Fact or alternative fact? Poor impulse control, chaotic interpersonal relationships, identity problems—a psychiatric disorder or typical adolescence? The issue of diagnosing borderline personality disorder in adolescence has been somewhat controversial for years. Adolescence is a time of tremendous change in brain development. A great deal of neural pruning is taking place in an effort to improve the efficiency of circuitry leading to more effective overall function.
Some studies have shown that the diagnosis of borderline personality disorder is not stable, especially in adolescence. Given the significant neurologic development that is occurring during adolescence, is it appropriate to make a diagnosis of a personality disorder at a time that is marked by ongoing change and likely to fail to demonstrate diagnostic stability?
Borderline personality disorder exists in the individual who may be described as meeting at least five of the following criteria:
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g., excessive spending, substances of abuse, sex, reckless driving, binge eating).
- Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper tantrums, constant anger and reoccurring fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
But, is it appropriate to diagnose in adolescence? In a review written by Miller et al., 2008, they reported that recent studies, in fact, have shown that symptoms of borderline personality in adolescence “have construct validity and can be reliably identified among adolescents.”
Personality disorders are defined as enduring patterns of perceiving, experiencing, relating to, and responding to others in such a way that leads to distress or dysfunction. Genetics determine temperament, i.e. traits such as novelty-seeking, harm-avoidance, and reward-dependence, upon which the social environment molds to determine ultimate personality. Research has been revealing that determinants of personality are present long before adolescence.
Borderline personality in adolescence has been found to have the same degree of reliability and validity in adolescence as in adulthood. Prevalence estimates have been determined to be approximately 0.9%. Adolescents with borderline personality disorder have been found to have an abnormal pattern of brain maturation.
Risk factors for the development of borderline personality disorder in adolescence include low family of origin socioeconomic status and adverse childhood experiences. Attachment disorganization, parental hostility, and maternal inconsistency have all been shown to play
a role in increasing risk. Sexual abuse is a common finding in the histories of those adolescents with borderline personality disorder; however, it has been found to be a weak and nonspecific risk factor.
Adolescents with borderline personality disorder have significant impairments in social relationships and academic performance, with overall poor quality of life. Non-suicidal self-injury and suicidal behavior are prevalent and are the most frequently met criteria. The lifetime suicide rate for borderline personality disorder is estimated to be 8%. Substance use is highly prevalent as is sexual risk-taking.
Adolescents with borderline personality disorder are at increased risk for other psychiatric disorders, the most common of which are mood disorders, eating disorders, dissociative disorders, Post-traumatic Stress Disorder, substance use disorders, and other personality disorders.
Borderline personality disorder has been found to be moderately heritable without the identification of specific genes as of yet. Neurobiologically, structural imaging studies have revealed reductions in volume of orbitofrontal cortex and anterior cingulate cortex. The hypothalamic-pituitary-adrenal axis activity has been shown to be abnormal, in that adolescents engaging in repetitive non-suicidal self-injury have an attenuated cortisol response to acute stress.
Adolescents with borderline personality disorder have been shown to have abnormal theory of mind tasks. Their ability to perceive socially is impaired. They have been described as having an “over-interpretive mental state”, i.e., they “hypermentalize” that leads them to make assumptions about other people’s mental states.
Given the serious long-term consequences of borderline personality disorder, including poor psychosocial functioning and high risk of ongoing sickness and possible death, it is important to recognize this illness as early as possible and to intervene appropriately. Treatment can be highly effective. A number of psychotherapies have been found to provide success. Cognitive analytic therapy was derived from object-relations theory and cognitive psychology. Mentalization-based therapy is based upon psychodynamic theory and encourages the use of one’s ability to mentalize representations of self and other. Dialectical behavior therapy for adolescents developed by Linehan was derived from cognitive-behavior therapy and involves skills-training for stress-tolerance, emotion regulation, and interpersonal difficulties. Finally, transference-focused psychotherapy is based upon object relations analytic technique, developed by Kernberg and has been adapted for adolescents.
There is no current evidence for specific medicines found to be helpful in borderline personality for adults or adolescents. However, given the high prevalence of comorbid psychiatric illnesses which do respond to psychopharmacologic agents, medicines are likely to be indicated. In addition, some studies have shown symptom-focused pharmacotherapy to be helpful. For example, naltrexone has been shown to decrease frequency of self-injurious behavior in borderline personality disorder in some studies.
References Upon Request
Dr. Robert A. Moran is Board Certified in Psychiatry, Addiction Psychiatry, and Addiction Medicine by the American Society of Addiction Medicine and the American Board of Addiction Medicine. He is a clinical instructor of psychiatry at Cornell University, and a member of the faculty of the Biomedical Science at Florida Atlantic University. Since 1993, Dr. Moran has dedicated his life to the study and treatment of substance and mental health disorders.