Context Although Axis II personality disorders in adolescence have been linked to psychopathology and psychosocial impairment in early adulthood, little is known about their effects over longer periods. Objectives To evaluate and compare long-term prognoses of adolescent personality disorders and co-occurring Axis I disorders.
Participants A community sample of adolescents interviewed at a mean age of Main Outcome Measures Clinically assessed psychiatric disorders and self-reported attainment and function. Results Axis I mood, anxiety, disruptive behavior, and substance use disorders and Axis II disorders in adolescence showed risks for negative prognoses lasting 20 years. Co-occurring Axis I and Axis II disorders consistently presented the highest risk, often approximating the sum of the axis-associated risk or even several times the risk of disorders in either axis alone.
Conclusions Long-term prognoses of Axis I and Axis II disorders are of comparable magnitude and often additive when comorbid. These findings are highly relevant to the current debate over how personality disorders should be handled in DSM-V. In recent decades, it has become clear that many psychiatric disorders, perhaps even most, have onsets in adolescence or even earlier in childhood.
However, longitudinal studies of childhood and adolescent psychopathology often focus on single disorders in severely impaired children from clinical samples. When comorbid disorders are assessed, researchers often investigate Axis I disturbances like conduct disorder, major depression, and 1 or more of the anxiety disorders.
Long-term dysfunction may also be linked to personality disorders PDs , which are now increasingly recognized as clinically significant disturbances in adolescents. The DSM-IV-TR 12 characterizes PDs as enduring patterns of inner experiences and behaviors that are inflexible and pervasive across personal and social situations that also deviate markedly from cultural expectations.
Personality disorders may manifest in persistent disturbances in cognition, affect, interpersonal functioning, and impulse control. Just as many Axis I disorders have their first onsets in adolescence or childhood, there is evidence that clinically significant PDs emerge earlier in adolescence than previously thought.
Adolescent PDs are associated with significant impairment and distress 13 - 16 and high rates of aggression and suicide. Although placement of PDs on Axis II was intended to encourage greater attention to their clinical significance, their separation from Axis I disorders may paradoxically cause them to be overlooked at times. Early epidemiological studies, including the Epidemiological Catchment Area Study 23 and National Comorbidity Survey, 24 largely ignored PDs, as have most longitudinal epidemiological studies that began in the participants' childhood.
Researchers conducting these studies may have ignored PDs based on common but then untested assumptions that PD symptoms were not stable before late adolescence or early adulthood. Partly for these reasons, diagnostic assessments by structured clinical interviews were developed for PDs well after comparable measures existed for Axis I disorders.
Current instruments for assessing PDs in children or adolescents are limited in number and their coverage of Axis II pathology is often incomplete. At present, the Children in the Community Study 26 is the only general population-based longitudinal study that has assessed PDs before late adolescence. Data from this randomly selected community sample provide estimates of the prevalence and confounding effects of co-occurring disorders, which are not inflated by ascertainment bias that characterizes clinical samples.
Comorbidity in clinical settings tends to be elevated because the presence of each separate disorder increases the likelihood of treatment seeking. Data include those for adolescents This population was selected because it was reasonably representative of the United States in on socioeconomic factors and residence in urban, suburban, and rural settings.
Using data supplied by both informants, researchers assessed psychiatric disorders and psychosocial functioning in for youths mean age, The most recent follow-up data were supplied at a mean age of Sample attrition was also unrelated to age, race, and socioeconomic status. Written informed consent was obtained from participants aged 18 years or older, and those under that age gave assent. When this sample was assessed in , no instruments existed to measure adolescent PDs.
Diagnostic algorithms were updated to reflect new diagnostic thresholds. Instead, we used data from a single assessment that roughly correspond to what clinicians encounter when they evaluate adolescents for diagnosis and make decisions about treatment. Adolescent Axis I disorders were assessed using the Diagnostic Interview Schedule for Children, version 1, 38 which was administered separately to the child and his or her mother. These interviews were conducted simultaneously in the home by 2 separate interviewers, each blind to information provided by the other respondent.
Computer algorithms generated Axis I diagnoses in a 2-step process. Symptoms and symptom-related severity and impairment were summed to create combined informant scales for each Axis I disorder. Those children meeting diagnostic criteria and scoring at least 1 SD above the sample mean were designated as having probable disorders; those at least 2 SDs above the mean were considered to have definite disorders. Similar combinations of diagnostic criteria and impairment ratings have been employed in other epidemiological investigations of children and adolescents to control for excessively high rates of diagnoses attributable to multiple informants with typical levels of disagreement.
Table 1 summarizes measures at a mean age of Each of these scales show moderate to good internal consistency reliability. Designed for use on Axis V in DSM 's multiaxial diagnoses, GAF scores higher than 70 indicate satisfactory mental health and good overall functioning; scores from 51 to 70 signify mild or moderate impairment or distress; and scores below 51 indicate severe impairment. Global Assessment of Functioning scores were assigned by clinicians after administering the structured clinical interviews for psychiatric disorders.
Clinicians were blind to the participants' diagnoses and functioning at younger ages. Most participants in this community sample had adequate overall functioning mean GAF score, Self-reported measures of antisocial behavior and psychotic experiences were included as scaled measures of dysfunction.
Psychiatric disorders at follow-up were assessed with widely used clinical interviews. To assess conduct disorder symptoms before age 15 years, which are required for a diagnosis of antisocial PD, we used conduct disorder diagnoses recorded in earlier prospective assessments of our sample. Altogether, 9 participants 1. This study focused on 3 groups, summarized in Table 2. Co-occurring disorders within these subgroups are common and often may reflect a common underlying disturbance.
Although other Axis I disorders were assessed, there were no cases meeting full criteria for anorexia, psychotic disorder, or panic disorder.
Bulimia was not included because its criteria have substantially changed since the assessment. Adolescent PDs were aggregated into cluster A paranoid, schizoid, and schizotypal PDs , cluster B borderline, histrionic, and narcissistic PDs , and cluster C avoidant, dependent, and obsessive-compulsive PDs disorders.
At least 1 PD was diagnosed in adolescents. Within this group, 24 participants had disorders in 2 PD clusters and 3 participants had diagnoses in all 3. Axis I—only, Axis II—only, and comorbid axes groups were used as independent predictors of adult attainment, well-being, global functioning, antisocial behavior, and psychotic experiences. Scaled outcome variables were standardized to facilitate interpretations of effect sizes and comparison of predictions across analyses.
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Mental disorders are diagnosed according to a manual published by the American Psychiatric Association called the Diagnostic and Statistical Manual of Mental Disorders.
A diagnosis under the fourth edition of this manual, which was often referred to as simply the DSM-IV , had five parts, called axes.
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