreased at the cost of a large residual category. This residual category includes 30 of 86 patients which could not be assigned to one of the research groups. Therefore especially the number of patients in the externalizing group was quite low. Furthermore, the group of patients with internalizing problems remains heterogenic. Compared to the other diagnostic groups, the “internal” group shows relatively large standard deviations in their AIDA scores. We can’t exclude that there might be patients in this group who will develop manifest personality disorders in the future. In this study we used the semi-structured diagnostic interview SCID-II[39] that has been developed to assess personality disorders in adults. Along with the ongoing revisions of DSM and ICD it would be very helpful if assessment instruments could be established that are focused on the symptomatology of adolescents with severe impairment of personality functioning.

From a theoretical perspective, it is very useful to know that mean differences in the AIDA scores exist between diagnostic groups, but mean differences do not translate automatically into accurate diagnoses. For diagnostic purposes, we have to consider whether cut-off points regarding identity diffusion and/or crisis might be useful. Once those markers are established, we could determine false positive and false negative rates. Furthermore, when comparing groups, such as adolescents with differing diagnoses, it is important to establish the equivalence of the groups on as many potentially confounding variables as possible. Including more variables (e.g. socio-economic status, level of education, type of parenting received, relationship status of their parents, or arrest records) as well as in-group comparisons or symptom-oriented rearrangements of the sample could lead to new interesting results and show clearly that the differences in the observed identity functioning have more to do with the psychiatric condition than with other variables.

All in all, further research with a bigger sample and even more homogenous groups is needed to highlight distinct profiles and to examine the thresholds between identity crisis and diffusion in detail to develop a more accurate conceptualization of the construct “Identity crisis”. For this aim, longitudinal studies would be of high interest to model the prognostic power of different levels of identity development on subscale level as well as possible changes over time.