Borderline Personality Disorder in Adolescents

Many therapists are hesitant to diagnose a teen with Borderline Personality Disorder because of the belief that the personality is not fully developed until after age 18.  One problem is that after 18, a child can refuse treatment or limit the parents access to their care. Another problem is that treatment If the Borderline Personality Disorder could be reliably diagnosed earlier, parents can do more for their children. This expert from Harvard's McLean Hospital believes that it can be.

Borderline Personality Disorder is marked by skills deficits in broad areas of developmental ability, including deficits in emotion regulation, distress tolerance, and interpersonal functioning. Blasé Aguirre, MD poinst out that recent developments in diagnostic techniques and treatments are showing that thousands of teens have borderline personality disorder. According to Aguirre,although symptoms typically begin in adolescence, there has been a strong reluctance in the psychiatric community to diagnose BPD in anyone younger than 18. Even in adults with BPD, it remains a highly stigmatized disorder among physicians and mental health professionals. Although the DSM (clinical guidelines) clearly allow for the diagnosis to be made in patients who have had enduring symptoms for more than a year, clinicians tend to write “deferred”, even when an adolescent meets sufficient diagnostic criteria. What this means is that in many adolescents, mood and other behavioral and psychiatric disorders are diagnosed, and often medication is prescribed for symptoms even when clinical criteria for disorders other than BPD are not met.

In his book, he describes how Borderline Personality Disorder is a neurodevelopmental disorder, influenced by the person’s genetics and brain development and shaped by early environment, including attachment and traumatic experiences. He brings into focus what we do and don't know about this condition. Parents and caregivers will also be aided in distinguishing the difference between BPD and other disorders.

He explains all the treatment options, comments on the cutting edge treatments, and educates on how to choose the right therapist for your child. He also explains how to establish and maintain boundaries with your teen and adopt effective communications techniques.

This is a very valuable text that focuses on adolescent BPD and will be an invaluable resource for parents who are seeking answers and support for their child. To our knowledge, there is no other adolescent BPD books on the market–only books focused on adults.

Blasé Aguirre, MD, received his medical degree from the University of the Witwatersrand in Johannesburg, South Africa. He completed the residency program in psychiatry at Boston University and a fellowship in child and adolescent psychiatry at the Boston Medical Center. After completion of his residency he served as assistant training director for the Boston University Child and Adolescent Fellowship program and after that was appointed as Medical Director of the Lowell Youth Treatment Center. He has been on staff at McLean (Harvard) since 2000. U.S. News and World Report consistently ranks McLean Hospital in Belmont, Mass., as the nation’s top psychiatric facility in the country. McLean is the largest psychiatric clinical care, teaching, and research facility of Harvard Medical School. He is board certified by the American Board of Psychiatry and Neurology in psychiatry. Dr. Aguirre is experienced in child, adolescent and adult psychopharmacology and psychotherapy, including DBT. He holds an appointment as an Instructor in Psychiatry at Harvard Medical School. Dr. Aguirre also has a small private practice where he specializes in adolescent and adult psychotherapy of Borderline Personality Disorder.

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Excerpts:

The DSM Diagnostic Criteria for Adolescents

The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) published by the American Psychiatric Association provides criteria for adolescents with BPD. I've described these below along with some discussion on how borderline adolescents behavior in our DBT unit.

1. Efforts to avoid real or imagined abandonment: Adolescents sometimes come to us after a suicide attempt triggered by a profound sense that someone essential to their well-being will never come back-for example, a break-up with a close friend or romantic partner. These are dramatic attempts such as severe overdoses, jumping in front of a truck, and shooting themselves with a gun. We are seeing a new trend in break-ups involving technology (text-messaging, Facebook, etc.).

In some, cases the adolescents recognize that by making these suicide attempts, they get reassurance that they are loved. If the BPD adolescent gets tremendous attention ONLY during suicidal and self-destructive acts, these so suicidal behaviors can be reinforced by loved ones and caregivers.

Self-harming behavior and other borderline defense mechanisms often come off as "manipulative" to others. While it can FEEL that way, it doesn't meet the definition of manipulation (link is external): "Shrewd or devious management, especially for one's own advantage." Truly manipulative behavior is planned, while BPD behavior is impulsive. When something triggers BPD behavior, it happens right away.

Manipulation is done for some kind of gain: to ultimately increase someone's happiness because something wanted has been obtained. But are people with BPD satisfied? No! They're miserable--even the high functioning ones. Would anyone in their right mind plan to end up in a psychiatric facility or in a desperately unhappy relationship? What people with BPD want most is closeness. And the tragedy is that the disorder pushes people away.

When we feel manipulated, we mistakenly conclude that our BP loved one is acting this way on purpose to drive us insane. It's that kind of thinking--ascribing devious intentions to borderline loved ones--that does the most harm. It can make parents feel like they've done something wrong when they haven't. That can cause needless guilt.

2. Unstable relationships characterized by over idealization and devaluation: Parents and friends can alternate between being best parent/friend in the world and then vilified. This all-or-nothing or black-and-white thinking is called "splitting" and is a fundamental trait of BPD.

When they get hospitalized, these adolescents can divide staff into "good" and "bad" and cause chaos on the unit. Staff has to be careful not to be too comfortable with being assigned as "good" or "bad" because these designations can change quickly and easily.

3. An unstable sense-of self: This criterion is harder to define in adolescents with BPD because adolescence is a time of defining identity. However, BPD adolescents have an enduring sense of self-loathing, which is a core symptom of BPD.

Some patients are like chameleons, adapting to whatever group of friends or trend is current. Flexibility is a helpful trait, but in our BPD kids it is because they have little sense of who they are.

Similarly, there is a sense of what one of one of my young patients recently described as being "porous." She readily (but painfully) takes on the positive or negative emotions of people around her.

4. Dangerous Impulsivity: This includes indiscriminate and dangerous sex, drug abuse, eating disorders, and running away from home. These "pain management" behaviors are often used to regulate emotions. However older adolescents take risks with driving and spending similar to adults. At times, dangerous behaviors are mediated through the Internet, (for example meeting strangers on-line for sex or drugs).

5. Recurrent Suicidal Behavior: Self-injury in the form of cutting is the most common presenting symptom on our unit.
We also see burning with matches or lighters, head banging, punching walls, and attempts to break bones.  Most of our patients have made at least one suicide attempt -- generally by overdose. But more recently we are seeing patients with self-inflicted gun shots, who have tried to hang themselves, or have jumped in front of moving automobiles.

As I mentioned earlier, suicidal and self-injurious behaviors can be reinforced by the well-intentioned attention of caregivers when the adolescents feel cared for by loved ones ONLY when they make such attempts.

6. Affective or Mood Instability: Notable about these mood states is that:

1. Moods tend to be in reaction to some conflict (e.g. a fight or a disappointment)
2. The adolescents on our unit recognize that they feel things "quicker" and with less apparent provocation than others their age
3. They say they feel things more intensely than others their age
4. They say that they are slower return to baseline than others
5. Mood reactivity is on a continuum, low to high, based on how much it affects the person's life

7. Chronic feelings of emptiness: These are intolerable states where the BPD adolescent feels that there is nothing of substance in their life. This is often expressed as boredom. The emptiness can be temporarily relieved by risky or intense behaviors (intense relationships, sex, drugs), as the extreme behavior leads to intense feelings that help the adolescent feel connected.

At other times adolescents express the emptiness as loneliness.

8. Anger regulation problems: Fights occur most with those closest to the BPD adolescent and can take the form of destruction of property, bodily violence, or hurtful verbal attacks. While the DSM specifies anger, other intense emotional states are also difficult to regulate-even positive ones! These can feel intolerable because high intensity emotions are anxiety provoking and lead to irritability.

9. Psychotic symptoms or loss of touch with reality: Some BPD adolescents have been abused (verbally, physically, and emotionally). This results in symptoms of post-traumatic stress disorder (PTSD). These symptoms can include dissociation and depersonalization which means that person disconnects their emotional experience from the reality they are experiencing. They can also experience paranoia and assume others have evil intentions.

Symptoms not in the DSM 5

We frequent see these similarities in adolescents on the unit:

1. They sometimes see themselves as loathsome and evil or contaminated. This contamination, they believe, can transfer to others.
2. They appear to have a profound sense of hopelessness and self-hatred without other symptoms that would indicate that they are depressed.
3. During intense moods, they appear to have a marked lack of a sense of continuity of time. One minute can feel like an hour and vice versa. If they feel miserable, even a moment of misery can feel like an eternity.
4. Some have great difficulty in consistently performing at school despite their intelligence.
5. Intense same sex emotional relationships may lead to physical intimacy even the person doesn't identify themselves as gay.
6. They complain that they are universally misunderstood or that they don't feel they deserve to be understood.
7. They seemed to be remarkably attuned to non-verbal communication and, as such, seem to be expert mind-readers.
8. They appear to be remarkably susceptible to others emotions and as such feel porous.

Some key points to remember are that:

1. Adolescent BPD looks a lot like adult BPD. Their symptoms are a reflection of a skills-deficit, or incapacity to regulate their emotions rather than simple stubbornness or willfulness or so-called "acting out." If they were capable of doing things otherwise, most would. Because of the skills deficit, we need to intervene as early as possible. This is true of most skills. If a child cannot talk or walk, we put them in early intervention in order to target the skills deficit. The same must be the case for emotion regulation deficits. Early treatment includes learning a new skill with the use of treatments like Dialectical Behavior Therapy to teach adolescents and parents about BPD.

1. Borderline personality has its roots in the genes that a child carries, the temperament and personality traits the child exhibits and the environment that the child grows up in. Recognizing the symptoms is critical in getting a jump start on treatment. The time is now for clinicians to make the correct diagnosis and for parents to demand scientifically based treatments for the disorder. As clinicians we can help reduce the stigma that we helped create by making this an "untreatable" condition.

1. And, as parents, we must insist on knowing how the proposed treatment approach will help reduce the often misery-inducing symptoms associated with this now better-understood condition.