43 - 31.17c Identity Problem

31.17c Identity Problem

affect and academic outcomes during adolescence. J Youth Adolescence. 2012;41:379–389. Lucio R, Hunt E, Bornovalova M. Identifying the necessary and sufficient number of risk factors for predicting academic failure. Dev Psychol. 2012;48:422–428. Pascoe L, Roberts G, Doyle LW, Lee KJ, Thompson DK, et al. Preventing academic difficulties in preterm children: A randomised controlled trial of an adaptive working memory training intervention-IMPRINT study. BMC Pediatr. 2013;13:144–156. Reinke WM, Herman KC, Petras H, Ialongo NS. Empirically derived subtypes of child academic and behavior problems: Cooccurrence and distal outcomes. J Abnorm Psychol. 2008;36:759–770. Roberts G, Quach J, Gold L, Anderson P, Richards F, Mensah F, et al. Can improving working memory prevent academic difficulties? A school-based randomised controlled trial. BMC Pediatr. 2011;11:57–66. Williams BL, Dunlop AL, Kramer M, Dever BV, Hogue C, et al. Perinatal origins of first-grade academic failure: Role of prematurity and maternal factors. Pediatrics. 2013;131:693–700. 31.17c Identity Problem The normative developmental process for an adolescent was conceptualized by the developmentalist Erik Erikson as an adolescent “crisis of identity.” The transition between a childhood identity and the process of accepting a more mature sense of self is the resolution of the “crisis.” Consolidation of identity encompasses cognitive, psychodynamic, psychosexual, neurobiological, and cultural development. As identity is confirmed in adolescence, a sense of self-sameness and continuity over time unfolds. The notion of an identity crisis in adolescence gained widespread attention by clinicians and the popular media during the late 1960s and early 1970s, when many adolescents displayed rejection of mainstream cultural values and ideas and demonstrated alternative lifestyles. The concept of identity disorder as a psychiatric diagnosis was embraced in the 1980s when the DMS-III was devised, as a disorder usually first evident in childhood. It was meant to include adolescents who presented with “severe subjective distress regarding uncertainty about a variety of issues relating to identity” to the point where they became impaired. Identity problem is not currently conceptualized as a psychiatric disorder, rather it refers to uncertainty about issues, such as goals, career choice, friendships, sexual behavior, moral values, and group loyalties. An identity problem can cause severe distress for a young person and can lead a person to seek psychotherapy or guidance; however, it is not included in the DSM-5. It sometimes occurs in the context of such mental disorders as mood disorders, psychotic disorders, and borderline personality disorder. A study examining Intolerance of Uncertainty (IU), that is, the tendency to react negatively to uncertain situations, in 191 adolescents found that IU is correlated with adolescent social anxiety, worry, and to a lesser extent, depression. EPIDEMIOLOGY No reliable information is available regarding overall prevalence; however, factors increasing risk for identity problems include psychiatric disorders, psychosocial

difficulties, and the pressures of assimilation as an ethnic minority into mainstream society. ETIOLOGY The causes of identity problems often are multifactorial and include the pressures of a dysfunctional families, the influences of coexisting mental disorders, and the degree to which adolescents feel integrated into their school and family environments. In general, adolescents with social skills deficits, major depressive disorder, psychotic disorders, and other mental disorders report feeling alienated from their peer group and family members, and experience some turmoil. Children who have had difficulty mastering expected developmental tasks all along are likely to have difficulty with the pressure to establish a well-defined identity during adolescence. Erikson used the term identity versus role diffusion to describe the developmental and psychosocial tasks challenging adolescents to incorporate past experiences and present goals into a coherent sense of self. CLINICAL FEATURES The essential features of identity problem seem to revolve around the question, “Who am I?” Conflicts are experienced as irreconcilable aspects of the self that the adolescent cannot integrate into a coherent identity. As Erikson described identity problem, youth manifests severe doubting and an inability to make decisions, a sense of isolation, inner emptiness, a growing inability to relate to others, disturbed sexual functioning, a distorted time perspective, a sense of urgency, and the assumption of a negative identity. The associated features frequently include marked discrepancy between the adolescent’s self-perception and the views that others have of the adolescent; moderate anxiety and depression that are usually related to inner preoccupation, rather than external realities; and self-doubt and uncertainty about the future, with either difficulty making choices or impulsive experiments in an attempt to establish an independent identity. Adolescents with identity problem may join “outcast” cult-like groups. A study examining relationships of social context and identity of high-risk Hispanic adolescents 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, schizophreniform 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

vocational 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 psychopathology. 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 anxiety, 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 identity 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 vulnerability 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 interactions. 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 provide 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 discontinue her self-injurious behaviors and focus on succeeding in school and with her peers. (Adapted from Efrain Bleiberg, M.D.) TREATMENT Considerable consensus exists among clinicians that adolescents experiencing identity