Page 125 - Personality disorders and insecure attachment among adolescents

because of the complexity of the concept attachment. In this study the AAI is used, which is a labour- intensive tool for clinical practice. Scoring of the AAI is a complex process and requires completion of a two-week intensive training course in scoring and coding procedures (Main, Goldwyn, & Hesse, 1998). As argued above, research on clinical high risk adolescents is complicated. More research is needed to advance prevention and treatment programs and to reduce the burden of this group on patients, their families and society. Simultaneously, it is questionable whether using mainly quantitative research methods for this target group is the correct course of action for current research in psychopathology. The validity of a questionnaire in high-risk adolescents with varying mental states seems doubtful for this group. Indeed, in this study written reflections on the treatment process appear to be more indicative of therapeutic recovery than a questionnaire. Perhaps qualitative instead of quantitative research methods, or a combination of both, offers more clarity on how to optimise prevention and treatment programs for clinical adolescents and how to reduce dropout. Co-occurrence in the sample As expected, in this study substantial co-occurrence between the personality disorders, insecure attachment representations and NSSI was found. The co-occurrence between the personality disorders parallels findings in other studies (Chiesa, Cirasola, Williams, Nassisi, & Fonagy, 2017; Tyrer, Crawford, & Mulder, 2011). Furthermore, no differences in attachment classifications and NSSI were found between personality disorder groups. Due to this substantial symptom overlap in combination with the overlap with symptoms of puberty, classifying personality pathology in adolescence correctly is difficult, perhaps even impossible, particularly in severely dysfunctional adolescents. As a result, the DSM categorisation by type of personality disorder seems arbitrary in adolescents with multi-morbidity. The general model of personality pathology currently in use seems especially limited for adolescents because it disregards overall adolescent developmental problems and family dynamics. The criteria for a personality disorder in the DSM-5 concern the individual and are not based on the context of the patient, even though the context is especially important in adolescents (Chen, Brody, & Miller, 2017; van Harmelen et al., 2016). A dimensional model that describes not only the core pathology but also the influence of adolescence, attachment insecurity and family interactions, may be more meaningful for high-risk adolescents than the current classification system. The substantial co-occurrence between attachment insecurity and personality pathology could confirm that attachment insecurity is indeed an underlying factor or a risk factor for developing a personality disorder in adolescence (Levy, Johnson, Clouthier, Scala, & Temes, 2015; Venta, Shmueli- Goetz, & Sharp, 2013), assuming that the insecure attachment occurred earlier than the personality disorder. This assumption would fit into the diathesis-stress model, which suggests that parent-child attachment along with current and past stressors, temperament and genes contribute to the emergence of psychopathology (Steele, Bate, Nikitiades, & Buhl-Nielsen, 2015). On the other hand, it may also 121