Borderline Personality in Teens

Borderline personality disorder (BPD) is a complex psychiatric disorder characterized by unstable personal relationships, intense anger, feelings of emptiness, and fears of abandonment. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) allows BPD to be diagnosed in adolescents when maladaptive traits have been present for at least 1 year, are persistent and all-encompassing, and are not likely to be limited to a developmental stage or an episode of an Axis I disorder. However, the personality of adolescents is still developing; therefore, the diagnosis of BPD should be made with great care in this population.

Borderline pathology in children refers to a syndrome characterized by a combination of disruptive behavioral problems, mood and anxiety symptoms, and cognitive symptoms. Follow-up studies of these children show that they have a tendency to develop a wide range of personality disorders, not just BPD. Although borderline pathology in childhood is not necessarily a precursor to BPD in adulthood, evidence suggests that both have strikingly similar risk factors, which may indicate a common etiology. These risk factors include family environments characterized by trauma, neglect, and/or separation; exposure to sexual and physical abuse; and serious parental psychopathology, such as antisocial personality disorder and substance abuse.

Characteristics of BPD

Adolescents with BPD have disturbed thinking patterns and always seem to be in crisis. They can be rational and calm one moment, and then explode into inappropriate anger in response to some perceived rejection or criticism the next. The disorder occurs in all races, is prevalent in females (female-to-male ratios as high as 4:1), and typically presents by late adolescence.[4] Signs and symptoms of BPD may include significant fear of real or imagined abandonment; intense and unstable relationships that vacillate between extreme idealization and devaluation; markedly and persistently unstable self-image; significant and potentially self-damaging impulsivity (spending, sex, binge eating, gambling, substance abuse, and reckless driving); repeated suicidal behavior, gestures, or threats; self-mutilation (carving, burning, cutting, branding, picking and pulling at skin and hair, biting, and excessive tattooing and body piercing); affective instability and significant reactivity of mood (intense dysphoria, irritability, or anxiety that lasts for a few hours or days); persistent feelings of emptiness; inappropriate anger or trouble controlling anger; and temporary, stress-related severe dissociative symptoms or paranoid ideation.[1]

Comorbidities are common with BPD. These disorders, which include mood disorders, substance-related disorders, eating disorders (notably, bulimia), posttraumatic stress disorder, other anxiety disorders, dissociative identity disorder, and attention-deficit/hyperactivity disorder, can complicate both diagnosis and treatment. Depression is particularly common in patients with BPD. Other personality disorders have also been documented as comorbid with BPD. A study of 138 adolescents and 117 adults with BPD showed a significant occurrence of schizotypal and passive-aggressive personality disorders in the adolescent group and antisocial personality disorder in the adult group. The researchers suggested that BPD may represent a more diffuse range of psychopathology in adolescents than adults, because adults had comorbidity only with another Cluster B disorder, whereas adolescent comorbidity encompassed aspects of Clusters A and C. (A brief explanation of the clustering system in personality disorders is available at the National Mental Health Association Web site.

Treatment Issues

Due to the complex nature of this disorder, therapists should consider the following when developing a treatment plan:

  • Chronic depression: Depression results from ongoing feelings of abandonment. Although the depression of BPD is intense and pervasive, the NPP must rule out major depression or consider it as a comorbid disorder.
  • Inability to be alone: Chronic fear of abandonment also leads to these adolescents having little tolerance for being alone. This results in a constant search for companionship, no matter how unsatisfying.
  • Clinging and distancing: Relationships tend to be disruptive due to the adolescents’ alternating clinging and distancing behaviors. When clinging, they may exhibit dependent, helpless, childlike behaviors. They over-idealize the person they want to spend all their time with, constantly seeking that person out for reassurance. When they cannot be with their chosen person, they exhibit acting-out behaviors, such as temper tantrums and self-mutilation. Distancing is characterized by anger, hostility, and devaluation, usually arising from discomfort with closeness.
  • Splitting: Splitting arises from the adolescents’ inability to achieve object constancy and is the primary defense mechanism in BPD. They view all people, including themselves, as either all good or all bad. If the therapist is supportive, the therapist will be idealized.
  • Manipulation: Separation fears are so intense that these adolescents become masters of manipulation. They will do just about anything to achieve relief from their separation anxiety, but their most common ploy is to play one individual against another.
  • Self-destructive behaviors: Self-mutilation is characteristic of BPD. The behaviors are typically manipulative gestures, but some acts can prove fatal. Suicide attempts are not uncommon and usually take place in relatively safe places, such as swallowing pills at home while reporting the deed to another person on the telephone. Other self-destructive behaviors include cutting and burning (eraser burns, a burn like lesion resulting from rubbing the skin with a pencil eraser, are common in adolescents).
  • Impulsivity: Poor impulse control can lead to substance abuse, binge eating, reckless driving, sexual promiscuity, excessive spending, or gambling. These behaviors can occur in response to real or perceived abandonment.

Treatment

Treatment studies on adolescents with BPD are virtually nonexistent. Although treatments effective in adults would be expected to be efficacious, research that demonstrates this efficacy is needed. Overall, treatment planning should address BPD, as well as any existing comorbid disorders, and must be flexible to respond to the changing characteristics of the adolescent over time. The therapist, adolescent, and family need to realize that treatment will take an extended amount of time.

Psychotherapy is the primary treatment of BPD. Extensive therapy is required to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning. Long-term dialectical behavior therapy (DBT) appears to be the most effective. DBT is a type of cognitive behavioral therapy that focuses on coping skills, so patients learn to better control their emotions and behaviors. This may be complemented with symptomatic psychopharmacology to address affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior. Psychoanalytic/psychodynamic therapies have also proven effective.

Therapists can use guidelines on the treatment of BPD from the American Academy of Psychiatry, although they need to realize that these recommendations are not adolescent-specific:

  • Consider the treatment setting to ensure that outpatient treatment is warranted over hospitalization:
    • Partial hospitalization — dangerous impulsive behavior, deteriorating clinical picture, complex comorbidities, symptoms unresponsive to outpatient therapy;
    • Brief inpatient hospitalization — serious suicidal ideation or attempt, imminent danger to others, symptoms unresponsive to partial hospitalization; and
    • Extended inpatient hospitalization — persistent suicidal ideation, nonadherence to other therapies, life-threatening comorbid Axis I disorder, continued risk of assaultive behavior, severe symptoms that interfere with living.
  • Establish a strong therapeutic alliance that includes empathic validation of the patient’s suffering and experience.
  • Coordinate and collaborate with the treatment team. Be aware of and manage splitting problems, and assist the adolescent in integrating both positive and negative aspects of self and others.
  • Provide education to the adolescent and the family on BPD.
  • Manage intense feelings produced by both the patient and the therapist. The use of supervision and consultation is strongly recommended.
  • Help patient take responsibility for his/her own actions, and promote reflective rather than impulsive behaviors.
  • Consider pharmacologic treatment for selected symptoms, but realize that data are lacking on their use with adolescents, and be aware of the US Food and Drug Administration’s (FDA’s) warning on suicidality in children and adolescents treated with antidepressants:
    • Affective symptoms: Initially treat with a selective serotonin reuptake inhibitor (SSRI), the treatment of choice for disinhibited anger occurring with affective symptoms. Mood stabilizers (lithium, valproate, and carbamazepine) are a second-line or augmentation treatment.
    • Impulsive behaviors: SSRIs are the treatment of choice. Valproate, carbamazepine, and atypical neuroleptics are also used, despite limited data.
    • Cognitive-perceptual symptoms: Low-dose neuroleptics are the treatment of choice, but clozapine may be useful for patients with severe, refractory psychotic-like symptoms.
  • Treat substance abuse. Drug counseling may be warranted.
  • Address violent and antisocial behaviors. Monitor carefully for impulsive and violent behavior because these are hard to predict. Address abandonment and rejection issues. Arrange for appropriate coverage when away; carefully communicate this to the adolescent; and document it. Take action to protect self and others if the patient makes threats.
  • Address trauma and posttraumatic issues and dissociative (depersonalization, derealization, and loss of reality testing) features.
  • Explore and address psychosocial stressors. Most adolescents with BPD are very sensitive to psychosocial stressors, particularly interpersonal ones.
  • Consider cultural factors. Avoid cultural bias related to sexual behavior, emotional expression, and impulsivity.

Managing adolescents with BPD can be challenging at best. But with careful planning, collaboration, and supervision, psychotherapy can assist these adolescents in reaching their optimal potential.

source: Mary E. Muscari, PhD

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Dr. Gnap

Dr. Gnap is a family practice physician and behavioral medicine specialist in suburban Chicago.  Dr. Gnap developed the Inner Control™ Program in 1970 and has worked with thousands of people to improve and correct medical, emotional, behavioral and learning problems including performance.  He started the Inner Control program because so many patients asked, “what more can be done along with traditional treatment methods?”

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