PATIENT EMERGING PERSONALITY PATTERNS AND DEFENSE MECHANISMS IN THE TREATMENT OF ADOLESCENTS WITH DEPRESSIVE DISORDERS: A PSYCHODYNAMIC DIAGNOSTIC MANUAL-ORIENTED EMPIRICAL INVESTIGATION

Introduction: In recent years, the incidence of depressive disorders is significantly increased in the adolescent population. Alarmingly, their spread appears to be even underestimated given that several cases of adolescent depression are not identified, accurately assessed, or dealt with in a timely and effectively manner. Thus, international health institutes and systems have recognized the urgent need to pay particular attention to early detection and prevention policies, as well as to the promotion of the best practices for the treatment of these disorders in adolescents Moreover, research has shown that depressive pathologies in adolescence represent a broad and more heterogeneous diagnostic grouping , and they co-occur with personality disorders. Moreover, this comorbidity seems to be associated with poorer therapeutic outcomes. This evidence highlights the need to pay particular attention to personality characteristics of this clinical population. Moreover, the assessment of the adolescents’ defensive style is also thought to contribute to an accurate psychodynamic-oriented diagnosis, considering its strong association with both personality pathology and depressive symptomatology. Lastly, specific therapists’ emotional responses (or countertransference) towards the patients is deemed to strongly inform about the adolescents’ intrapersonal and interpersonal functioning. Starting from these premises, the current study aimed at exploring the relationship between patients’ emerging personality patterns, defenses mechanism, and the therapists’ emotional responses in the treatment of adolescents with depressive disorders according to the Psychodynamic Diagnostic Manual-2 (PDM-2) framework. Method: One hundred clinicians completed the Psychodiagnostic Chart-Adolescent of the PDM-2 to provide a comprehensive assessment of psychological functioning of a depressed adolescent patient in their care. They also filled in the Therapist Response Questionnaire for Adolescents to investigate their countertransference responses towards patients. Moreover, adolescent patients completed the Defense Mechanism Rating Scales Self-Report-30 to evaluate their defensive functioning. Results: Four emerging personality profiles related to depressive pathology in adolescence were identified: depressive/introjective, anxious–avoidant, emotionally dysregulated, and narcissistic. These emerging personality patterns were characterized by distinct intrapsychic and interpersonal dynamics which were able to better differentiate this broad and more heterogeneous diagnostic grouping. For instance, depressive symptoms in the context of depressive/introjective emerging personality pattern were usually associated with feelings of guilt and perfectionism, whereas those ―embedded‖ in the narcissistic emerging personality pattern were mostly related to severe self-esteem problems. The results also showed that the emotionally dysregulated and narcissistic emerging personality patterns were significantly related to the borderline personality organization, whereas the depressive/introjective and anxious–avoidant emerging personality patterns were associated with the neurotic level of personality organization. Regarding to defensive functioning, adolescents presenting with the emotionally dysregulated and narcissistic personality patterns tended to use more immature defense mechanisms, especially major and minor image-distorting defense levels respectively. Conversely, patients with depressive/introjective emerging personality pattern tended to use neurotic and minor image-distorting defenses, whereas those presenting with anxious–avoidant emerging pattern mainly used neurotic defense mechanisms. Finally, countertransference patterns were significantly related to patients’ emerging personality patterns in a clinically meaningful and systematically predictable manner. Adolescent patients showing the emotionally dysregulated and narcissistic personality patterns tended to elicit in their clinicians more negative emotional reactions characterized by anger, irritation, worry, and sense of inadequacy. On the contrary, the depressiveintrojective and anxious-avoidant emerging personality patterns were associated with less intense and difficult-to-manage countertransference reactions. In particular, anxious-avoidant patients evoked protective reactions in therapists. Conclusions: The present study sought to extend the current knowledge on the emerging personality patterns in the context of depressive disorders in adolescent patients, providing meaningful information to their psychological functioning. According to a psychodynamically-oriented assessment, the evaluation of defensive functioning also helps to deepen the understanding of selfregulation strategies in dealing with emotional conflicts and to internal or external stressors. Lastly, the nuanced view of countertransference reactions evoked by these patients in psychotherapy offers the opportunity to improve diagnostic accuracy and guide clinicians in planning effective therapeutic interventions. Overall, all the clinicians of different therapeutic orientations should use the information derived from an accurate psychodynamic assessment to generate clinically meaningful diagnoses and promote treatments tailored on adolescents’ psychological functioning other than on their manifest symptomatology. The new PDM-3 will include the findings of this research project in order to provide a more complex and articulated perspective of depressive disorders in adolescence.