Contemporary Challenges in Adolescent Mental Health

Abstract

The aim of this chapter is to show the possible relations between the particularities of our time and certain pathologies in mental health that our young people experience today. It is in adolescence that the various mental illnesses begin to manifest themselves and that to understand them properly, it is essential to include the historical, social and cultural particularities dominant at a given time, this chapter sets forth some of the current difficulties observed in young people that would hinder them from entering adulthood. This chapter will focus on the psychopathological manifestations and the concomitant subjective discomfort that would afflict the young person and make it difficult for them to successfully adapt to their environment. Specifically, we will review the most prevalent phenomenon that physicians may face in their clinical work with adolescents will be reviewed, namely, borderline personality disorder (BPD) and three of its most frequent manifestations: addictions, self-harm and eating disorders.

1. Introduction

The different knowledge disciplines are in consensus as to the way in which mental pathologies manifest themselves is related to the historical period and the prevailing culture at a given time. Thus, for example, when going over the studies that deal with the history of mood illness and schizophrenia, we find that the pathology of schizophrenic psychosis, as we know it today, was first described in the year 1800 only, within the framework of a modern rationality that does not allow for arbitrary logic but seeks scientific certainty. Before the enlightenment and rationalism, the “madman” had a place in art and religion, creative and timeless spheres in which such people develop best [1]. Studies on the historical origins of this pathology conclude that before the nineteenth century schizophrenia did not exist and its description would be a consequence of civilization, so, therefore, schizophrenia and civilization would be strongly correlated [2].

Respecting mood disorders, that is, depression, bipolar disorder and mania, we see changes related to their classification and diagnosis. In the twentieth century, cross-cultural studies show differences in the intensity and form of presentation between countries. The first studies on this subject belong to Hoch [3], who found that in India depressions were not seen in psychiatric hospitals, but in the general population. In parallel, Yap [4], who researched manic-depressive psychosis, shows us that in certain parts of Africa forms of bipolar disorder type I would be more prevalent, with a very low rate of suicides, while in other parts of that continent, melancholic depressions would be more common. At the same time, there are descriptions that point to how, for example, for the Egyptians, climate was a determinant of mood [5].

All this shows how sensitive diseases are to social and cultural influences and invites us to reflect on how, in our current time, factors such as changes in family structure, the growth in urban population and longer life expectancy may be influencing. Thus, it should be considered that in each era there are people unable to properly adapt to the demands of the new times, so their ways of living are socially unsuitable for that community.

Examples of the importance of social factors in the manifestation of psychopathological conditions would be the relationship between the ideal of thinness prevailing in society and anorexia or between morbid obesity and the philosophy of life of unbridled consumerism or the picture of conversion hysteria described in the nineteenth century and the repression of sexuality at the time [1]. Thus, various cross-cultural studies on the manifestations of mental pathologies throughout history make us see the influence the environment has on the way suffering, illness or subjective discomfort occurs.

Regarding adolescence, as a qualitatively different stage of life, social scientists agree on the importance of social and cultural determinations to understand the experience of the adolescent subject.

In the second half of the last century, adolescence came to be defined as a specific phase of the course of human life and its conceptualization has become increasingly complex. In the West, adolescence is characterized by its long duration, its indeterminacy, its burden of conflicts and the great asynchrony between sexual and social maturity (Salazar in [6]). However, the “from” and “to” adolescence, in terms of its chronological delimitation, is a dynamic criterion, not fixed, subject to the era, cultural context and scientific discoveries. This would be one of the reasons to explain why there is no total coincidence, or rather equivalence, between the socio-legal criteria and the latest discoveries made by neuroscience about the age at which the maturity of brain development is reached to enter adulthood. Notwithstanding the above, it should be noted that in the last 20 years, the criteria for determining the age range for adolescence have not changed much, according to what the World Health Organization established: from 16 to 20 for women and from 17 to 21 for men [7].

On the other hand, neuroscience also contributes to the understanding of adolescence and the period it covers. In recent times, this discipline has shown how the brain develops and learns, being a plastic organ that reaches its maturity between the second and third decades of life. The brain of a newborn is only a quarter of the size of the adult brain and during childhood and adolescence, it will experience an intensive and massive growth of neurons, a biological phenomenon that will be conditioned by the environment. That is, the brain grows and specializes according to a genetic program and with modifications given by environmental influences. But it is in adolescence when the changes that mainly distinguish homo sapiens from other species occur, by which we refer to the most anterior portion of the frontal lobe or prefrontal cortex. This region would be the one that makes us “more human,” since it regulates functions of our species, such as logical reasoning (inductive and deductive), decision-making, working memory, the ability to plan an idea and carry it out, the inhibition of impulses and other functions related to the ethical dimension, necessary to live in society. Thus, from adolescence until the third decade of life, the frontal lobes would finish maturing and produce a brain remodeling as a result of neuronal pruning, which would eventually be transformed into more efficient brain circuits. If the development is optimal, the young person will have the ability to control the most impulsive behavior, the possibility of accessing abstract thinking, imagining, planning as well as to consolidate identity, that is, knowing who they are, who they were and who they want to be. Thus, we see how knowing these phenomena of brain maturation is a contribution that can help to illuminate the understanding of the strengths and potentialities of adolescents as well as the age period that comprises this stage [8, 9].

Finally, regarding our current era and its relationship with the way in which certain psychopathological conditions manifest themselves in youth, the contributions of certain philosophers and sociologists to the understanding of these clinical phenomena are very illuminating. Luis Zoja, Byung-Chul Han, Zygmund Bauman and James Côté offer us theoretical keys that shed new light on the understanding of the particularities of our societies as well as the challenges and difficulties they pose to young people.

2. Adolescence in the twenty-first century

Zoja [10], an Italian sociologist, writer, psychoanalyst and economist, argues that in our society there would be a loss of common life and closeness to the others, stating that after the “death of God” announced by Nietzsche, there would be a “death of the other,” an essential loneliness that would occur, basically, due to the effects of overpopulation in cities (of people and stimuli) and the irruption of technology that would have an impact by increasing the experience of the other’s distance. With regard to the former, he argues that in the context of the exacerbation of the self-indulgence of narcissistic and egocentric values, typical of our time, the experience of encountering the other as an existential companion “on the journey” or “in the destination” would have been damaged, so that the man from the city would be surrounded by strangers so they would need to put distance to protect themselves from this other seen as an invader. In other words, our society would have lost the “shame of narcissism,”, which results in an individuality characterized by an autarkic self that demands that its desires be satisfied without others or against others. This distance from others will have the effect of “a deprivation that represents real psychic damage” ([10], p. 23), a psychological fragilization.

As for technology, he argues that, although it enables us to increase the possibility of communication, it entails, at the same time, the so-called “paradox of the internet,” which consists of the illusion of being connected, but with a non-real, non-close being, whom one cannot touch, a fact that promotes the experience of emptiness. Thus, because human beings are social beings, this emotional and psychological distance from a real other would generate psychic damage that is experienced as a distressing and threatening emptiness. This predominance “of distance and relationships mediated by technology” means that intimacy is experienced in a tortuous way, “disguised as sexuality or other impulses that are now formally permitted” (p. 14).

Bauman [11], a sociologist and philosopher of Polish-British origin, calls our era “liquid modernity” and states that in this society change would be the only permanent thing in an abundance of uncertainties and unrest. Things become temporary, fleeting, without permanence and their correlation in human relationships is that they are characterized by the fluidity, inconsistency and fragility of bonds, all of which would affect the process of identity formation. Like Zoja, Bauman believes that being part of the liquid society leads young people to experience a sense of emptiness, along with a lack of meaning and try to anesthetize themselves through drug consumption and abuse, self-harm and technology, etc.

In a dizzying and changing sociocultural scenario, where the old references of meaning and identity have fallen, adolescents encounter a series of difficulties on their path to finding themselves and strengthening their convictions, values and self-identity. In this regard, it is worth quoting in extenso the words of Novella [12] as to the impact of post-traditional societies on the construction of identity:

the unstable identities of our time and their clinical variants refer us—as it could not be otherwise—to a world that has lost its way and its referents, but which offers all kinds of navigation tools and possibilities of identification; a world that fosters expressive richness, but tends to dissolve it in the incessant search for spectacularity, immediacy and impact; a world, in short, that permanently oscillates between omnipotence and insufficiency, opportunity and despair, abundance and emptiness (p. 134)

In the same line, the South Korean philosopher Byung-Chul Han [13] in his work “The Fatigue Society,” speaks of a “hypertransparency” or existence traversed by overexposure and highlights, like previous authors, a subjective discomfort associated with the experience of emptiness and meaninglessness. This phenomenon is significantly linked to the technical world inhabited by today’s young people, in which “the other,” constitutive of the formation of a stable self, disappears, and there is a virtual other that applauds or attacks them through the networks. Han [14] also argues that social networks make us live in a kind of “digital swarm,” where there are many people, but ultimately no one. These would be new groupings or a new “mass” or “digital swarm,” which differs in several ways from a classic mass, in which a leader or a conductor is expected to exist. In the case of the digital swarm, there would be no leaders or voices that manage to integrate this mass, which is why, in the end, we live in a space of solitude, made up of isolated individuals, who lack a “we” capable of guiding a common action. Thus, for the swarm, there are no “places of congregation” as for the traditional mass. In Han’s words: “The digital inhabitants of the network do not congregate. They lack the intimacy of the congregation, which would produce a we. They form a concentration without congregation, a multitude without interiority, a group without soul or spirit.” ([14], p. 17).

At the same time, social networks favor a kind of immediate emptying or unloading: young people have quick experiences and go from one image to another without stopping. It is an immediate and rapid transport of affection, which hinders the achievement of certain tasks involved in the adolescent stage, such as the elaboration of grief, meaning the loss of the child’s body, the change in the image we had of our parents and the distance from parental authority. Grief is a spiral of experiences that require a period of processing and elaboration and a time of silence.

Thus, we see that these three authors, Luigi Zoja with his idea of the death of others, Byung-Chul Han and his concept of the society of tiredness, and Zygmut Bauman with his interpretation of liquid modernity, come to the same conclusion: our current Western society would promote feelings of emptiness in young people that would have a negative impact on the possibility of consolidating identity, making it difficult for them to enter adulthood.

Regarding this problem, we need to mention the German philosopher Martin Heidegger, who enlightens us with his reflections. Surprising is Heidegger’s [15] visionary way of thinking about the technical world and the difficulties that it could give us in our way of life, a reflection that can be linked to manifestations of subjective discomfort that we observe in our young people. In his words:

What is truly disturbing… is not that the world is entirely technified. Much more disturbing is that human beings are not prepared for this universal transformation; that we have not yet been able to meditatively face what is properly coming in this age. (p. 25)

Han [14], when referring to Heidegger’s warning about irrational technological development, speaks of the fragmentation, acceleration, discontinuity and atomization of time, noting that: “when time loses its rhythm, when it flows into the open without stopping aimlessly, any appropriate or good time also disappears” (p. 20).

Another thinker who has profoundly studied the issue of how adolescent identity is configured in different historical moments is Côté [16], an American sociologist who argues that cultures promote certain personality characteristics by fostering “character types.”

In pre-modern societies, young men were led by tradition, while in modern societies, they would have been self-made men. In the current or postmodern era, young people would be led by others, and these “others” would be the means of consumption, a sort of being what one has and, at the same time, not knowing who one is. The biggest problem with being directed by the means of consumption is that these incessantly stimulate a greater consumption of ephemeral, obsolescent and transitory objects, which would be detrimental to the construction of a “firm floor” from which young people can situate themselves and face the world, thus remaining at the mercy of a changing internal and external world, a kind of presentist, unanchored and “seismographic” existence [17], which would affect the sense of historical continuity, the sense of belonging to a succession of generations (…), any firm concern for posterity” ([18], p. 5).

According to Côté, this would happen due to the crisis and discredit of traditional socializing institutions (family, parents and school), which fail to constitute a sufficiently solid guide to help young people to shape their identity and thus enter adulthood. This failure of institutional support gives way to excessive consumption (of objects, people, experiences and relationships) that does not offer institutional support and guidance to make the transition to development (Côté in [19]).

This background reaffirms the need for an understanding and a contextualized clinical approach to the main psychopathological manifestations of our current youth, which we will review below.

3. Adolescence and psychopathology

In general, in adolescence, the different mental pathologies begin to manifest themselves. This chapter will not refer to the most serious ones, such as schizophrenia and manic-depressive psychosis, which are diseases for whose diagnosis and treatment there is agreement and common criteria, but it will concentrate on the psychogenic conditions that account for a subjective discomfort that makes it difficult for young people to successfully adapt to their environment. Specifically, the most prevalent phenomenon that physicians may face in their clinical work with adolescents will be reviewed, namely, borderline personality disorder (BPD) and three of its most frequent manifestations: addictions, self-harm and eating disorders.

The essential developmental task of adolescence is the achievement of a new sense of identity that is associated with an experience of internal cohesion: I recognize myself as the same person who goes to school, who goes shopping with parents, who attends a party with friends and who does sports. I am the same person when I am sad as when I am happy, I am able to recognize myself as possessing feelings of hatred or love toward someone. You could say that identity has to do with recognition in a temporal continuum: I am the same person despite the change. A subject who has achieved internal cohesion and a solid identity does not present major psychic breakdowns or splits. It is precisely this internal coherence that fails in borderline personality. The person is not able to see themselves in a cohesive way and shows dissociated, split psychic functioning. This feature of borderline personality disorder is also accompanied by a sense of unreality, a lack of genuine feeling, confusion and depersonalization. All these sensations are manifested in self-harm without suicidal intent, for example, in making cuts in the skin.

The diagnosis of borderline personality has increased substantially in recent years, from 2% of the population in 1995 to 3.5% today. The diagnosis is also being made at an increasingly younger age [20, 21]. The prevalence of borderline personality disorder is 11% among adolescents in outpatient psychiatric settings [22], while in inpatient psychiatric settings the rate among adults is generally higher, with studies showing prevalences of 35.6 and 32.8% [23, 24].

In relation to its conceptualization, this disorder has been theorized in different ways, on a spectrum ranging from a form of mood disturbance to psychosis. In 1953, R.P. Knight introduced the term “borderline,” based on the idea—now abandoned—that some patients would be on the border between neurosis and psychosis. Its official use was established in the 1980s when it was included among the DSM-III axis II disorders, under the name of “borderline personality disorder.” The most relevant diagnostic criteria of this pathology indicated in the DSM-V include a general pattern of instability and conflict in interpersonal relationships, identity problems (unstable self-image or sense of self) and chronic feelings of emptiness [25].

Research on BPD over time shows that the pattern of affective and behavioral instability, as well as the great difficulty in shaping identity, are elements that are always present when it comes to characterizing the essence of this personality type [21, 26, 27, 28, 29, 30, 31, 32].

However, the reflection of the relationship between the significant increment in the diagnosis of borderline conditions, the sociocultural transformations and the difficulties in the consolidation of identity, is still a pending task. As we have pointed out before, several authors have raised the urgency of rethinking the challenges and problems of our current time and their impact on personal identity, an aspect of our being that would be a necessary condition to find a place for ourselves in society.

The psychoanalyst Scalozub [33] tries to understand why this phenomenon occurs in our time by giving us a rather enlightening reading from psychoanalysis. According to her, it is crucial that nowadays the generational difference and asymmetry of the bond between parents and children is altered or erased. This fact often generates confusion in children compared to their parents, who have neglected their role as adult guides, an issue that can be observed, for example, in their eagerness to respond to the social demand for a desirable and youthful body image, which makes the marks of generational differences blurred.

The phenomenon would also lead to the experiences of previous generations being less appreciated and used by the offspring in the process of shaping their identity. Hence, their future appears uncertain, in the sense that only they would now have the task of becoming the main architects of their own identities. In a way, they are left alone when they do not yet have the maturity or experience to decide their future autonomously and without protective guidance.

4. Non-suicidal self-injury (NSSI)

In the last decade, the phenomenon of self-injury has become a relevant public and social health problem, whose clinical manifestation has been increasing and has affected the adolescent population to a greater extent [34, 35]. Including it in the DSM-V [25] as a specific nosological entity “requiring further investigation” has led to an increased interest in studying it. It consists of a direct and deliberate destruction of one’s own body surface without lethal intent, such as cutting, burning, rubbing one’s skin, hitting or biting oneself [36]. However, even if there is no suicidal intent, unintentional lethality is approximately 0.6% [37]. When an elevation in the frequency and severity of non-suicidal self-injury is observed, it becomes a predictor of suicide attempts [38].

NSSI should be approached from three levels: (1) descriptive; (2) comprehensive and (3) therapeutic. The first level includes information on symptoms and prevalences. At the comprehensive level, biological and psychological dimensions are incorporated, as well as the sociohistorical impact or influence, that is, “the epochal mark” or how society generates “footprints” at the psychic level during development.

Although NSSI is present in children, adolescents and adults, research shows a higher frequency in adolescence [39]. Likewise, an increase in its incidence has been observed in both the child-adolescent and adult population [40], a phenomenon that is increasingly being associated with the impact the uncontrolled use of social networks is having on the mental health of children and young people [41].

This phenomenon has become a public health problem with an increasing prevalence. In 2013, studies indicated that between 13 and 29% of adolescents had exhibited at least one NSSI behavior in their lives [42], a figure that rose in 2018 from 13 to 45% [43]. In clinical samples, the prevalence has also risen in recent years to 40–60% in adolescents and 20% in adults, with rates between 32 and 27% according to studies carried out in Spain.

Meta-analysis on the subject shows that the figure in this population increases from 50 to 72% [44]. It has also been observed that the behavior is self-limiting and disappears after a few years, although in 20% it persists after 5 years [45]. The age of onset is puberty, at the age between 10 and 15 [42, 46], and happens more in women than in men, with a ratio of 4:1 [47, 48].

The meta-analysis by Bresin and Schoenleber [49] indicates that women have a greater history of NSSI, and that the most evident difference is in the clinical population. Differences have also been observed in the method used for self-injury. Adolescent females use methods that involve bleeding (seeing blood), while adolescent males are more likely to hit or burn themselves. According to Doctors [50], for boys and men self-cutting would be a secondary phenomenon, more frequent in special circumstances (such as juvenile detention and prisons).

On a comprehensive level, NSSI is no accidental behavior, but an intentional one that becomes an addictive ritual that is mostly performed in solitude. It is paradoxical in nature, in the sense that it is simultaneously a greatly impulsive as well as a calculated act, triggered by experiences of deep helplessness when facing pain and that generates feelings of omnipotence, enabling one to go from suffering to relief [51]. In patients who cut themselves, at first glance it seems to be an impulsive act, but on closer inspection, we see a cut with very precise and ritualized calculation, from the instrument to be used to the physical space for the self-injurious behavior to take place. Also subject to calculation is the place on the body where the cut is generated, which is usually repeated (forearms, abdomen and inner thigh, areas that are not visible to others).

Feelings of helplessness are associated with a great psychological fragility that prevents the young person from managing their affections in a more satisfactory way, so they resort to a means that allows them to “sedate” these affections. This painful act would have greater control, as it is a self-generated physical suffering that can be governed [52]. This dynamic leads to the behavior generating omnipotence, since the effect that an anxiolytic could have, for example, is compensated for through self-harm. The paradox between suffering and relief is seen in the anguish suffered by the young person and the sensation of deep relief produced by the cut, trying to produce with this act a more pleasant emotional state and an escape from their suffering.

The cut, an aggressive and painful act, causes important psychic relief, even if temporary, which favors repetition. That is why NSSI is considered a repetitive way of escaping from significant emotional frustration, which constitutes a non-adaptive strategy for managing or regulating affects, in the absence of other psychological, affective or relational resources [53, 54].

Thus, NSSI can be understood as a resource to alleviate an unknown and unmanageable suffering, which cannot be identified or named, as it is not possible to put the overwhelming emotion into words. This resource of attacking the skin or the edge itself, as a way of bringing psychic pain to the terrain of a bodily ailment, more concrete and visible, would be maladaptive and risky.

Regarding the influence of epoch or culture, it is important to note that it is a complex phenomenon associated with a multiplicity of factors, necessary to consider in order to understand it properly. By reviewing and analyzing the codes of the time, to enrich the understanding, it is possible to ask why self-harm is so frequent today.

However, lately, self-harm is considered an early symptom of borderline personality disorder [55]. Epidemiological data show that an overwhelming “80% of BPD patients have had at least one episode of NSSI” ([56], p. 52).

As already mentioned, BPD is a condition fundamentally characterized by a fragility of the ego that is accompanied by great relational and affective instability. Today’s society fails in its task of helping young people to work on their identity. Therefore, adolescents who are more fragile and have a more dysfunctional biography would have even more difficulty to successfully overcome the challenges of this era [19]. Cultural transformations and the consolidation of identity are tightly linked in a way described by philosophers and sociologists with great precision.

Côté [16] refers to an increment in subjective malaise associated with the particularities of late modernity, in the context of societies characterized by the overabundance of goods, high levels of consumption and an “accelerated” time or immediacy, whose increasing speed leads to poorer resting and reflection, which are necessary to understand oneself and the world. Young people who resort to self-harm and pain would be violently expressing a subjectivity where the body is marked because words are scarce or impotent in their symbolic function.

Today’s youngsters frantically seek to “belong,” to be part of some group that gives them identity, that helps them to know who they are, causing phenomena such as “urban tribes,” extreme body modifications, all manifestations that would fulfill the function of leaving an indelible mark, something that does not disappear, which ultimately serves them to manage their identity [19].

In 1927 Heidegger warned of the dangers the “technical world” would bring and raised his fears about the “velociferous” nature of the future. This term condenses two concepts, velocitas and Lucifer, and alludes to the demonic character of the search for increasing speed that leads to the loss of rest and patience (necessary for thinking and reflection), causing intolerance to frustration and falling into presentness. The speed reaches such a point that everything must be done immediately. We know that intolerance to frustration and being trapped in the present without being able to transcend and achieve projects are common characteristics in addictive behavior, which could include NSSI [57, 58].

We cannot fail to mention the impact that social networks have had on the psyche of children and young people. Facebook, Instagram and TikTok, among the most popular, are digital platforms that have come to change the way we communicate and relate, present ourselves and make ourselves intelligible to others, and particularly impact the shaping of the child and adolescent psyche, in ways whose scope we have not yet managed to understand in depth [41].

In recent years, there has been an increment in research linking adolescent mental health and the use of social networks as well as interest in studying the presence of NSSI in these networks [59, 60, 61].

Literature shows that in many cases of NSSI, social media would reinforce or even perpetuate self-injurious behavior. A recent study on the type of Twitter user interactions found that:

“Twitter reinforces self-injurious behavior, mainly by gaining community recognition through likes. Interactions between self-harming individuals and health professionals on Twitter are minimal, if not non-existent. These social media posts seem to offer solutions to their distress as they exchange information with other peers, feel part of a group instead of isolated, get quick responses and believe they find an emotional outlet” ([35], pp. 238–239).

Without wanting to present a biased and partial (catastrophic or celebratory) image of communication and information technologies, evidence shows that their indiscriminate and unmediated use carries a series of potential risks for the child and adolescent population (eating disorders, self-harm, effects of cyberbullying, etc.) [62, 63].

Along with the above, the importance of the role of parents and family is worth mentioning. Failing as an adult society or as parents, renouncing the complex task of caring for and exercising an authority that operates as a subjective support, necessary to maintain the social bond and shape the identity of the adolescent, is an act of abandonment that leaves young people in a situation of loneliness and psychic suffering, right at a time of the internal combat in which they are not able to take charge of their impulsive and aggressive forces. Baumann [64] delves into current orphanhood and grief, pointing out that “flying light produces joy, flying adrift is distressing” (pp. 68–69). In self-harm, therefore, an aggressive impulse could emerge, turned on oneself, on one’s own skin, an extreme reaction in which one tries to discover the love that accompanies, according to Winnicott, destruction.

To treat borderline personality disorder and severe non-suicidal self-harm, recent studies recommend dialectical-behavioral therapy and mentalization-based therapy, because of their greater effectiveness [56], however, the effects of these therapies are small or medium [38].

In general, the therapeutic approach is recommended to be multimodal, starting with a rigorous clinical examination to investigate or rule out the presence of other pathologies, such as major depressive disorder. If the self-injurious behavior is related to depression, the treatment plan focuses on this disorder as well as the self-injurious behavior. Pharmacological interventions are based on neurobiological models of the opioid, dopaminergic and serotonergic systems to alleviate emotional distress [65]. Strict control of treatment is required, as these drugs can in certain cases produce unexpected or paradoxical reactions [66].

For the psychotherapeutic approach, the main objective would be to work on self-injurious behavior and depressive symptoms by working on the relationship with family history and the difficulty in identifying and expressing the patient’s emotions. Achieving this would allow them to integrate their emotional pain and adapt to manage it. The family needs to be included in the process too, to restructure the family environment and relationships.

5. Adolescent drug abuse

The abusive use of drugs at this stage is tremendously harmful and can leave consequences in the young people’s biography that are difficult to recover, such as unfulfilled life projects. It is precisely in adolescence when aspects of great importance for the future are defined when youngsters consciously and willingly assume the orientation that will give meaning to their lives. In this regard, Guidano [67] states that it is at this time of life when identity processes become increasingly complex and articulated to enable them to form a more comprehensive point of view about themselves and the world, from which they can begin to structure their life project. The fact that precisely at this stage young people take risks and consume drugs, thus putting their future at risk, is related to biological, psychological and sociocultural factors.

From a biological perspective, the most decisive thing is that the prefrontal cortex, a structure involved in judgment, planning, decision-making and self-control, is the last area to develop in the adolescent. This explains why young people take risks and are particularly vulnerable to drug abuse, and why consumption in this critical period can affect the propensity for future addictive behavior (Maturana in [68]).

At the same time, there are substances considered “sequence drugs” or “gateway drugs,” because they produce neurobiological changes that will increase the response of the Central Nervous System (CNS) to other addictive substances, that is, the sequence in which the use of one substance precedes and increments the likelihood of the use of another illicit substance. The most studied are marijuana, tobacco and alcohol [69].

Regarding alcohol, according to studies by SENDA [70], in Chile 29.8% of youth consumed alcohol in the past month, women more than men (32.5 vs. 27.2%, respectively) and 64% of school students reported getting drunk at least once in the last month. In the pandemic, this figure dropped to 24% prevalence of consumption in the last month, which is attributed to greater parental control [71]. On the other hand, the prevalence of alcohol consumption in the last month in the university population is 68% (71% in men and 65% in women), while the level of drunkenness reaches 68.1%.

Especially adolescents are harmed by the abusive consumption of alcohol, since it begins at a very early age, right when their brain is in the process of maturing its neural networks, and causes brain damage at the level of the mitochondria—those responsible for producing the energy of all cells. This phenomenon has implications for memory development and learning. This damage, however, is not visible in the short term, as it remains silent for a long time and then manifests itself in adulthood [72].

As for abuse of other drugs, we are interested in analyzing marijuana consumption in greater depth, because of its high prevalence among Chilean adolescents, and because its increasing consumption in the global population is also alarming [70, 73]. This phenomenon has been evidenced throughout the region of the Americas and in Europe, with the United States being the country with the highest prevalence in adolescents, with 35.2% of students having consumed in the last year. This has led to a rise in the percentage of subjects addicted to this substance, which, in turn, has significantly increased the number of subjects who engage in psychosis due to consumption [74, 75]. This fact contributes the low perception of risk and the fact that the available marijuana is more potent than that existing in previous decades, since, through sophisticated biotechnology methods, cannabis plants can be genetically manipulated to obtain a higher concentration of tetrahydrocannabinol (THC) [76].

Common marijuana in the 1980s contained an average of 3% THC, while hashish (gummy resin from the flowers of female plants) can have up to 20% THC [77, 78]. This increment in THC content suggests that the consequences of marijuana use could be worse now than in the past. When the body receives external cannabinoids, which can also be synthetic (remedies made in laboratories) or phyto-cannabinoids (cannabinoids from the marijuana plant), our endocannabinoid system is tricked. Thus, the system becomes confused and reduces its own receptors, which leads to the subject needing more of the substance to achieve pleasure. Thus, the classic addiction circuit is triggered.

In Chile, a very active and lucrative market that has increased its profits in the last decade has contributed to these very high consumption figures and low-risk perception [70]. This reality places Chilean schoolchildren as the ones who consume the most tobacco, cocaine and marijuana in the Americas [79], and puts the future of our adolescents at risk, since the probability of becoming addicted if started before the age of 17 is high [80, 81, 82, 83, 84], in addition to the well-known damage it causes to the developing brain.

One of the most important studies on the effect of continued marijuana use on the brain, sponsored by the European community and conducted by several universities and research centers [85], concluded that marijuana in adolescents damages the brain even with low doses of consumption and interferes with the correct neuronal pruning that takes place at this stage of life. In turn, the study by Meier et al. [86] in which 1037 subjects who began using at the age of 14 were studied and evaluated at three different times, between the ages of 14 and 30, showed that those who smoked marijuana consistently during adolescence lost an average of 8 to 10 IQ points. That means, in terms of IQ , that the subject who was brilliant became normal and the normal one went down to borderline. This is the largest study ever conducted on the effect of continued marijuana use on the brain.

Recent scientific evidence [75, 87] shows the relationship between the rise in certain mental health disorders and the use of marijuana, specifically schizophrenia, mood disorders, panic attacks and suicide, largely due to the high concentrations of THC currently contained in the plant.

Respecting drug abuse in adolescence and its relationship with psychological factors, most noteworthy is not the individual or the circumstantial situations that could affect the increase in the probability of falling into consumption behavior, but those psychological phenomena common to the youth psyche that make them a population at risk. With formal thinking, which opens the possibility of abstract thought, another form of egocentrism arises in the adolescent, different from that of childhood and which marks one of the most constant characteristics of adolescence. The young person seeks to adapt their ego to the social environment and, at the same time, to adapt the environment to their ego, for which they think about the future activity that will allow them to transform this environment. Their egocentrism is reflected in the relative indifference they feel toward the point of view of the group they are trying to reform, attributing unlimited power to their thinking, a phenomenon that diminishes as they join social groups and in discussions with peers, since, through criticism, they discover the fragility of their own theories [88].

We could summarize the egocentrism of adolescent thinking through four phenomena: (1) criticism of authority figures, manifesting itself in a tendency to idealize and easily devalue people they held very high, feeling obliged to say so; (2) tendency to argue, motivated by a desire to practice their new ability to see the slightest nuances of a fact; (3) heightened self-awareness, as a phenomenon having to do with the “imaginary audience,” which would be a kind of observer existing only in their mind and equally concerned with their behavior and thoughts. This leads to the assumption that anyone thinks the same way they do, e.g., they may react badly when discovering a strain on their clothes when going to a party or when asked to speak in class, because they think everyone is aware of their stain or of how they speak. This excessive “self-awareness” predisposes to distressing experiences during adolescence and that is why adults are advised not to ridicule or criticize them in public and (4) self-focus, or “personal myth,” which refers to the conviction that they are special, that their experience is unique, and that they are not subject to the rules that govern others. This is a very important aspect of adolescent egocentrism, since it is responsible for many self-destructive conducts, to the extent that adolescents think they are magically protected from harm.

It is important to emphasize that the interplay of the different factors (biological, psychological and sociocultural) that intervene in whether or not a young person falls into risky behavior like drug abuse, will have an impact on their future personal project. In the specific case of marijuana, this abusive consumption would affect the experience of temporality, in the sense that the user is more focused on the immediate “presentized” here and now [57], without a more explicit connection between the past, the longing for the future and present praxis. Although the young person has goals, the abusive consumption of marijuana would affect their ability to anticipate the behavior to achieve such a project, leaving them unable to transcend the present, imprisoned in themselves, which is finally reflected in tasks not assumed, decisions not yet made regarding what to study, whether or not to prepare for this or that task, etc., which drastically affects the personal project [89].

Finally, regarding treatment, it is essential to be clear about when it is required, distinguishing whether abusive behavior or addiction is involved, for which we must place ourselves on a continuum, whose ultimate criterion is loss of control and risky use, of any substance, whether legal or illegal. According to the DSM-V, substance use disorders refer to a set of cognitive, physiological and behavioral symptoms indicating that an individual continues to use a substance despite the problems it causes. In this case, the person would spend good amounts of time obtaining the substance, using it or recovering from the effects. At the same time, tolerance would be developed, to the extent that the subject uses the drug more and increases their ability to eliminate the substance, or there is a desensitization of receptors which makes them need more substance to obtain the effect.

Young adolescents are a high-risk population, even though most get through the stage without developing an addiction. However, one must keep in mind that not just any young person falls into addiction, there are risk factors that contribute, like the environment (friends and parents), education, social vulnerability, the prevailing culture and of course, personality. Regarding this last variable, young people with a clear introversion (very shy or with social phobia), with low self-esteem or who seek a high level of sensation, would be at greater risk. Suffering from some degree of cognitive deficit, scattered attention, psychopathological alterations, depression, etc., also play a role [68].

Thus, many times what is behind a substance abuse behavior is the use of a dysfunctional strategy to cope with a stressful situation, so therapies should focus on finding more adaptive ways. The help of parents and/or relatives is important, as they are essential as a role model for the adolescent.

Psychological treatment is a fundamental aspect of the approach to substance abuse or addiction. This should focus not only on addiction but also on the reinforcing factors of the environment and on protective factors, like family relationships and activities carried out together (watching movies, cooking, etc.) or the stimulation of sports activities [90]. Literature shows that in the psychotherapeutic treatment of substance abuse or addiction, we find various intervention approaches, however, there is more empirical evidence that cognitive-behavioral therapies (individual or group) are more recommended for young people and adolescents and are the most used by professionals in clinical practice [91]. These approaches direct to the “development of strategies aimed at increasing personal control over oneself” (p. 24), with special attention to the analysis of ideas, beliefs, behavior and affections associated with substance use, as well as the reinforcement of coping skills in risk situations.

6. Eating disorders

Eating disorders (ED) can appear in childhood, but usually occur during adolescence. Their emergence is influenced by the prevailing lifestyle in the West and, when this behavior is prolonged over time, they become a medical condition.

According to the DSM-V and the Eleventh Edition of the International Statistical Classification of Diseases (ICD-11), the most common types of eating disorders are: (1) anorexia nervosa; (2) bulimia nervosa and (3) binge eating. Although all are complex mental health diseases that entail a high level of suffering, morbidity and mortality, severe disability, high comorbidity, therapeutic resistance and tendency to chronicity, the one with the most biomedical compromise is anorexia. In adolescents, the prevalence in females is 2.8% and in males 0.8%. In Chile, prevalence studies range from 3 [92] to 3.8% [93].

Anorexia nervosa consists of a significant loss of body mass due to a voluntary decision to lose weight by drastically restricting food intake [94]. It was first described in the nineteenth century by the Englishman Sir William Withey Gull, who published in the British Medical Journal the phenomenon observed in four female patients between 14 and 18 years of age who, without a demonstrable medical disease, suffer from anorexia, cachexia, bradycardia, amenorrhea, constipation and incomprehensible motor activity. Gull recognizes the psychic origin of this disease and renames it from “hysterical apepsia” to “anorexia nervosa” as he attributes it to psychic trauma.

Simultaneously France featured similar descriptions, with Charles Lasègue speaking in 1873 of a condition he called “hysterical anorexia,” which occurred in young girls who refuse to eat but claim to feel well [95]. The interesting thing about this author is that he makes a sort of differential diagnosis, comparing the “hyperactivity” of these anorexic patients with the “passivity” of people who had suffered hunger in the Franco-Prussian War of 1871. Both Gull and Lassègue give complete descriptions of anorexic symptoms, and both consider hysteria as the cause of the disorder and call it hysterical anorexia. Freud, in his article “History of an infantile neurosis” (1918), interprets this illness as a “neurosis” that would occur in young people of pubertal age who would reject sexuality and link the picture to melancholy. Later, the condition disappeared from medical discussion and was thought to be caused by atrophy of the anterior lobe of the pituitary gland (Simmonds disease), and then re-emerged as an independent clinical entity in 1965, within the framework of an international congress held in Germany, in which psychiatrists, endocrinologists, anthropologists and sociologists gathered to address this pathology. In this meeting, a remarkable consensus was reached about the disease being related to the transformations of puberty, the conflict being bodily and not strictly of the alimentary function, and the etiopathogenesis and the clinical being different from neurotic processes [96]. Nowadays the view of the problem is more pragmatic and heterodox, considering that biological, psychological and social factors must influence the appearance of this disorder.

Anorexia has a severe impact on a biological level, with this being more severe in adolescence. The most significant damage is related to a compromise in growth and an impact on height, which is greater if the condition precedes the pubertal growth spurt. Anorexia nervosa is also associated with low BMD (bone mineral density) and deterioration of bone structure and strength, with a heightened risk of fractures, so the development of this disease in this period enlarges the risk of persistently compromised bone health. The degree of BMD impairment is strongly influenced by the longer duration of amenorrhea and the later age of menarche. Likewise, acute anorexia in adolescence can lead to a significant global decrease in gray and white matter in the brain, more pronounced in adolescents than in adults [97]. Finally, up to 80% of cases of anorexia show cardiovascular compromise, which can be mild and reversible or severe and life-threatening (they are responsible for a third of the deaths in this pathology) and become more significant as there is greater nutritional compromise [98].

Psychologically, there is consensus that this disorder is accompanied by a perfectionist and self-demanding personality profile, which seeks total control to achieve its goals, in this case, losing weight [1]. Contempt for the body would be accompanied by an excessive valuation of everything intellectual. They are always the best students, they reason admirably, they show extraordinary ability to lie, evade controls and achieve their goals of continuing to lose weight. As for the importance of the social factor, anorexia nervosa responds to the search for an ideal of beauty imposed by a fashion that promotes bodies of extreme thinness that would enable social and economic success to be achieved, an ambition that in the past, when this disorder occurred, was associated with the ascetic desire to possess non-corporeal characteristics, such as the emblematic case of Sor Juana Inés de la Cruz [95].

We can conclude that anorexia nervosa appeared with modernity (second half of the nineteenth century), grew slowly throughout the twentieth century to experience a sort of “boom” in the 1960s and continues to increase, albeit more slowly, until today. Although the literature shows that its prevalence has been extended to other age ranges [99], adolescence continues to be the vital period where this disorder appears most and forms an important public health problem that mainly affects young women. These young women seek, with an immovable will, to lose not only weight but also the feminine forms, as a way of rejecting bodily maturation and sexuality and, with it, the possibility of a satisfactory erotic life and motherhood.

Bulimia nervosa is a condition that consists of recurrent episodes of excessive intake of high-calorie foods, which ends up producing physical and psychological discomfort. As a compensatory behavior to this discomfort, people who suffer from this disorder self-induce purging behavior [100]. Until the early 1970s, the difference between anorexia nervosa and bulimia as two different diseases had not been established, and it was Doerr [101] who first described the condition under the name of “Hyperphagia and Vomiting Syndrome in Young Women,” characterized by the overwhelming desire to eat large amounts of food. Regardless of its quality, the person would vomit. Later, in 1979, Gerald Russell published in the journal Psychological Medicine a paper on hyperorexia that, for some time, was considered the first description of bulimia nervosa as an independent entity and whose main symptom was the uncontrollable desire to ingest large amounts of food, followed by the induction to vomiting to avoid gaining weight, along with a morbid fear of obesity.

The age of onset of this disorder is usually around 16, as they usually hide the behavior earlier [102]. Hyperphagia and vomiting crises would initially occur in isolation and be episodic but finally become almost permanent behavior. Concomitantly, constipation, laxative abuse and increasingly intense and frequent dysthymic states were observed, with no significant weight gain or decrease. From a taxonomic point of view, this syndrome would belong, like anorexia, to the group of addictive behaviors, which also include obesity, alcoholism and drug addiction, which are largely culturally mediated [103].

Among the sociocultural factors, the particularities of our consumer society stand out, characterized by imperatives of extreme success, productivity and control, as well as by a “morbid culture of thinness” [104], which translates into ideals of female beauty (widely disseminated by the media), which would have a significant impact on adolescence, being this a critical stage of life characterized by greater psychological vulnerability [99]. This way, as to Turner [105], our consumer society would be permanently directing “contradictory social pressures on women (…) and an anxiety directed at the surface of the body in a system organized around narcissistic consumption” (p. 93).

For Doerr and Pellegrina [106], other characteristics of our current societies to help us understand the sociocultural framework in which these disorders appear, would be the predominance of technical-instrumental reason and the artificial, the virtual and the image or appearance, over reality. In these conditions, the body, which is experienced as a thing or an “enemy” that must be totally controlled, becomes a mere object manufactured “from instrumental reason, as something that can be modeled to give it any appearance that is exposed to the gaze” (p. 13). Linked to the above, “obscenity,” typical of an information society, in which everything is hyper-transparent, visible and incessantly exposed to the public gaze, would also be a key enabling us to get closer to the understanding, especially, of anorexia. Thus, the anorexic’s body would be obscene, in the sense of being “staged”:

Whether it is when they hide their body in large robes or when they show it disembodied, in the literal sense of the word, there is a human being in a scene, there is a predominance of appearance, an empire of image, to say, obscenity. Let us remember that “ob” in Latin means to be in front, in sight and “stage” is naturally derived from the scene ([107], p. 189).

Likewise, for these authors, the hedonism of our time, resulting in a “loss of the religious sense” or transcendence of existence, would be paradigmatically exemplified in these disorders, shown to us as an existence fixed in the immediacy of an “enemy” or “prison” body that must be controlled, subdued or suppressed.

Finally, with regard to the therapeutic management of eating disorders, the earlier they are diagnosed and treated, the better the prognosis. Treatment should be carried out by interdisciplinary teams with experience in working with adolescents and specialization in eating disorders, to provide an effective intervention that includes nutritional and psychological management, the use of psychotropic drugs when indicated and addressing medical complications and psychiatric comorbidities [97]. The personality profiles of patients with anorexia or bulimia are very different from each other, as well as their biographies, so the therapies recommended must be adjusted to each case. Perhaps this is why the literature recommends different psychotherapeutic approaches, such as family therapy, cognitive-behavioral therapy and behavioral-dialectical therapy [108]. However, family therapy has the most scientific support for anorexia nervosa [109, 110, 111].

7. Discussion

In this chapter, we wanted to highlight that the understanding of the psychological characteristics of the most common disorders in adolescence can be enriched by considering the particularities of our current way of life and the sociocultural patterns of the behavior that it promotes.

In a world of contingencies, in which social and intergenerational bonds have been weakened and a presentist temporality has been installed, mobilized by the eagerness to consume objects that the image market offers as a promise of happiness and volatile identity—always changing and eternally unsatisfied—borderline disorders, self-harm, eating disorders and drug abuse can be seen as an expression of the malaise of subjectivity and the dynamics of contemporary culture.

In this general environment just described, it is not surprising that there is a rise in the diffusion of identity and the loss of a meaning or direction enabling life experiences to be articulated coherently.

Especially regarding the borderline personality, because of its high prevalence and different forms of presentation, the relationship between the pathology and our current society is made visible and characterized by the decline of the traditional institutions of socialization, whose mediation makes it possible for the new members of a society to be effectively incorporated into the culture (family, school and political or religious institutions).

The crisis of these institutions of socialization, with the subsequent lack of referents, would affect the process of consolidating the identity of the young person. This could help to understand why young people in situations of greater psychological vulnerability carry out a search for identity or belonging through often dangerous and even openly self-destructive means, such as drug abuse or the various extreme interventions on the body, which they experience as a way of having something “forever” and that fulfill the function of a lasting brand that makes it possible to deny the expiry inherent to the passage of time, which is experienced in a more anguished way in an age in which acts lack a transcendent meaning.

There is consensus that the generalized increase of certain types of youth practices of body intervention can be understood as a way to achieve inclusion in a reference group and to have a magical experience of changing the self—resisting pain, feeling more powerful, improving self-esteem, etc. 2000 [33, 112, 113, 114]).

In this context, the disorders reviewed here would be the extreme case of many young people’s difficulty in attaining a successful consolidation of their identity, in the sense of achieving the experience of unity and continuity [115]. When the perception of the internal is experienced as fragile and somewhat chaotic, the elements of the external world (habits, fashions and belonging to homogeneous groups) acquire great importance, and there is a marked lack of preparation for adult social life. This gradually accentuates the structural insufficiency, leaving the subject at the mercy of despair, with an unintegrated adult identity with little possibility of joining a world of increasing complexity [116].