Emerging Personality Disorder in Adolescence
Ways of seeing: Ways of being
John Berger
Professor Sue Bailey
President, Royal College of Psychiatrists
BIGSPD 13th Annual Conference, Manchester, 22nd March 2012
Historical perspective, public
health and individual
psychopathology
 ‘I would there were no age between ten and threeand-twenty, or that youth would sleep out the rest;
for there is nothing in between but getting wenches
with child, wronging the ancientry, stealing,
fighting.’
(William Shakespeare: A Winter’s Tale, Act III, Scene III)
 ‘I am one, my liege
Whom the blows and buffets of the world
Have so incensed, that I am reckless what
I do, to spite the world.’
(William Shakespeare: Macbeth XIII, Scene I)
 Rights
 Mental disorder and children
 Context, ecology and resilience
 How adult literature can help
 Nature-Nurture
 Ethical framework for classification,
interventions and research
 How can we impact on policy matters in this
field – WHO, mental health strategy,
working at interfaces and transitions
 The requirement to ensure that all children and
young people are provided with mental health
care of appropriate quality in response to their
needs is emphasized by International human
rights treaties.
 e.g. Article 24, Convention on the right of the
child, and Article 12, International covenant on
economic, social and cultural rights.
 Both the Marmot Review (2010) and the WHO
(2008) have stated that health is a matter of
social justice.
An ecological framework for
understanding child and youth
development (Garbarino)

Children are embedded in families

Families are embedded in neighbourhoods

Embedded in neighbourhoods are schools

Embedded in families, neighbourhoods and schools are
children who will be violent and sexually abusive and who
may have mental disorder

Families where parents have personality disorder and
addictions

‘Think Families’ to enable them to develop adaptive
functioning
Psychosocial Resilience, pyschosocial
care and forensic mental health
(Williams, R. & Kemp, V. , 2011)
 Triangle of concepts:
1. Psychosocial resilience is a concept that is in
prominent use in the fields relating to disasters,
emergencies and adversity;
2. Psychosocial resilience as a concept in child
development, and;
3. The backgrounds and needs of children and young
people who are in contact with youth justice and
forensic mental health services, failure to achieve
resilience or unable to maintain it in the face of
cumulative adversity
Children, mental disorders,
and conduct disorder
(Bailey & Campion, 2012)
 In the UK, only 30-40% of children and adolescents who
experience clinically significant mental disorder have
been offered evidence based interventions at the earliest
opportunity for maximum life time benefits (Meltzer et
al, 2003, Green et al, 2005).
 Parents with children with conduct disorder (Green et al,
2005):
 60% approached a professional source, most
commonly a teacher
 28% sought advice from a mental health specialist
 24% sought advice from the special educational
services, such as a psychologist

Some research suggests that even if all mental disorder was treated with the best
available intervention, this would still alleviate less than 30% of the burden of
mental disorder (RCPsych report, 2010).

This highlights the importance of promotion of mental health and prevention of
mental disorder.

Half of lifetime mental illness, excluding dementia, arises by the age of 14, and
three-quarters by the mid-20s (RCPsych report, 2010).

It is a major underlying cause of health risk behavior in 5-16 year olds with:


six-fold higher rates of smoking,

four-fold higher rates of drinking

twelve-fold higher rates of ever using hard drugs

five-fold higher rates of self harm in those with conduct disorder.
Such impacts then continue across the life-course, with higher rates of
unemployment, crime, violence and rates of mental disorders (RCPsych report,
2010)
Moving beyond the debate
 Is personality developed by adolescence?
 Is the PD label harmful? Classifications
 Challenges getting the formulation right (Adshead,
2012)
 Ethics, values based practice and safe-guarding
children - anyone under the age of 18 years
 What should clinicians be doing in day to day practice?
ICD10 Multiaxial Diagnosis
WHO (1996)





Axis
Axis
Axis
Axis
Axis
One
Two
Three
Four
Five
1
2
3
4
5
6
7
8
9

Axis Six
Clinical Psychiatric Syndrome
Specific Disorders of Psychological Development
Intellectual Level
Medical Conditions
Associated Abnormal Psychosocial Situations
Abnormal intrafamilial relationships
Mental disorder/deviance or handicap in the child’s
primary support group
Inadequate or distorted intrafamilial communication
Abnormal qualities of upbringing
Abnormal immediate environment
Acute life events
Societal stressors
Chronic interpersonal stress associated with school/work
Stressful events/situations resulting from the child’s own
disorder/disability
Global Assessment of Functioning
 Working group on the classification of mental and
behavioural disorders in children and adolescents:
International Advisory Group for the revision of
ICD10 mental and behavioural disorders
 One of the most striking differences between
services for adults and services for young people is
that the latter frequently involve non-medical as well
as medical professionals.
 In addition, services for young people involve
individuals whose growth and psychological
maturation is still continuing. That is so at the level
of specialist services as well as primary care.
Challenges for those working
with adolescents and adults
 Identify those most at need of intervention
at an early stage
 Pathway approach to initial screening
 If not been lost in transition and are
identified
 Case formulation(CF) together with
organisational intervention that will seek to
enhance engagement with interventions
Learning from adults
PIPEs psychologically informed post
treatment environments
(Initial findings including young adults hopeful)
 Key aspects to CF (Sim et al., 2005):





Integrative
Explanatory
Prescriptive
Predictive
Therapist
 Together with ‘milestones to recovery’ for
in-patients (Logan, Doyle & Holloway, 2010)
Readiness conditions required
Improving engagement
Internal





Cognitive
Affective
Volitional
Behavioural
Identity
External






Circumstances
Location
Opportunity
Resources
Support
Programme timing
(Sellen, 2009; McMurran, 2009; Day, 2009; Howells, 2009)
Livesey, 2007
 Integrated diagnostic approach – life tasks
individuals need to carry out:
 The three areas of potential failures:
 Achieving a coherent sense of self
(intrapersonal failure)
 Developing intimacy in interpersonal
relationships (interpersonal failure)
 Behaving prosocially (social group failure)
Tools and testing
Qualities of a good screening test
(Blazer & Hayes, 1998)
 Inexpensive
 Easy to administer
 Minimally uncomfortable to those in whom it is
administered
 Detects a disorder earlier than would occur if a
behavior was severe enough to prompt an
intervention
 Balances the ability to detect most cases of the
disorder with the ability to rule out non-cases
 Not subject to variability across different testers or
across time in the same tester
Learning from adult literature (Duggan et al, 2010)
A three-step, top down evaluation model for
personality disorder (Livesey)
Step 1
Screening for personality disorder
Ask a few questions to establish evidence of
intrapersonal, interpersonal and social group
difficulties
Yes
Step 2
Identifying secondary domains
Ask more questions to establish which
secondary domains are predominantly
dysfunctional, to provide ‘extent’ or ‘breadth’
rating
Step 3
Trait evaluation
Make detailed evaluation for presence of traits
and their summation to provide ‘severity’ or
‘depth’ rating
No
The mapping of Livesey’s secondary domains
and primary traits and Mulder & Joyce’s four
‘As’ of personality (Duggan, 2010)
Livesey
Secondary
domain
Mulder & Joyce
Associated primary traits
Emotional
dysregulation
(12 traits)
Anxiousness; emotional reactivity; emotional
intensity; pessimistic anhedonia; submissiveness;
insecure attachment; social apprehension;
oppositional; need for approval; self-harming
ideas; cognitive dysregulation; self-harming acts
Asthenic
Dissocial behaviour
(9 traits)
Narcissism; exploitativeness; sadism; conduct
problems; hostile dominance; sensationseeking; impulsivity; suspiciousness;
egocentrism
Antisocial
Inhibitedness
(7 traits)
Low affiliation; avoidant attachment;
attachment need; inhibited sexuality; selfcontainment; lack of empathy; inhibited
emotional expression
Compulsivity
(2 traits)
Orderliness; conscientiousness
Asocial
Anankastic
Using the evaluation schema for
the four secondary domains
 In expounding the case for an integrated
diagnostic system, Duggan et al discuss:
 Severity or ‘depth’ of personality disorders
 Extent or ‘breadth’ of personality disorder
 The concept of ‘episodes of personality
disorder’
 Potential utility for clinical prediction and
treatment planning
Recommended evaluation scheme for the
four secondary domains (Duggan, 2010)
Asthenic
Antisocial
Asocial /
anankastic
Impulses
Alternating high or low
High, with sensationseeking
Inhibited
Affects
Increased intensity,
reactivity and
instability: range of
affects
Increased expression
of hostility and
suspiciousness
Inhibited emotional
expression,
unempathic
Cognitions
Dysregulated, selfharm ideas
Egocentric and selfaggrandising views,
exploitative and rulebreaking ideas
Poor narrator,
unexpressive, limited
theory of mind
Behaviours
Alternating
oppositional and
submissive, self harm,
chaotic interpersonal
relationships
Conduct problems,
sadistic
Low affiliation, selfcontained, avoidant,
orderliness
Positive and negative personality traits:
Big Five v. Bad Five (Ashead, 2012)
Big Five
Bad Five
Found dimensionally in the general
community
Found mainly in populations with
personality disorder diagnoses and
associated with significant harm: also
dimensional

Extraversion: outgoing
personality, sociability

Avoidance of others and mistrust

Conscientiousness: seeing things
through

Impulsivity and attentional
problems

Agreeableness: likeability,
prosocial stance

Antisocial attitudes: contempt for
social relations, especially need
or vulnerability

Openness to experience

Rigidity of thought and lack of
curiousity

Neuroticism: anxiety and
tendency to hyperarousal when
stressed

Emotional dysregulation:
unpredictable, unmodulated
affects when stressed
Pros and cons of personality
disorder diagnosis
(Ashead, 2012; Bailey, 1993, 2006, 2010)
Pros

Early diagnosis means early
intervention

Improved diagnosis means
improved treatment planning and
implementation



The personality disorder
diagnosis reflects a
developmental account of the
young person and their
experience
Personality disorder is a real
disability: we may contribute to
stigma and myths if we do not
name it when we need to
There are effective treatments
for personality disorder
Cons

Tendency of personality disorder
diagnoses to ‘stick’ and not be
revised as the young person
changes

People with personality disorder
diagnoses are often refused
access to services

The diagnosis is a stigmatising
label, and puts the young person
at risk of rejection by services
and ignorant professionals

The diagnosis does not reflect the
trauma histories in young people

It is pointless to make a diagnosis
where there is no treatment
service
History
 The concept of psychopathy was first
introduced by Cleckley in 1941, emphasizing
features of reduced guilt and impaired
empathy (Blair and Viding, 2008).
 Four decades later, Hare developed a
questionnaire measure to identify it.
 Twelve years later, the psychopathy
construct was extended to childhood (Frick
and O’Brien, 1994).

Over the past decade, several important and distinctive features
have been identified, that separate psychopathy from antisocial
behavior as a whole:
 Twin studies have shown a high heritability that exceeds that for
antisocial behavior unaccompanied by psychopathy (Viding and
Jones, 2008).
 An RCT trial has shown that there is a worse response to
treatment when antisocial behavior is associated with
psychopathy (Haws and Dadds, 2005)
 A modest degree of continuity between psychopathy and early
adolescence and adult psychopathy is assessed some years later
using a difference measure (Lynam, Caspi and Moffitt, 2007).
 Brain imaging studies in adults and adolescents who exhibited
both psychopathy and antisocial behavior have produced striking
findings with respect to amygdala dysfunction in the oribitofrontal cortex (Blair and Viding, 2008).
 However, it is crucial to recognize that the findings so far lack
diagnostic specificity.
 Research on psychopathic traits suggests
that reactive aggression is more strongly
linked to negative emotionality, whereas
proactive aggression is more closely linked
to decreased emotional reactivity, and an
increased tendency to exhibit a callous and
unemotional response to threat or
provocations.
 As such, ‘child psychopathic’ traits may show
different interactions with parenting, for
reactive vs. proactive aggression.
What do we know about children with
psychopathic traits
Are callous unemotional traits – stable across different
developmental periods?
What is the genetic and neurobiological framework
Affective processing



Lack of empathy
Lack of guilt
Insincere charm
Neural basis
Genetic basis
What stops a general
acceptance of psychopathy?

There are several different questionnaire measures of psychopathy,
with only moderate agreement on the different scales, with its
uncertainty on the extent to which there should be a reliance on self
reporting ratings, or other informal reportive ratings. (Kumsta, R;
Sanuga Barke, E; Rutter, M, 2012).

It remains to be shown that the relevant features can be reliably and
validly assessed clinically. The evidence relies almost entirely on
questionnaire scores.

Many, but not all, of the questionnaire measures assume that
psychopathy is intrinsically related to antisocial behaviours, both the
empirical findings in childhood as well as broader consideration.
Skeem, JL and Cook, DJ (2010) cast doubt on this assumption. Many
individuals with psychopathy have not shown either oppositional
defiant disorder or conduct disorder.

It cannot be assumed that all forms of apparent lack of concern for
others reflects psychopathy (Jones, AP; Happie, 2010).
Parenting
(Yeh, Chen et al., 2011)
 Reactive and proactive aggression are
related to different antecedents.
 e.g. harsh parenting is more predictive of
reactive aggression;
 Whereas indulgent parenting is more
strongly associated with proactive
aggression.
Child-parent Innovative
research
(Dadds et al, 2012)







Sample of 4-8 year olds demonstrated that callous and emotional traits
(thought to index psychopathy) can be manifest quite early in
childhood.
Concept of psychopathy is usually involved in assumption that its
origins lie early in life, but it can be measured in early childhood.
A novel ‘love task’ was used as a social ‘press’ for interactive eye gaze.
Fitting with Dadds’ suggestion from earlier research, that lack of
attention to the eyes underlies the fear recognition deficits in child
psychopathy.
Findings show that the lack of attention to eyes is not associated in
any difference in the mother’s interactions with the children.
This implies the deficits lie in the child rather than a parenting feature.
Rutter argues therefore that a good case exists for recognizing
psychopathy in childhood, but neither ICD10 nor DSMIV include a
diagnosis of psychopathy for any age period. It is alluded to by its
inclusion of callous and unemotional traits, in the criteria for ASPD, but
this leaves no room for diagnosing antisocial behavior in adult life,
when it does not include these features.
Some personality disorder
assessment tools used in adolescence

Hare Psychopathy Checklist – Youth Version: young
people’s version of standard measure of psychopathy
(Forth, 2005)

Millon Adolescent Clinical Inventory: developed to be used
in teenagers (Millon 2006)

Minnesota Multiphasic Personality Inventory – Adolescence
(MMPI-A): an empirically based measure of adolescent
psychopathology (Butcher, 2006)

NEO Personality Inventory – Revised: a general measure of
Big Five personality traits (Costa, 1992)

CAPP (Cooke, Logan et al, 2012)

SAVRY (2000)
Potential new tools






Content validity of the CAPP in juvenile samples (Johnston,
Cooke, Logan et al. In Press: 2012).
The authors stress that psychopathic personality traits
have been implicated in understanding conduct disordered
youth.
The PCL-YV derived from Hare’s PCL-R.
The challenge to use this tool are the levels of concept,
developmental appropriateness, ethics and actual utility
when used in youth (Johnston & Cooke, 2004).
CAPP as I understand has been developed to capture the
construct of psychopathy across several domains of human
functioning, and defines psychopathy in terms of
personality, instead of mixing personality in with antisocial
behavior.
The application of the CAPP to a youth population is of
potential great interest.
Lennox, 2012, EFCAP

Aim:
 To explore the SAVRY protective factors
 Look at the post-dictive validity of the protective
factors, by examining their association with past
behavior
 Examine the predictive validity of the SAVRY protective
factors to predict desistence from reconviction

Conclusions and clinical implications:
 Protective factors are likely to be just as important as
risk factors, and should be integrated into risk
management

Risk management and intervention:
 One protective factor
 Build resilience of temperament
Treatment Efficacy
Adult psychopathy seen as hard to treat (Salekin, 2002; Duggan,
2011: In press).

Need evidence base which evaluates current treatment in
relation to children with high-CU Traits (Viding, 2007; Yeh &
Chen, 2011).

Neuro affective profile – suggests need modification of
current treatment approaches.

Avoid ineffective treatments

Avoid punishment approach either boost weak affective
response system (Hawes and Dadd, 2007) identify treatment
strategies congruent with presenting strengths and
weaknesses.

Response to reward appears intact address features
associated with malleability in relation to parenting style e.g.
IQ, gender and timing and nature of interventions.
What can we do
(Duggan, 2012)
 Improve psychological health
 Reduce young person's risk of serious
harm to others
 Develop skills in the workforce to
achieve both of these
Systematic review of what works
for interventions in children and
adolescents with emerging antisocial
personality disorder
Summary of recommendations:
Early interventions
Identify vulnerable parents including ante natally
Parents with other mental health problems
Significant drug alcohol problems
Mothers under 18, particularly with history of
maltreatment in childhood
 Parents with significant previous or current contact
with CJS
 Whilst avoiding increasing stigma associated with
intervention / Labelling as anti social





Early interventions for at risk
children










Infant mental health programmes
Non maternal care nursery pre 1 year olds
Remove school exclusion
Improve poor parenting
Target multiple risk factors
Interventions for children with conduct problems and
associated disorders: ADHD; SLD; LD; and autism
Functional family therapy
Multi systemic therapy
Dialectical behaviour therapy
‘Support therapy at all transitions continuity’
What is known?

Anti-social behavior and callous, unemotional traits have an asymmetrical
relationship for both children and adults.

High level of antisocial behavior often occur in the absence of callous,
unemotional traits.

High levels of callous, unemotional traits often occur in the presence of antisocial
behavior (Hart and Hare, 1997; Fontaine, 2011).

However, several longitudinal studies now suggest that callous, unemotional
traits can also occur in the absence of clinical levels of antisocial behavior
(Barker et al, 2011; Frick et al, 2003; Row et al, 2010; Fontaine et al, 2011).

In large community samples, callous, unemotional traits only were associated
with subclinical levels of antisocial behavior, or later developing antisocial
behavior.

Individuals with callous, unemotional traits commonly showed elevated levels of
other types of impairment, including:




Poor relationships
Low prosociality
Increased hyperactivity
Callous, unemotional traits may therefore have the potential to serve a useful
clinical indicator of psychiatric vulnerability and psychosocial maladjustment, in
addition to their potential utility and sub-typing children with conduct disorder.
Children with CU traits appear to be characterised by a
particular neuro affective profile may reflect strong
genetic vulnerability is it “chicken and egg” impact of
maltreatment on developing brain.
Even if high heritability does not equate with
immutability.
All subgroups however developed may respond best to
modified treatment approaches matching /
“personality type to treatment”.
Implications for ICD 11.
The ‘Challenge’
‘Policy the Dance of Change’
The Elephant in and out of the Room
Good practice and
decision making

Openness and transparency, where the decision making
process, including the evidence and arguments on which they
rely should be open to full scrutiny

Inclusiveness

Respect

Proportionality

Accountability

Reasonableness and lawfulness

Effectiveness and efficiency

Exercising a duty of care

Whether developing a classification system or running a unit
for those with emerging personality disorder in adolescence, a
system that is capable of reviewing learning and accepting
criticism and complaint

‘Change continues throughout the life cycles, but changes for better
or worse are always possible. It is continuing potential for change
that means that no time is a person invulnerable to every possible
adversity, and at no time is a person impermeable to favourable
influence.’ (Bowlby, 1965).

‘We are made by others,
and others are the making
of us in every
biopsychosocial sense’
(Crossley, 2012).
Contact Professor Sue
Bailey at:
patopresident@rcpsych.ac.uk
