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264 Chapter 14 Substance-Related Disorders, Personality Disorders, and PsychoticDisorders
Increasing heritability
Genetic Factor Environmental Factor
That said, twin studies, family studies, and adoption
studies provide overwhelming evidence of a moderateto-high inherited vulnerability. Genetic influence varies
depending on age (with increasing influence over the course
of adolescence) and appears related to both initiation and
continued use or dependence (Rose et al., 2019; Vitaro et
al., 2018).
The role of genetics in alcohol use and abuse has
been extensively researched. The Stockholm Adoption
Study is one example of a large-scale longitudinal
investigation providing valuable data (Cloninger et al.,
1981; Sigvardsson et al., 1996). Multiple alcohol problems
are genetically influenced, including motivation to drink,
alcohol sensitivity, the amount of alcohol consumed,
steady drinking, and eventual dependence (Dick, 2011).
The age of the first drink is also influenced by genes,
but environmental factors and gene-by-environment-bytime interactions are even more influential (Rose et al.,
2019; Vitaro et al., 2018). The genetic and environmental
interplay over time is presented in Figure 14.6. Similar and
overlapping genetic effects are also observed for substance
use and behavioral addictive disorders (Kotyuk et al.,
2020; Vidal & Meshi, 2022).
Physiological Factors
Both animal and human studies illustrate many of the
potential mechanisms of drug use and abuse, with different
brain pathways underlying drug reinforcement, tolerance,
dependence, and addiction. The adolescent brain, in and of
itself, is a risk factor, with age-related changes in sensitivity
to the effects of alcohol and drugs (Spear, 2013). The
initial stages of drug use and drug liking are associated
with the brain’s reward centers, which are embedded in
the mesolimbic system. Activation of the mesolimbic
pathway, particularly the dopamine receptors, depends on
the particular substance; the most addictive drugs have the
most rapid effects (Bart et al., 2021; Kosten et al., 2005).
Individual differences in sensitivity to these immediate
effects and the ability to digest or metabolize substances
(likely attributable to genetic influences) may relate to
individual differences in the levels of pleasure or aversion
that accompany drug experimentation.
Chronic use leads to neurobiological changes that may
underlie tolerance (Kosten et al., 2005; Rose et al., 2019).
Further, “repeated exposure to escalating dosages of most
drugs alters the brain, so that it functions more or less
normally when the drugs are present and abnormally when
they are not” (Kosten et al., 2005, p. 7). With tolerance,
transitions to dependence may occur, with cravings,
compulsive drug seeking and urgent attempts to escape
withdrawal (Kosten et al., 2005; Schulenberg et al., 2014).
Going beyond the hedonic view that emphasizes the
pleasure associated with drug use (i.e., drug liking) and
the need to avoid withdrawal symptoms, the incentive-
sensitization theory is a multistage explanation of
addiction (Berridge, 2007). First, various substances alter
brain organization and function. Second, these altered brain
systems affect behavior in situations involving motivation
and reward. The dopamine system that usually signals that
certain stimuli will lead to positive reinforcement becomes
hypersensitized to drugs and drug stimuli. This is referred to
as incentive salience. At this stage, drug cues are increasingly
difficult to ignore, and craving may become a more
important factor in continued drug use than the pleasurable
effects. To understand craving as an essential aspect of
drug use, researchers must address both physiological
and psychological factors (Berridge, 2007; Harden &
Mann, 2015; Khurana et al., 2015). Taken together, these
neurophysiological and neurocognitive processes reflect
the continuity between typical and atypical development
predicted by the dual systems model at the start of this
chapter (McClure & Bickel, 2014).
Figure 14.6 Genetic and environmental interplay in adolescent substance use disorders
Opportunity
Initiation of Use
Regular/heavy Use
Abuse/dependence
Source: Hines, Morley, Mackie, & Lynskey (2015). Genetic and environmental interplay in adolescent substance use disorders.
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Genes associated
with novelty seeking
and risk taking
Genes associated
with subjective effects
of use
Genes associated
with drug metabolism
Parental monitoring
X
Substance availability
X
Peer substance use
X
Childhood sexual abuse
Assessment and Diagnosis 265
Psychological Factors
A history of childhood psychopathology is one important
influence on the development of substance abuse disorders in
adolescence. As noted, both internalizing and externalizing
disorders increase the likelihood of substance use and abuse.
Child maltreatment is another powerful risk factor (Rose
etal., 2019; Schulenberg et al., 2014).
Many of the associations between childhood disorders
and adolescent substance use and/or behavioral addictive
disorders are likely mediated by individual variables such
as deficits in executive function, high levels of negative
emotion and emotional dysregulation, and poor selfcontrol. Disinhibition and/or impulsivity are key constructs
underlying increased risk (Rose et al., 2019; Schulenberg
etal., 2014). Integrating physiological and cognitive factors,
the cognitive-deficits model of addiction is based on the idea
that repeat, chronic drug use results in abnormalities in the
prefrontal cortex, impairing judgment, decision making,
and impulse control (Kosten et al., 2005).
Motivations, expectancies, and attitudes are cognitive
variables associated with drug use and other problem
behaviors. Perceptions of risk (such as relatively low risk
versus higher risk) as well as positive expectations related to
substance use vary with age. Individual differences are also
observed (Lansford et al., 2021; Rose et al., 2019). There
appears to be a balance between adolescent perceptions
of risk and benefits, on one hand, and personal and peer
experiences of substance use, on the other hand. Several
studies describe personality profiles that are linked to
substance use and behavioral addictions. These studies
highlight the role of sensation seeking (Reardon et al., 2019;
Schulenberg et al., 2014).
Parents, Peers, and Sociocultural
Factors
Parents influence adolescent substance use and abuse in a
variety of ways. The first way is through exposure. Many
children a re exposed to alcohol abuse or dependence in family
settings. Parental use increases adolescent use; parental
nonuse moderates adolescent use, even when peer use is
taken into account (Li et al., 2002; Maggs & Staff, 2018).
In addition, parental gambling problems predict adolescent
gambling problems (Slutske & Richmond-Rakerd, 2014).
Marijuana use and abuse appear especially influenced by
parent and family factors (Epstein et al., 2016). Siblings also
have an important role to play, legitimizing, promoting, or
discouraging various forms of substance use (Schulenberg
et al., 2014). Parenting expectations and parenting practices
also influence substance use and abuse. Although parents
differ in their perceptions of their ability to prevent drug
use, parents who convey expectations that drug use will
not occur and who monitor their adolescents’ activities do
provide protective benefits (Schulenberg et al., 2014).
Whether friends drink, smoke, or use drugs influences
adolescent beliefs and behaviors, although there are gender
and cultural variations (Gersh et al., 2019; Schulenberg
etal., 2014). The transition to high school appears to be a
turning point. At this time, peers who support deviance and
rule breaking lead to increases in adolescent substance use
(Albert et al., 2013; Dishion, 2014). Researchers describe
a pattern of reciprocal influence, from peers to substance
use, to more exclusive selection of deviant peer groups,
and then to more frequent and more serious substance
use and abuse (McDonough et al., 2015). Adolescents who
are disconnected from peers and peer networks are also
at increased risk for substance use and abuse (Hussong
et al. 2018). The results of one study provided evidence
that “brains of a feather flock together,” with heightened
peer influence, peer affiliation with other substance-using
adolescents, and less cognitive control leading to increases in
substance use over time (Kim-Spoon et al., 2019).
The school setting is also extremely important. School
policies that involve more monitoring of students reduce
substance use (Schulenberg et al., 2014). The norms of the
student and staff population, as well as the social image of
smokers, are also influential factors. Other environmental
variables i nclude the ava ilability and att ractiveness of substanc es,
such as flavored e-cigarettes that are perceived as less harmful
and deliver higher levels of nicotine. Peer and media messaging
related to the effectiveness of vaping as a coping strategy is also
linked with greater use (Less et al., 2021). Neighborhood and
community norms, poverty, and accumulation of adversity
all increase risk (Rose et al., 2019; Schulenberg et al., 2014).
High-SES backgrounds involve risks related to easy access to
money and substances coupled with peer expectations and
reinforcement for using drugs (Luthar et al., 2013; 2019).
Assessment and Diagnosis
As with every other form of psychopathology, comprehensive
assessment of substance abuse disorders is critical. And given
physiological complications such as tolerance or withdrawal,
medical evaluations are an important component of
complete assessments. With respect to the substance abuse
itself, patterns of use (whether episodic or continuous),
availability and accessibility of drugs, perceived importance
of drugs, the effects of drugs, and family histories of alcohol
and drug abuse are key criteria.
The multifactorial etiology of substance abuse requires
a full assessment of psychological functioning, including
deficits or maladjustment related to cognition, emotion, or
behavior. Cognitive assessments include neuropsychological
testing and tests of skills frequently impaired by drug use,
such as abstract thinking and memory. Cognitive difficulties
related to attributiona l style, perceptions of risk, and mi staken
beliefs must also be considered. The emotionality and
emotional flare-ups observed in adolescents with substance
abuse disorders must also be carefully assessed. Clinicians
must collect information about behavioral maladjustment
in personal, family, peer, school, and employment domains.
The extent to which an adolescent has access to social
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266 Chapter 14 Substance-Related Disorders, Personality Disorders, and PsychoticDisorders
support from family or friends (or is connected to deviant or
delinquent groups) is another important piece of data.
In addition, an adolescent’s underlying personality and
other comorbid psychopathologies require review and
appreciation. Even though many adolescents do not see
connections between substance abuse and other problems
or disorders, mental health professionals need to encourage
disclosure. Another critical component of assessment
involves the appraisal of the adolescent’s strengths. Given
that few adolescents seek treatment for substance abuse
on their own, acknowledgment of these strengths may lay
the foundation for initial rapport and allow for discussions
about readiness for intervention.
Intervention
Prevention
Avoidance of drugs is a developmental challenge, with
theoretical and practical issues complicating prevention
research, design, program delivery, and evaluation (Sussman
& Arnett, 2014). Even with multiple viewpoints and
assorted difficulties, prevention efforts aimed at reducing
substance use and abuse can be successful (Schulenberg
et al, 2014). Universal prevention programs cast a very
wide net and often promote healthy lifestyles and healthy
choices to adolescent populations. Many mental health
and public health professionals point out that declines in
drug use parallel the widespread use of prevention efforts
in early and middle adolescence (SAMHSA, 2014). Even
so, there is ample evidence of their ineffectiveness, as well
as data that prevention programs actually increase interest
in drug use for certain adolescents (Hogue et al., 2021).
One of the important aspects of prevention efforts, and
one of the more controversial, is whether to acknowledge
that most adolescents will, at some time, use mood-altering
substances, and whether and how to include harm reduction
(i.e., non-abstinence-based) approaches as well as abstinence
messages.
One example of harm reduction for older adolescents
involves emphasizing safe or sensible drinking (Bagot &
Kaminer, 2020). This approach is focused on identifying and
clarifying adolescents’ goals for substance use, reinforcing
healthy behaviors, and improving self-regulation. Harm
reduction is also part of many programs designed to reduce
binge drinking and other substance use in college students
(Richards et al., 2021). It is also important to consider
substance use prevention programs that take place in noncollege settings to better address the distress and dysfunction
experienced by young adults with, perhaps, different sets of
risks and protective factors (Davis et al., 2017).
Selective prevention efforts are more focused. Several
effective programs converge on developmental transitions
that are associated with increased risk (Cadigan et al.,
2019). For example, family-centered programs that begin in
middle school can delay the initiation of substance use for
both typical and at-risk adolescents (Stormshak et al., 2011).
School-based programs that focus on adolescent resilience
have been implemented with some success (Hodder et al.,
2017). Parent training and collaborative, community-based
efforts can also be effective (Allen et al., 2016; Ladis et al.,
2019; Moreland et al., 2020).
Targeted prevention is even more specifically directed
and is based on the idea that risk and vulnerability can
be reliably measured in individuals and subgroups of
adolescents. Although there are many risk factors and
individual differences in vulnerability to those factors, it is
imperative to design programs that will reach those most in
need. For example, embedding prevention programs in early,
related services such as Head Start might involve fostering
the personality characteristics that are associated with later
drug avoidance (Kaminski et al., 2002). Paying attention
to children’s sex/gender, personalities, social challenges, and
environmental contexts maximizes prevention outcomes
(Brown et al., 2011). Prevention efforts frequently target
at-risk youth, including indigenous youth (Ivanich et al.,
2020; Snijder et al., 2020). Cultural and ethnic differences
related to exposure, norms, risk, and vulnerability must be
taken into account. Other targeted groups include youth who
have already been diagnosed with other psychopathologies,
such as externalizing disorders or youth with experiences of
trauma that increase risk for substance use (Shin, 2021).
Treatment
The treatment of substance abuse disorders involves
outpatient therapies, inpatient programs, day treatment
placements, special school environments, and, for some,
the juvenile justice system. Treatments vary widely across
settings, and outcome statistics are mixed. Although
adolescent treatments are less effective than adult
treatments, treatment is superior to no treatment. Reviews
of outcome studies suggest that relapse is common and
multiple therapeutic attempts are likely (Hogue et al., 2018;
Silvers etal., 2019). Meta-analytic reviews also suggest that
treatments for adolescents who use cannabis are less effective
than treatments focused on other substance use (Meisel et al.,
2022). In addition, reviews of treatment outcome research
emphasize the positive impact of culturally-relevant and
culturally-sensitive approaches (Steinka-Fry et al., 2017).
There are many adolescent variables that cut across
types of problems and therapies (Meisel et al., 2022).
Adolescent motivation for substance abuse treatment is a
primary concern because most adolescents enter treatment
due to external pressure. Incentive to change in adolescents
abusing substances is modest. The strongest predictors of
incentive are the negative consequences attributed to drug
use. Adolescents who recognize that change is necessary do
better in treatment than those who do not (Feldstein Ewing
et al., 2022).
Therapeutic alliances are essential to establish. Many
adolescents come into therapy with various negative
beliefs and concerns related to authority, autonomy, and
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self-efficacy (Karver et al., 2018; Yeager et al., 2018). These
beliefs and concerns must be identified and addressed.
Parents, too, may enter therapy with erroneous beliefs
related to confidentiality and process. Because alliances
with adolescents and their parents are both related to
treatment success, ongoing attention to trust and rapport
is needed. Paying close attention to ethnic and culturally
relevant factors may enhance alliances for some adolescents
(Steinka-Fry et al., 2017). Retention and premature dropout
are constant concerns; addressing these concerns early and
often is important.
One of the first treatment decisions for adolescents
involves the level of care (e.g., outpatient versus inpatient).
Specialty care is often needed for those who have previously
relapsed after outpatient programs, those with comorbid
psychopathologies, those experiencing suicidality, those
in need of medical supervision for withdrawal, and those
requiring isolation from family, friends, or communities.
Crisis situations require immediate placements. For some
adolescents, drug courts are more effective than family
courts in reducing substance use and externalizing behaviors
(Belenko & Dembo, 2003; Henggeler et al., 2006).
Individual Approaches
Individual treatment is a common intervention paradigm.
Variations include behavior therapy, cognitive-behavioral
therapy, 12-step programs, and pharmacotherapy. Positive
outcomes associated with 12-step programs are often
dependent on adolescent motivation and severity of disorder
(Kelly et al., 2018). Among the most well-defined, wellstudied, and well-supported treatments for substance abuse
are cognitive-behavioral approaches (Hogue et al., 2018;
Silvers et al., 2019). Working with adolescent beliefs is core
to the cognitive model of psychotherapy. Beliefs about self
(such as negative beliefs about worth, self-efficacy, and
vulnerability), beliefs about life experiences, and substancerelated beliefs are all important. The process by which
change occurs involves the identification of automatic
thoughts and the eventual understanding by the adolescent
that these thoughts are not completely accurate or valid.
Modification of these thoughts must take place at both
surface and deep levels for sustained improvement.
Motivational interviewing is another individual therapy
that shows potential. Motivational interviewing is a
brief intervention incorporating aspects of motivational
psychology, client-centered therapy, and stages-ofchange theory. One unique contribution of motivational
approaches is their attempt to capitalize on some of the most
developmentally-salient adolescent challenges related to
autonomy and self-regulation (Feldstein Ewing et al., 2022;
Richards et al., 2021). A meta-analytic review found that
motivational interviewing was more effective for adolescents
using alcohol compared to adolescents using cannabis
(Steele et al., 2020).
Individual psychotherapies that account for age, sex/
gender, neurocognitive and emotional dysregulation, and
Intervention 267
iStock.com/SDI Productions
Group interventions are common treatments for substance
use disorders in adolescents.
social contexts are likely to produce better results (Bachrach
& Chung, 2021; McClure & Bickel., 2014; Rose et al.,
2019). Psychotherapy for adolescents with substance abuse
disorders must, in many cases, include treatment for
additional disorders (Hogue et al., 2017). Pharmacotherapy,
as well as combinations of individual, family, and milieu
therapies, may be beneficial for some adolescents.
Family and Group Approaches
Given the role of parents and families in the development
and maintenance of substance abuse disorders, it makes
sense that family approaches would be an important source
of therapeutic impact (Allen et al., 2016). Greater parental
monitoring and involvement, for example, increase the
likelihood of positive treatment outcomes. Youth-focused
components of family treatments, such as emphasizing
positive relationships and a positive future orientation,
increase the effectiveness of interventions (Meisel et al.,
2022; Van Ryzin et al., 2016). Mental health professionals
working with diverse families need to account for variables
such as race/ethnicity, level of acculturation, and access
to evidence-based interventions to provide culturally
competent treatments (Steinka-Fry et al., 2017).
Because most interventions for adolescent substance
use take place in group settings, it is especially important
to understand the benefits and risks of group treatments
(Hogue et al., 2021). Group approaches can be effective,
particularly those based on cognitive-behavioral principles
(D’Amico & Ewing, 2018). And peer recovery support is
often very helpful (Bergman et al., 2018). In addition to
positive impacts, peers may also increase risk and worsen
outcomes. As with treatments for conduct disorder and
eating disorders, group treatment for substance use is
related to both improvement and deterioration because
peers often provide deviancy training, as well as support
and modeling of varieties of substance abuse (Dishion,
2014; Hogue et al., 2021). Managing the peer environment
in group therapy is critical to treatment success (Dishion,
2014; Hogue et al., 2021).
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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268 Chapter 14 Substance-Related Disorders, Personality Disorders, and PsychoticDisorders
School-based quitting programs and sober high schools
are also treatment options (Finch et al., 2014; 2018).
Students who display higher motivation to change, who
have previously attempted to quit, and who experience
fewer stressors are more likely to benefit from schoolbased interventions. As with group treatments, peer-related
risks must be considered. Residential treatments often
report the most marked improvement, but meaningful
reductions in drug use must be understood in the context
of the more distressed and dysfunctional adolescents who
enter residential programs and who frequently relapse when
discharged (Lichvar et al., 2018).
Given that relapse is a fairly common occurrence,
relapse prevention must be incorporated and emphasized
in individual, family, and group treatments. Research has
identified the variables most associated with relapse. These
include comorbid psychopathology, negative emotion and
dysregulation, withdrawal symptoms, and peer pressure.
The likelihood of drug exposure and renewed drug use must
be addressed. It is essential to learn to manage cravings and
urges, to deal with high-risk situations, to make necessary
lifestyle changes, and to reach out for help to support
recovery.
Personality Disorders in Adolescence and Young Adulthood
Personality disorders have a long and complicated history
in clinical psychology as well as in various editions of the
DSM, including the DSM-5-TR. For our purposes, we
want to consider how best to think about personality and
personality disorders in youth so that patterns of distress and
dysfunction are identified early, and child and adolescent
well-being is enhanced in current and future circumstances.
There are a number of ways to think about typical
personality development in children and adolescents,
and several approaches were presented in the section on
temperament in Chapter 5. One influential approach
described temperament characteristics such as surgency,
negative affectivity, and effortful control as early
contributors to basic personality characteristics (Shiner,
2015). Over time, as summarized in the opening section
of this chapter, temperament and personality traits become
increasingly differentiated and organized, and patterns of
emotion, cognition, and behavior become associated with a
particular child or adolescent. The constructs of personality
and personality disorder are discussed in various ways. The
terms that are used most often are provided in Table 14.1.
Dimensional models describe two core components
of personality. One is concerned with the self, including
identity, esteem, and regulation. The other is concerned with
relationships, including capacities for connection, empathy,
and intimacy (Shiner & Tackett, 2014). In the dimensional
models, personality disorders are descriptions of ways in
which children and adolescents display atypical experiences
of self and/or relationships that are associated with significant
distress or dysfunction. Factor-analytic models of adolescent
personality disorder focus on three pattern clusters: an
internalizing cluster, an externalizing cluster, and a borderlinedysregulated cluster (Westen et al., 2014; Westen & Kegley,
2021). Developmental models, embedded in the developmental
psychopathology framework, provide multiple perspectives to
explain the emergence and course of personality difficulties
(Altschuler & Krueger, 2021; refer to Table 14.2).
In addition to these models and approaches, there has been
considerable focus on the promise of the DSM-5-TR Alternative
Model of Personality Disorders (AMPD) for understanding the
development and nature of personality disorders in general and
as a way of thinking about this domain of psychopathology in
terms of adolescent development (Sharp, 2020; Shiner, 2022).
Table 14.1 Terms Used for Describing Personality Pathology
Term Definition
Personality Individual differences in cognition, affect, behavior, and interpersonal functioning
Normative personality Less extreme or adaptive variants of personality
Pathological personality More extreme or maladaptive variants of personality
Personality disorder Psychiatric constructs of maladaptive personality delineated by the Diagnostic
and Statistical Manual of Mental Disorders and similar authoritative classification
systems, such as the International Classification of Disease
Personality pathology An overarching term that encompasses both personality disorders and the range of
configurations across dimensional maladaptive personality traits
Source: Altschuler & Krueger (2021). Towards a contemporary approach for understanding personality pathology in developmental context:
An integrative model.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Personality Disorders in Adolescence and Young Adulthood 269
Table 14.2 Developmental Perspectives on Personality Disorders
Title
Spectrum/Continuity Psychopathology is an extreme manifestation of personality traits.
Vulnerability Personality traits may predispose an individual to be more likely to develop
Resilience Personality may act as a protective factor against the development of
Pathoplasty Personality traits may influence the course and manifestation of
Scar/Complication The experience of psychopathology may leave lasting impressions on children
Source: Altschuler & Krueger (2021). Towards a contemporary approach for understanding personality pathology in developmental context:
An integrative model.
Description
psychopathology.
psychopathology.
psychopathology.
in ways that alter their personality functioning.
The AMPD is grounded in dimensional ratings of personality
functioning and a set of pathological personality trait domains
(Krueger & Hobbs, 2020). The dimensional foundation of the
AMPD is especially well suited to the task of understanding
personality disorders in light of the important adolescent and
young adult tasks of consolidation of identity and personality
organization.
Categorical models emphasize pathological personality
traits and impaired personality functioning. Among the
current DSM-5-TR categorical syndromes are antisocial
personality disorder, avoidant personality disorder, borderline
personality disorder, obsessive-compulsive personality disorder,
narcissistic personality disorder, and schizotypal personality
disorder. Although many believe that their age precludes youth
from being diagnosed with a personality disorder, children and
adolescents can be diagnosed if they meet the set of criteria for a
particular personality disorder. Caution is necessary, however,
as the diagnosis of a personality disorder is often accompanied
by beliefs about a chronic course, poor response to treatment,
and negative stigma (Shiner & Tackett, 2014).
Even with compelling information about the dimensionality
of personality disorders, DSM-5-TR diagnoses of personality
disorder are increasingly identified. Personality disorders are
diagnosed much more frequently in youth when another
form of disorder is also present (Shiner & Tackett, 2014).
Overall, diagnoses of personality disorders in youth are less
stable in adolescents than adults, but there is considerable
variability in diagnosis stability across specific disorders
(d’Huart et al., 2022). For example, diagnoses of antisocial
personality disorder are much more stable than diagnoses
of narcissistic personality disorder. Personality disorders are
associated with a variety of short- and long-term problematic
outcomes, including lower levels of education, problems in
relationships, less success in work, and worse overall health
and well-being (Shiner & Tackett, 2014).
Much of the research and clinical attention focused on
personality disorders in children, adolescents, and adults
involves antisocial personality disorder and borderline
personality disorder. Developmental pathways from
oppositional defiant disorder to conduct disorder to
antisocial personality disorder were described in Chapter 9,
with particular emphasis on children and adolescents who
displayed callous-unemotional characteristics.
Borderline personality disorder is a disorder
characterized by identity disturbance, affective instability,
relationship difficulties, and impulsivity. The disorder can
be reliably diagnosed in adolescence (Videler et al., 2019).
Developmental pathways to borderline personality disorder
have been proposed that include early forms of emotion
dysregulation and impulsivity, disrupted attachment, and
the experience of trauma or maltreatment. Dialectical
behavior therapy (DBT), an evidence-based form of cognitive
behavioral therapy, has been found to be an especially
effective intervention for treating the dysregulation of
emotion and behavior, including self-harm and suicidal
behavior, common to psychopathologies of adolescence and
young adulthood such as borderline personality disorder
(Brueger et al., 2019; Tebbett-Mock et al., 2020).
Personality disorders, regardless of how exactly they are
defined, represent maladaptive patterns of experiencing
one’s self and one’s relationships. While it may make
us uncomfortable to think about an enduring pattern
of psychopathology such as personality disorders in the
context of adolescence, we must recognize adolescence as a
sensitive period for their development if we are to achieve an
understanding of these disorders and potential interventions
(Sharp et al., 2018). Indeed, as research and clinical
experience with personality disorders in adolescence has
increased, our understanding of how to identify and treat
these disorders has led to a broader array of interventions
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270 Chapter 14 Substance-Related Disorders, Personality Disorders, and PsychoticDisorders
Box 14.1 Emerging Science
The Transition to Psychosis
The North American Prodrome Longitudinal Study (NAPLS),
begun in 2008, is an ongoing and compelling example of how
a developmental psychopathology perspective can help us
better understand not only major psychiatric disorders, such as
schizophrenia, but the developmental course leading to such
disorders. There have been three distinct but related projects
as part of the NAPLS consortium (Addington et al., 2015;
Addington et al., 2022; Cannon et al., 2008). Together, they are
advancing the understanding of the predictors and mechanisms of
conversion to psychosis, as well as other outcomes, for adolescents
at high risk for developing a psychotic disorder. This dynamic
understanding allows us to ask important questions concerning
risk, prevention, and the developmental course of disorders that
are central to a lifespan understanding of psychopathology.
NAPLS represents a national consortium of sites focused on
understanding the psychosis prodrome, subsequent developmental
trajectories, and specific mechanisms that lead to psychotic
disorders. The term psychosis prodrome refers to the group of
symptoms linked to the onset of psychotic disorders. These
include, for example, unusual and idiosyncratic thinking, atypical
social functioning characterized by suspiciousness, and
communication problems. In and of themselves, these types of
symptoms do not represent a psychotic process. However, while
concerning in their own right, they also indicate a heightened risk
for the development of psychotic disorders. It is the early
identification and prospective assessment of individuals at risk for
prodromal syndromes, schizophrenia, and other psychotic
disorders that allows for the study of the specific mechanisms that
lead to major psychopathology. The initial phase of the NAPLS
focused on finding those variables that might allow for more
accurate prediction of later psychotic disorders. To do this, they
first recruited adolescents at risk for major psychopathology based
on a number of potential factors.
The initial study results established the viability of this
research model (Cannon et al., 2008). The rate of conversion to
psychosis of the initial sample of over 300 high-risk adolescents
was 35% over a 2½-year follow-up period. In addition, of the
76 potential predictors of psychosis, five were found to have
highly significant predictive value in identifying individuals
likely to develop a psychotic disorder. These factors included
genetic risk for psychosis (with a decline in functioning),
unusual thought content, suspiciousness or paranoia, impaired
social functioning, and a history of drug abuse. The NAPLS
researchers found that by combining certain variables, they
could markedly increase the predictive power of their
algorithms. For example, the combination of genetic risk (with
decline in functioning) + unusual thought content + lower
social functioning identified those who converted to psychotic
disorders with 81% accuracy.
While approximately one-third of the original NAPLS
sample went on to develop a psychotic illness, two other roughly
equivalent clusters were identified as well. A second cluster of
the high-risk sample had their original symptoms remit and
went on to show no signs of thought disorder, while a third
cluster continued to show a relatively stable pattern of
attenuated psychotic symptoms (Addington et al., 2015). This
last finding has important implications for broadening our
understanding of the domain of thought disorders as
representing a spectrum of psychopathology. This spectrum
seems to include some individuals who become asymptomatic
over time, some who progress to a full psychotic disorder, and
some who continue to present with the partial expression of
thought disorder symptoms. The continued study of this final
group may bolster the case for including a version of attenuated
psychosis syndrome in future editions of the DSM classification
system (Yung et al., 2012; refer to Table 14.3).
and improved outcomes across development (Chanen et al.,
2018; Hagan & Choi-Khan, 2021). Ongoing research and
clinical attention is necessary so that adolescents and those
who care about them can look to the future with realistic
and positive expectations for health and well-being.
Psychotic Disorders in Adolescence and Young Adulthood
Adolescence, particularly late adolescence, is a critical
period for the onset of psychosis and especially severe
forms of psychopathology, such as bipolar disorders and
schizophrenia. Given the voluminous literature available,
we will not provide a comprehensive overview of the
clinical presentation, the developmental course, etiology,
and interventions for these disorders. Instead, we will
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
focus on contemporary research and clinical investigations
of the transition to psychosis that are grounded in the
developmental psychopathology framework (refer to
Box14.1). The case of Finn provides additional perspective.
The Case of Finn
As a 16-year-old high school student in the 11th grade,
Finn was first referred to a community psychologist for
a diagnostic evaluation by his therapist, who was growing
concerned about Finn’s increasing social isolation at school
and reports of conflict with his parents. Although Finn has
a history of moderate emotional and learning problems,
his therapist, who has worked with him for several years
to address both anxiety and mood symptoms, hoped that
he would thrive in high school, where his intelligence,
sociability, and varied interests would be valued and
supported. Unfortunately, after a modestly successful first
Psychotic Disorders in Adolescence and Young Adulthood 271
Table 14.3 DSM-5-TR Conditions for Further
Study
Attenuated Psychosis Syndrome: Summary
ofDSM-5-TR Diagnostic Criteria
A. At least one of the following symptoms
is present and is of sufficient severity or
frequency to warrant clinical attention:
●
Attenuated delusions
●
Attenuated hallucinations
●
Attenuated disorganized speech
B. Symptoms present at least once per week for
the past month.
C. Symptoms begun or worsened over the past
year.
Source: American Psychiatric Association
Findings from the NAPLS initiative have also shown
significant neurodevelopmental differences involving both
gray matter (functional) and white matter (connectivity) in
high-risk individuals who develop psychotic disorders
compared to typically developing adolescents (Cannon, 2015;
Chung et al., 2015). For example, in typically developing
adolescents, gray matter changes include the progression from
a high proliferation of neuronal synapses to the orderly pruning
of up to 40% of these synapses as functional specialization
occurs. In contrast, adolescents who go on to develop
schizophrenia show a decrease in synaptic density and a
disrupted process of neuronal pruning. There appears to be a
similar pattern of differences regarding white matter
development. Specifically, in typically developing adolescents,
white matter tracts increase (enhancing brain connectivity),
while both the volume and quality of white matter tracts are
compromised in adolescents who go on to develop psychotic
disorders.
As the NAPLS consortium increases the number of
individuals being followed and expands the research questions
being investigated, it is deepening our understanding of key
pathophysiological and developmental mechanisms inf luencing
the progression from prodromal psychotic symptoms to
psychotic disorders. For example, although evidence for
increased exposure to stress among the NAPLS sample is
inconsistent, the prodromal group that went on to develop
psychotic disorders was found to have heightened sensitivity
and reactivity to the stress they did experience (Trotman et al.,
2014). In addition, NAPLS findings suggest that early
traumatic experiences are associated with a heightened risk for
the onset of psychosis later in life (Stowkoly, 2016). NAPLS
findings are now informing investigations and validating
predictive measures utilizing similar risk populations from
around the world (Koutsouleris et al., 2021; Zhang et al., 2019).
Research projects such as the NAPLS reflect an
understanding that the clinical prodrome represents a critical
period for studying changes associated with the onset of
psychosis. This approach minimizes the confounding
influences associated with studying individuals at the time of
their first psychotic episode. In addition, the prodromal
approach allows for the possibility of developing predictive
heuristics, including predictive biomarkers, that may lead to
earlier identification of individuals at risk for psychotic
disorders as well as the development of preventive and early
interventions.
year, a pattern of difficulties began early in his sophomore
year, leading to a gradual deterioration in academic and social
functioning and an increase in concern on the part of Finn’s
parents and teachers. Over the course of that school year,
Finn was described as increasingly vigilant and suspicious.
He developed an extreme sensitivity to light and noise, and
this became a source of stress to him each day, leading to an
increasing level of social withdrawal. Although Finn’s grades
in math and science dropped compared to ninth grade, he
continued to do well, despite his problems, in his English
and social studies courses, where his love of reading, strong
verbal skills, and engaging writing style served him well.
Following the end of the school year, Finn was excited
about finding a summer job at a fast-food restaurant.
However, after several weeks, he found it stressful to
interact with coworkers and the public, began arguing with
the manager, and frequently skipped shifts, complaining
that he was too tired to work. Finn was eventually let
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
go, and he spent the majority of the summer on his own
playing video games.
As Finn began his junior year, his parents reported that
“everything began to fall apart.” His social and academic
problems at school, as well as conflict at home, intensified.
He was briefly hospitalized after endorsing significant
suicidal ideation as part of the psychological evaluation.
Finn’s treatment team tried a variety of medications and
psychosocial interventions, but none seemed to slow the
acceleration of symptoms or deterioration in functioning.
As the school year progressed, Finn was described
as becoming even more mistrustful. His sensitivity to
light and noise intensified. Partly in response to these
sensitivities, Finn began to develop increasingly rigid
behavioral routines to minimize his exposure to light and
sound. For example, he insisted on wearing sunglasses
indoors and stuffing his ears with cotton—behaviors
that often led to being teased by classmates. In situations
272 Chapter 14 Substance-Related Disorders, Personality Disorders, and PsychoticDisorders
that would have previously made Finn uncomfortable, he
now tended to quickly escalate to outbursts of anger and
frustration. This was an especially common response to
what he perceived as classmates deliberately slamming
lockers and talking loudly in an effort to annoy him.
Finn’s explanations for his frustration became
increasingly complex and idiosyncratic and reflected
extreme suspicion of the motives and intent of his teachers
and parents. He sent a long, rambling letter to all the
members of the school board accusing the principal of
installing more intense lighting throughout the school as
part of a plot to affect student behavior by forcing them to
walk through the halls with their eyes shielded. Finn also
insisted that his father was pretending not to understand
his struggles as a way to mock and torment him.
Late in Finn’s junior year, the police were called to
his house when he threatened his family with a hammer,
insisting that they were plotting to poison him. When
questioned, Finn said that his parents were introducing
toxins into the air by chemically altering food through
the process of cooking it. Finn’s school attendance
became erratic, and he ended the year with several course
incompletions. That following summer, he became
reluctant to travel outside the house during daylight for
fear that radiation from the sun would instantly and
irreparably damage his DNA. His personal hygiene
deteriorated as well, due in part to his refusal to shower.
His explanation for why he wouldn’t shower was his
belief that dangerous gases were released when water was
converted to steam.
Throughout this shift into more frankly delusional
beliefs, Finn insisted that he was being entirely reasonable
and that his family was trying to make him feel like an
irrational, unstable person in an attempt to drive him
from his home. Shortly after reporting this to his therapist,
he became preoccupied with the belief that he had been
switched at birth and that his family was perpetrating an
elaborate hoax on him.
Finn’s isolation and erratic behavior continued through
the summer and into his senior year. Eventually, he
refused to attend school or leave his home. He spent much
of his time in the bathroom to protect himself from light,
sound, toxins, and radiation. Attempts by Finn’s parents
to get him to leave the bathroom led to an escalation of
his threats to the family, claiming that he had the ability
to stop their hearts with his mind. The police were
once again called to the home, this time leading to an
emergency psychiatric hospitalization.
Finn was diagnosed with a psychotic disorder, possibly
schizophrenia, and a medication regimen was found that
helped reduce the most disturbing psychotic symptoms.
Eventually, he made the transition from the hospital to
a residential treatment program, where the combination
of medication, individual, and group therapy helped
him to develop more effective coping strategies. Finn
rediscovered his love of reading and writing fiction and
gradually reengaged in productive academic work. He
continues to struggle with symptoms of confusion and
agitation when feeling stressed. However, following his
return home, Finn successfully completed high school in
an alternative learning center and hopes to continue his
education through a local two-year community college
program.
The case of Finn provides an example of the prodrome,
the period of time before the first episode of psychosis, and
the transition to the early phase of psychosis. The prodrome
phase can last for months or years, with a gradual decline
in functioning across adolescence and young adulthood
(Ferrarelli & Mathalon, 2020; Walker et al., 2013). During
the prodromal phase, impaired functioning is common
in various domains, including academic, social, and
occupational domains. Along with declines in functioning,
there are increases in prepsychotic symptoms such as unusual
ideas, suspiciousness, and atypical perceptual experiences.
While other adult-onset disorders may be linked to
symptom patterns that precede a formal diagnosis, the
symptoms identified as prodromal to psychotic disorders
have been found to be distinctive in kind and predictive
power (Salvatore & Baldessarini, 2021). By focusing on these
characteristics of prodromal psychosis, researchers hope
to identify more precisely both risk and protective factors.
Clinicians hope to develop more targeted and effective
assessment tools and interventions (Taylor & Huque, 2021;
Zheng et al., 2022).
Individuals like Finn often manifest early signs of an
evolving thought disorder in the unusual ways in which
they interpret the unremarkable and common stimuli of
everyday life. This process of making atypical attributions
of significance to objectively benign aspects of their
environment is known as aberrant salience (Chun et al.,
2020). Finn’s progression from being sensitive to light and
sound to believing others were intentionally manipulating
these stimuli to cause him distress are examples of aberrant
salience, as are his beliefs that sunlight would damage his
DNA and that steam from a shower constituted a dangerous
gas. Research has shown aberrant salience to be a frequent
prodromal symptom linked to later symptoms of psychosis,
such as disorganized thinking, paranoia, and impaired social
functioning. Consequently, aberrant salience is increasingly
recognized as a meaningful prodromal symptom. Research
is being conducted to develop valid and reliable measures
to assess aberrant salience before the formal onset of major
psychopathology (Ballerini et al., 2022).
Investigations, like the North American Prodrome
Longitudinal Study described in Box 14.1, are focused on
ways to identify individuals at the highest levels of clinical
risk and to intervene to delay or prevent the development
of severe forms of psychopathology. So far, this research
has carefully examined atypical brain development, geneby-environment-by-time processes, epigenetic processes,
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Psychotic Disorders in Adolescence and Young Adulthood 273
the role of stress and trauma, prodromal neurocognitive
profiles, and the activation of brain-behavioral stress systems
in high-risk adolescents (Velthorst et al., 2019; Walker et al.,
2013).
With respect to developmental pathways, several
general trajectories have been described for high-risk
adolescents. These include stable-good trajectories (with
relatively good functioning maintained over time), stableintermediate trajectories (with some functional impairment
and some prepsychotic symptoms displayed over time), and
deteriorating trajectories (with increases in impairment and
psychotic symptoms over time) (Beck et al., 2022; Cannon
et al., 2015).
With respect to etiology, complex, multifactorial models
are emphasized (Walker et al., 2013; refer to Figure 14.7).
Questions that are currently being addressed include:
What are the early genetic variants that contribute to
high-risk status? How do the genetic load differences map
onto observed cognitive vulnerabilities or impairments or
onto increased sensitivity to stressful experiences? Atypical
brain structures and development have been documented,
including reduced volume in multiple brain regions, atypical
connectivity, and neurotransmitter dysfunction. A number
of researchers have hypothesized that pubertal hormones
may inf luence atypical brain development. Other researchers
have focused on atypical activation of the HPA axis by both
external stressors and internal neurophysiological processes.
Still others have investigated whether immune system
factors increase the risk in vulnerable individuals. (Cullen
etal., 2020; Trotman et al., 2014; Walker et al., 2013).
The experience of stress and trauma may influence
whether high-risk individuals transition from the prodrome
phase to the development of a psychotic disorder. There is
some evidence that high-risk adolescents who convert to
psychosis are more likely to have histories of maltreatment
and peer bullying. These histories are often coupled with
greater sensitivity to stress and trauma (Braun et al., 2022;
Walker et al., 2013). A lack of social support and residential
instability are also linked to conversion to psychosis for at-risk
youth (Ku et al., 2021). Social maladjustment appears to be
more predictive of conversion to schizophrenia (compared
to other psychotic disorders) than academic maladjustment
(Tarbox et al., 2014). Marijuana use is also associated with
conversion to psychosis for those in the high-risk group and
those with certain genetic dispositions for schizophrenia
(Lebowitz et al., 2021; Walker et al., 2013).
Adolescence is increasingly recognized as an important
time to identify individuals at a clinical high risk for
Figure 14.7 Developmental factors in prodrome models of psychosis
Prenatal Environment Postnatal Environment
Maternal stress
Maternal infection
Genetic:
• Inherited risk alleles
• Mutations
Epigenetic:
• Parentally transmitted
• Prenatally acquired
Prenatal Complications:
• Hypoxia and other
complications
• Inflammatory processes
Origins of congenital
brain vulnerability
Childhood trauma
Increased stress sensitivity
Hormonal Changes:
Gonadal hormones
HPA activity
Immune System:
Thymus function and
immune protection
Brain Maturation:
Gray matter
Synaptic pruning
• Formation of neural
circuitry
Adolescent neuromaturation:
Prodromal phase
HPA Activation:
• Heightened cortisol release
• Augmented inflammatory processes
• Neurotoxicity
• Compromised neuroplasticity
• Increased striatal DA activity
Inflammatory processes:
• Activation of dormant
neuroinflammatory processes
• Augmented HPA activity
Epigenetic changes:
Aberrant Structural Brain Changes:
• Accelerated gray matter decline
• Accelerated pruning
• Abnormal connectivity
• Abnormal frontal-striatal
neurocircuitry
Neuropathological processes:
Substance abuse
Infectious agents
Psychosis
Source: Walker et al. (2013). Developmental mechanisms in the prodrome to psychosis.
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