4 Personality Pathology in Adolescence: a Review

In working with adolescents, clinicians receive minimal guidance from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; American Psychiatric Association [APA], 1994). Aside from the diagnosis of conduct disorder (and its near-neighbor, oppositional defiant disorder), clinicians are on their own in assessing the personality characteristics that contribute to adolescent distress and dysfunction. DSM–IV is explicit in its caution to avoid making personality disorder (PD) diagnoses in adolescence. However, this caution is based on the relative lack of data on adolescent personality pathology, not on any research suggesting that adolescent personality pathology does not exist or cannot be diagnosed. Indeed, a recent series of studies suggests that PDs not only can be diagnosed in adolescence but show considerable continuity over time (Bernstein et al., 1996; Johnson et al., 1999). Of relevance, as well, is a growing body of literature suggesting that adolescent conduct disorder is a highly heterogeneous category (see Moffitt, 1993; Moffitt et al., 1996). For example, some adolescents showing delinquent behavior, including those diagnosed with conduct and oppositional defiant disorders, are callous, remorseless, and psychopathic, whereas others are relatively high-functioning, are able to maintain loving and intimate relationships, and show a very different quality of moral functioning. In this sense, the research literature is beginning to catch up with the clinical literature, in which a distinction has long been made between psychopathic adolescents, who tend to have a poor prognosis, and teenagers for whom oppositional, destructive, or delinquent behavior is an expression of neurotic conflicts, masked depression, and other normative and non-normative adolescent concerns.