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National Health and Medical Research Council. Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne: National Health and Medical Research Council; 2012.

www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh25_borderline_personality_guideline.pdf

Diagnostic Assessment for Borderline Personality Disorder; Identifying BPD Features In Young People

In making consensus-based recommendations on diagnostic processes for BPD, the  Committee agreed on the following considerations:

• In people aged 12–18 years, the presence of any of the following features indicates the need for a full assessment for BPD: frequent suicidal or self-harming behaviour, marked emotional instability, other psychiatric conditions (e.g. mood disorders, substance abuse disorders, disruptive behaviour disorders or anxiety disorders), non-response to established treatments for current symptoms, high level of impairment in general psychosocial functioning, self-care, and peer relationships and family relationships.1, 184

• The diagnosis of BPD in a young person should only be made after comprehensive assessment by a health professional with experience and skill in the assessment of mental health problems in young people. Comprehensive assessment includes a developmental history and family history, preferably involving the young person’s family, partner or carers. Health professionals should refer the person for an expert diagnostic assessment if they do not have appropriate skills and training, or are not confident to make the diagnosis.

• Although some clinicians have been concerned that it may be inappropriate to diagnose a personality disorder in a young person whose brain is still developing, current evidence shows that diagnostic criteria for BPD in a person under 18 years are as reliable and valid as in adults,185, 186 and the diagnosis is similarly stable over time as for adults.187 BPD diagnosed in adolescence is associated with serious and persistent morbidity in adulthood.80 Accordingly, the diagnosis can be made with reasonable confidence when a person aged 12–18 years meets diagnostic criteria for BPD.

• While the DSM-IV-TR79 diagnosis only requires symptoms to have been present for one year, some experts have argued that the diagnosis should only be made if symptoms have been present for at least 2 years.187, 188

• There is currently not enough data to support the application of diagnostic criteria for BPD to a child under 12 years.

The issue of whether or not to tell an adolescent that they have BPD has been controversial. Some health professionals have preferred to withhold the diagnosis, even when confident of its accuracy, due to concerns about stigma and discrimination the person may experience as a result of the BPD label. However, prompt disclosure of the diagnosis has potential benefits. Young people often experience relief when they learn that the difficulties they have been experiencing can be attributed to an identified syndrome and that effective treatment is available.189 In general, health

professionals should make the diagnosis of BPD in adolescents and young people who meet diagnostic criteria, so that early intervention can begin without unnecessary delay.182

Note on Recommendation 5: Not all members of the Committee agreed with this recommendation.

The alternative view was that the term ‘BPD features’ should be used instead of ‘BPD’ for people

under 18 years.

Discussion: diagnostic process in young people

There is some evidence to support the use of specific self-report screening tools to identify individuals for further assessment among young people attending mental health services. The following screening instruments performed well in identifying BPD in an Australian study of people aged 15–25 years attending a mental health outpatient service, of which 22% met diagnostic criteria for BPD:190

• the Borderline Personality Questionnaire (BPQ)191

• the BPD items from the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II)192

• the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD)193

• items from the International Personality Disorder Examination Screening Questionnaire.194 The BPQ had the highest diagnostic accuracy and test–retest reliability.190 Instruments suitable for the assessment of BPD in people aged 12–25 are listed in Table 4.4.

The Committee determined that there was insufficient evidence to formulate evidence-based recommendations on special diagnostic processes that apply to adolescents and young people.

Instruments for screening BPD in young people

Borderline Personality Questionnaire191

Personality Questionnaire Screen from the Structured Clinical Interview for DSM-IV Axis II disorders

(15 BPD items)192

McLean Screening Instrument for BPD (10 items)193

International Personality Disorder Examination Screening Questionnaire (5 BPD items)194

Clinical implications of the recommendations

Increased rates of identification of people with features of BPD, including adolescents with early features of BPD (recommendations 4–7) in primary care and emergency departments could result in early referral to specialist, specialised and allied health services for thorough assessment and earlier diagnosis, in turn leading to prompt treatment.