Assessment of Identity in Adolescents

MIDAP Conference Santiago, 24.08.2016

Klaus Schmeck
Child and Adolescent Psychiatric Hospital
Psychiatric University Hospitals Basel / Switzerland
 The person behind the illness

DSM / ICD Classification:

phenomenological approach (description of criteria)

There are much more levels of analysis and exploration:

• Genetic factors
• Neural structures and mechanisms
• Neuropsychological mechanisms
• Psychological mechanisms and processes
• Meaning structures (personal constructs)
• Personal narratives
Personality Disorders in DSM-V Chapter III
«The essential features of a personality disorder are
impairments in personality (self and interpersonal) functioning
and the presence of pathological personality traits.»
A. Significant impairments in personality functioning manifest
by:
1. Impairments in self functioning (a or b):
a. Identity
b. Self-direction: Goal-setting; values; prosocial internal
standards; academic aspirations.
2. Impairments in interpersonal functioning (a or b):
a. Empathy: concern for feelings, needs, or suffering of
others.
b. Intimacy: Incapacity for mutually intimate
relationships
| 4
 Identity
the contributions of James and Mead

distinction between
› the “I”: an intuitive, emotionally experienced vital self-
evidence, and
William James › the “ME”: a result of a self-reflective process leading to an
1842-1910 integrated awareness and knowledge about oneself.

Thus, identity can be divided into two higher order domains

› “subjective self” (focussing on continuity, “stable core”,
emotional access)
› “definitory self” (focussing on coherence, “integrated whole”,
cognitive access)

George H. Mead
1863-1931

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 5

 Identity: E.H. Erikson’s definition

› “The term ‘identity’ expresses such a mutual relation in

that it connotes both a persistent sameness within oneself
(self-sameness) and a persistent sharing of some kind of essential
character with others.” [Erikson, 1959:109]

Components:
› conscious sense of individual identity
› unconscious striving for a continuity
› ego synthesis
› inner solidarity with a group’s ideals and identity.

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 6

Assessment of Identity

Instruments to assess identity:

› IPO (Inventory of Personality Organization): Primitive Defences,
Identity Diffusion, Reality Testing (+ Aggression, Moral Values)
› STIPO
› Interview of Personality Organization Processes in Adolescence
(IPOP–A)

› MACI (Millon Adolescent Clinical Inventory)

› OPD-CA-2 (Operationalized Psychodynamic Diagnostic in

Childhood and Adolescence)
Spanish version: Diagnóstico Psicodinamico Operacionalizado
para la edad de la infancia y la adolescencia

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 7

OPD-CA-2

Four Axes (dimensions)

1. Interpersonal Relations
2. Conflict
3. Structure
4. Prerequisites for Treatment
OPD-CA-2 Identity Scale

Coherence
Axes “Structure”
Self-perception
› Control (Self-Direction)
› Identity Self–object differentiation
(Identity)
› Intersonality (Empathy)
Object-perception
› Attachment (Intimacy)
Belonging

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 8

AIDA -Assessment of Identity
Development in Adolescence (Goth et al., 2011)

AIDA is…
› a self-report questionnaire for adolescents between 12 - 18 years
to assess identity development
› 58 items, 2 dimensions, 6 facets

The Aim of AIDA is…

› to assess the complex dimension of identity development,
especially in adolescents with emerging personality disorders
› to differentiate between healthy identity integration, identity
crisis and identity diffusion
› to be useful as screening tool
› to evaluate treatment outcome

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 9

 AIDA International Study Group
› 1) Child and Adolescent Psychiatric Hospital, University of Basel, Switzerland
2) University de los Andes and Instituto Medico Schilkrut, Santiago, Chile
3) University of Barcelona, Department of Basic Psychology, Barcelona, Spain
4) Psychiatric Hospital for Children and Adolescents, Zagreb, Croatia
5) Iberoamerican University, Mexican Institute of TFP, Mexico City, Mexico
6) Mykolas Romeris University; Department of Psychology, Vilnius, Lithuania
7) University Hospital Alexandrovska, Clinic of Child Psychiatry, Sofia, Bulgaria
8) Charles University, Department of Psychology, Prague, Czech Republic
9) University of São Paulo, Institute of Psychology, São Paulo, Brazil
10) Child and Adolescent Psychiatry, University of Prishtina, Kosovo
11) Child and Adolescent Psychiatry, University of Belgrade, Serbia

› Further study centres:

Bosnia-Herzegovina, Denmark, Finland, France, Germany, Greece, Hungary, Italy, Japan,
Luxembourg, Netherlands, Nigeria, Portugal, Singapore, South-Africa, Tunisia, Turkey, USA

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 10

AIDA -Assessment of Identity
Development in Adolescence

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 11

 AIDA Dimensions

ID-Diffusion
Discontinuity PD

Incoherence

Coherence

ID-Integration
healthy

Continuity
 Results
Reliabilty

D / CH Chile Mexico Brasilien Kroatien Spanien Tschechien Kosovo Litauen Bulgarien

Item-
Norm1 Norm pilot2 pilot3 pilot1 pilot2 Norm1 Norm pilot3 pilot1
zahl
N=357 N=749 N=265 N=207 N=314 N=310 N=276 N=703 N=210 N=311
ID gesamt 58 .94 .94 .94 .91 .93 .93 .91 .88 .93 .93
1. Diskontinuität 27 .86 .87 .85 .79 .83 .82 .79 .73 .83 .83
2. Inkohärenz 31 .92 .91 .92 .88 .89 .91 .87 .84 .90 .90
Verteilung girls girls  boys   girls  girls   boys 

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 13

 Clinical example of two boys age 16
Phenotype: both seem to be self-confident, pretentious and superficial

Boy 1: ADHD
Boy 2: Narcissistic PD + depression
80
AIDA 75
70
65
60
55
T-Scores

50
45
40
35
30
25
20
S…
S…

Discon: Identity Discontinuity Incoh: Identity Incoherence

d1: Stability in attributes / goals i1: Consistent self
d2: Stability in roles / relations I2: Autonomy
d3: emotional self reflection I3: cogn. self reflection

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 14

Samples used for psychometric analysis

› Sample I: School sample

1437 adolescents (614 boys, 823 girls) mean age 14.7 y. (SD 2.4)

› Sample II: clinical sample

- 140 adolescents (40 boys, 100 girls), mean age 15.3 y. (SD 1.7),
- both inpatients and outpatients
- structured clinical interviews: SCID-II and K-DIPS
› Diagnoses:
BPD: N= 25
other PD: N= 31
Internalizing N= 38
Externalizing N= 13
Comorbid N=33

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 15

Differences in AIDA between different diagnostic groups,
school sample and a subsample of healthy controls
(Goth, Zimmermann, Birkhölzer, Schrobildgen, Schlüter-Müller, Schmeck, subm.)

diagnostic groups students

BPD other PD internalizing externalizing school sample healthy controls

raw scores N= 25 N= 31 N= 38 N= 13 N=1437 N=1154

dBPD-ss dBPD-
M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) hc
Identity Diffusion 137.6 (25.1) 120.4 (34.3) 95.3 (36.2) 63.8 (32.3) 64.9 (27.6)
2.64 58.1 (21.4) 3.71
1. Discontinuity 63.4 (12.0) 52.4 (15.1) 42.4 (16.8) 30.1 (14.0) 27.5 (12.1) 2.97 24.6 (9.3) 4.13
2. Incoherence 74.2 (16.4) 68.0 (22.6) 52.9 (21.0) 33.6 (23.3) 37.3 (17.3) 2.14 33.5 (14.1) 3.56

1.1 Discontin_attr 23.7 (6.5) 19.2 (6.8) 18.1 (6.9) 15.8 (7.3) 13.0 (5.1) 2.11 12.0 (4.6) 2.53
1.2 Discontin_rel 21.5 (5.2) 18.4 (7.1) 12.2 (6.7) 8.6 (7.3) 6.4 (5.2) 2.92 5.3 (3.9) 4.10
1.3 Discontin_emot 18.2 (5.0) 14.7 (6.5) 12.1 (6.3) 5.8 (5.2)
8.2 (4.7) 2.14 7.3 (4.0) 2.74
2.1 Incoher_consis 30.4 (6.9) 28.3 (8.7) 20.1 (8.7) 14.5 (9.8)
12.5 (7.4) 2.45 10.9 (6.0) 3.27
2.2 Incoher _auton 24.8 (9.0) 22.3 (9.0) 19.2 (7.7) 9.5 (8.4)
14.8 (7.2) 1.37 13.5 (6.3) 1.78
2.3 Incoher _cogn 19.0 (5.2) 17.3 (7.6) 13.5 (6.7) 9.5 (7.3) 10.1 (5.1) 1.74 9.2 (4.6) 2.16

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 16

 AIDA mean scores:
diagnostic groups vs. normative population

140

120

100

80

60

40

20

0
BPS
BPD PS
PD INT EXT NORM Gesund
Healthy

d=3.7
Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 17
Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 18
 Evaluation of AIT Study (EAST)
Process-Outcome Study on Psychotherapeutic Interventions in
Adolescents With Personality Disorders
› ClinicalTrials.gov ID: NCT02518906

Santiago Basel Heidelberg

MIDAP › CAP, Psychiatric › CAP, Univ. Centre for
Schilkrut Institute Universitiy Hospital Psychosocial Medicine
› N. Valdez › K. Schmeck
› M. Krause › S. Schlüter-Müller › M. Kaess
› P. Foelsch › R. Zimmermann › König
› A. Borzutzky › N. Schenk › Cindy
› AIT-Therapists: › O. Pick › DBT-A-Therapists
del Solar, Quevedo, › AIT-Therapists:
Maturana, Reinel, E. Jung, V. Guri,
Scharfstein, Spuler A.C. v. Orelli,
› Orellana, Gómez, M. Birkhölzer,
Altimir, Morales, S. Brunner-Kunz
Risso, Matamala
| 19
 EAST (Evaluation of AIT Study)
Screening in outpatient departments
Inclusion Criteria:
Age 13-19 Baseline Exclusion Criteria:
Personality Pathology: Assessment (T0) - IQ<80
AIDA-T-Score >60 - Psychotic disorder,
>= 3 Borderline-Criteria pervasive developmental disorder
persistent substance dependence
antisocial personality disorder
- severe somatic/neurological dis.
- need for inpatient treatment
Informed consent

Adolescent DBT-A
Identity Indiv. Therapy
Process Treatment
Evaluation + Skills Training
weekly 1 session/week
+ every 1 session/week
2 months Duration: Duration:
25 sessions 25 sessions

Post-treatment Post-treatment
Assessment Assessment

Follow-up I + II Follow-up I + II
(12 + 24 months) (12 + 24 months)
 EAST Process-Outcome Research
Moderator Variables:
• Therapists’ experience Dependent Variables:
• Severity of disorder • psychosocial functioning
Independent • …
Variable: • personality functioning
treatment • psychopathology
condition • quality of life

generic therapy principles Outcome

Baseline assessment

Process

Follow-up assessment

Follow-up assessment
Outcome assessment
Video- Session Psycho-
rating evaluation physiology

Mediator Variables:
• Therapeutic relationship
• …

month
0 Therapy 8 12 24
 Preliminary Results (Schenk, 2016)
Rupture and Resolution Episodes during Treatment
 Preliminary Results (Fürer, 2016)
Physiological Measurements during Psychotherapy
 Summary
Identity disturbance
• is one of the core impairments of BPD
• is already present in adolescent BPD patients
• can reliably be diagnosed in adolescents

AIDA
• can be used as an economic screening instrument for early detection of
PD in general and BPD in particular

EAST
• International multicenter study to evaluate the efficacy and the basic
therapeutic processes of AIT in comparison to DBT-A

| 24 25. August 2016

 A.C.v.Orelli

Thank you for your attention!

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch | 25. August 2016 | 25