Borderline Personality Disorder in Adolescents
What is BPD?
Borderline Personality Disorder (BPD) is a commonly encountered disorder, with 20 percent of inpatients and 11 percent of outpatients meeting the diagnostic criteria. Still, however, BPD has not been given the same public awareness or the same amount of research funding as other major psychiatric diagnoses. Further lacking is research regarding BPD in adolescents. On the other hand, clearly understood is that BPD is based upon a psychodynamic construct, rooting within a child’s genetics, temperament, and environment.2 Marked by skills deficits in developmental ability, emotion regulation, distress tolerance, and interpersonal functioning, BPD is able to be diagnosed in adolescence.2 McLean Hospital’s Adolescent DBT Residential Program Medical Director Blaise Aguirre, M.D. discusses BPD’s characteristics, issues in diagnosis, and treatment options in his article “Borderline Personality Disorder in Adolescents.”2
BPD Often Surfaces During Adolescence
Symptoms of BPD often surface during adolescence; however, clinicians are reluctant to diagnose the disorder in any patient younger than 18.2 The DSM-IV states that BPD may be diagnosed in patients who have had enduring symptoms for a year or more, but still clinicians are uncomfortable making the diagnosis.2 This leads to the disorder being under-recognized and underdiagnosed in adolescents, and, consequently, the disorder is understudied in this population.2 Studies often show that treatment commonly begins in early adulthood for patients diagnosed with BPD, which leaves a lag of years between symptom onset and treatment initiation. According to Aguirre, This means years of suffering and practice of damaging behavior.2
The Nine Criterion of BPD
The DSM-IV lists nine criteria for BPD, which need to be present for at least one year for the diagnosis to be made in patients younger than 18. The first criterion is “efforts to avoid abandonment.” There is an increased risk of suicide in adolescents who have recently undergone a breakup with a romantic partner or a fight with a friend. The adolescent feels that the certain person is essential to their well-being and has abandoned them.
The second criterion is “unstable relationships.” Individuals with BPD often over-idealize or devalue their relationships. For instance, one moment a parent or friend may be the best in the world, and suddenly, the next moment they are the worst. This reflects upon the individual’s black-and-white thinking pattern that is typical of BPD.
Third is an “unstable sense of self.” As adolescence is a time of defining identity, this is often difficult to diagnose during that period of life. However, clinically, a sense of self-loathing is seen in patients with BPD.
Criterion four is “dangerous impulsivity.” Adolescents often do not have access to cars and money; therefore, reckless driving and overspending is often not seen. Instead, promiscuous sex, drug abuse, eating problems, and leaving home are more common.
Fifth is “recurrent self-injury and suicidal behavior.” Oftentimes, self-injury is in the form of cutting, self-burning, head banging, punching walls, attempting to break bones, ingesting nonnutritive substances, and inserting foreign objects into the skin.
The sixth criterion is “affective instability/extreme mood reactivity.” Adolescents with BPD often feel emotions more quickly and intensely than others and are also slower to return to a normal state. Their moods are easily influenced by interpersonal and intrapersonal conflicts and usually only last a few hours.
Criterion seven is “chronic feelings of emptiness.” Oftentimes, adolescents with BPD state that they are unable to sit still for long periods of time as they become bored easily, a feeling that is intolerable to them. Usually, they begin to relieve the emptiness through engaging in risky behaviors.
The eight criterion is “anger regulation problems.” If an adolescent presents with physical aggression, it is usually directed towards those closest to them. The anger can take the form of physical violence, destruction of property, or verbal attacks.
The ninth and final criterion is “paranoia and dissociation.” Approximately 30 percent of adolescent patients with BPD have undergone some form of abuse; therefore, they present with dissociation, depersonalization, and derealization.
According to Aguirre, studies on the course of BPD in adults have shown that the majority of patients who are diagnosed with BPD oftentimes will no longer qualify for the diagnosis after a period of approximately four years. However, although most patients go into remission, acceptable psychosocial functioning is only reached in 60 percent of those patients. Often, vocational impairment is more apparent than social impairment. Therefore, Aguirre states that patients with BPD should be directed to undergo specialized treatments at an early age, to ensure that they are equipped with the skills that are necessary for long-term functioning.2
There are several psychotherapies that are approved for the treatment of BPD and have proven effective in patient improvement; however, most have not been studied in the adolescent population.2 Those studied with proven efficacy in adult patients are dialectical behavioral therapy, mentalization-based treatment, schema-focused therapy, and transference-focused psychotherapy.
Overall, Aguirre states that BPD is a neurodevelopmental disorder, influenced by genetics, brain development, and early environment.2 As it is a disorder clinicians are often reluctant to diagnose, clinicians should remember that the prognosis is good, with remission often after four years.2 Also, early detection and diagnosis leads to effective treatment timing and an even more promising outcome.2
 Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV borderline personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162:1911-1918.
 Aguirre, B. (2012, May 9). Borderline Personality Disorder in Adolescents. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/display/article/10168/2070310
 Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J. Treatment histories of borderline inpatients. Compr Psychiatry. 2001;42:144-150.
 Skodol AE, Oldham JM, Bender DS, et al. Dimensional representations of DSM-IV borderline personality disorders: relationships to functional impairment. Am J Psychiatry. 2005;162:1919-1925.
 Zanarini MC, Frankenberg FR, Hennen J, et al. Prediction of the 10-year course of borderline personality disorder. Am J Psychiatry. 2006;163:827-832.
 Zanarini MC, Frankenberg FR, Reich DB, Fitzmaurice G. The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Acta Psychiatr Scand. 2010;122:103-109.
 Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients [published correction appears in Arch Gen Psychiatry. 1994;51:422]. Arch Gen Psychiatry. 1993;50:971-974. BPD