Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.18a Individual Psychotherapy

Treatment Considerable consensus exists among clinicians that adoles- cents experiencing identity problems may respond to brief psychosocial intervention. Individual psychotherapy directed toward encouraging growth and development usually is consid- ered the therapy of choice. Adolescents with identity problems often feel developmentally unprepared to deal with the increas- ing demands for social, emotional, and sexual independence. Issues of separation and individuation from their families can be challenging and overwhelming. Enlisting the concepts out- lined by Erikson with regard to adolescent development, psy- chotherapy may include discussion of adolescent exploration (active search among alternatives for activities and friendships that fit) and commitment (demonstrated investment) in activities that promote independence and autonomy. Treatment is aimed at helping these adolescents develop a sense of competence and mastery about necessary social and vocational choices. A thera- pist’s empathic acknowledgment of an adolescent’s struggle can be helpful in the process. R eferences Bleiberg E. Identity problem and borderline disorders in children and adolescents In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 8 th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2005:3457. Boelen PA, Vrinssen I, van Tulder F. Intolerance of uncertainty in adolescents. J Nerv Ment Dis. 2010;198:194–200. Chabrol H, Leichsenring F. Borderline personality organization and psychopathic traits in nonclinical adolescents: Relationship of identity diffusion, primitive defense mechanism and reality testing with callousness and impulsivity traits. Bull Menninger Clin. 2006;70:160. Erikson EH. Identity and the life cycle: Selected papers. Psychol Issues. 1959;1:1. Ivanovic DM, Leiva BP, Perez HT, Olivares MG, Diaz NS, Urrutia MS, Almagia AF, Toro TD, Miller PT, Bosch EO, Larrain CG. Head size and intelligence, learning, nutritional status and brain development. Head, IQ, learning, nutrition and brain. Neuropsychologica. 2004;42:1118. Mackinnon SP, Nosko A, Pratt MW, Norris JE. Intimacy in young adults’ nar- ratives of romance and friendship predicts Eriksonian Generativity: A mixed method analysis. J Personality. 2011;79:3. Marcia J, Jossleson R. Eriksonian personality research and its implications for psychotherapy. J Personality. 2012;81:617–629. Rossi NE, Mebert CJ. Does a quarterlife crisis exist? J Genet Psychol. 2011; 172:141–161. Schwartz SJ, Mason CA, Pantin H, Wang W, Brown CH, et al. Relationships of social context and identity to problem behavior among high-risk Hispanic ado- lescents. Youth Sci. 2009;40:541–570. Thomas JJ. Adolescents’ conceptions of the influence of romantic relationships on friendships . J Genet Psychol. 2012;173:198–207.

found that school problems and identity confusion among these adolescents were related to behavioral problems and risk-taking behaviors including alcohol use, illicit drug use, and sexual risk- taking behaviors. Differential Diagnosis Identity problems must be differentiated from sequelae of a mental disorder (e.g., borderline personality disorder, schizo- phreniform disorder, schizophrenia, or a mood disorder). At times, what initially seems to be an identity problem may be the prodromal manifestations of one of these disorders. Intense, but normal, conflicts associated with maturing, such as adolescent turmoil and midlife crisis, may be confusing, but they usually are not associated with marked deterioration in school, in voca- tional or social functioning, or with severe subjective distress. Considerable evidence indicates that adolescent turmoil often is not a phase that is outgrown but an indication of true psycho- pathology. Course and Prognosis The onset of identity problem most frequently occurs in late adolescence, as teenagers separate from the nuclear family and attempt to establish an independent identity and value system. The onset usually is characterized by a gradual increase in anxi- ety, depression, regressive phenomena (e.g., loss of interest in friends, school, and activities), irritability, sleep difficulties, and changes in eating habits. The course usually is relatively brief, as developmental lags respond to support, acceptance, and the provision of a psychosocial moratorium. Extensive prolongation of adolescence with continued iden- tity problem can lead to the chronic state of role diffusion, which may indicate a disturbance of early developmental stages and the presence of borderline personality disorder, a mood disorder, or schizophrenia. An identity problem usually resolves by the mid- 20s. If it persists, the person with the identity problem may have difficulty with career commitments and lasting attachments. Jenna, an 8-year-old girl, was adopted in Taiwan at 10 months of age by a white midwestern couple. As she grew, her vulnerabil- ity to separations became increasingly more pronounced. Jenna developed school refusal, and would exhibit outbursts of rage and misbehavior when she was forced to go to school. She pleaded with her mother to care for the many aches and pains that plagued her. By the time she reached adolescence, Jenna had an entrenched habit of cutting and self-mutilating. She responded to frustration, separations, or perceived threats of abandonment by cutting herself or burning herself with cigarette lighters. Eventually, she was able to verbalize the multiple functions that self-injury served for her. She noted that she was able to stay home from school, be in the company of her mother, and avoided the stresses of peer interac- tions. Jenna and her mother began a course of psychotherapy in which Jenna learned that she would still need to attend school, regardless of her cutting behavior, and her mother learned to pro- vide incentives for Jenna to diminish her maladaptive behaviors. Over time, Jenna became more flexible and realized that she was harming herself, and not others around her. Jenna was able to return to school, and with the help of her therapist, she was able to discon- tinue her self-injurious behaviors and focus on succeeding in school and with her peers. (Adapted from Efrain Bleiberg, M.D.)

▲▲ 31.18 Psychiatric Treatment of Children and Adolescents

31.18a Individual Psychotherapy Individual psychotherapy with children and adolescents gen- erally begins by establishing rapport through developmentally appropriate psychoeducation regarding the target symptoms and disorders to be addressed. As a rule, the younger the child, the more extensively family members participate in the treatment. Even among adolescents, family members are often