Borderline Personality Disorder in Adolescents

Parents: Are you concerned about your teenager's intense emotional reactions and behaviors?  

Being an adolescent is tough, especially if there is underlying emotional sensitivity. 

DBT can be an effective treatment for adolescents who have symptoms of Borderline Personality Disorder (BPD).  

Below are the criteria of BPD in Adolescents written by Blaise Aguirre, MD Medical Director of the Adolescent DBT Residential Program, McLean Hospital, Belmont, MA in a blog post titled, Stop Walking On Eggshells.  Dr. Aguirre is also an instructor at Psychiatry Harvard Medical School. 

The DSM Diagnostic Criteria for Borderline Personality Disorder in Adolescents 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) published by the American Psychiatric Association provides criteria for adolescents with BPD. 

1. EFFORTS TO AVOID REAL OR IMAGINED ABANDONMENT

Adolescents sometimes come to therapy 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. I am also 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 suicidal behaviors can be unintentionally 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 which is, "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 the 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 in my practice.

I also see burning with matches or lighters, head banging, punching walls, and attempts to break bones. Most of my patients have made at least one suicide attempt -- generally by overdose.  But more recently I am seeing patients with self-inflicted gun shots, who have tried to hang themselves, or who 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:

Moods tend to be in reaction to some conflict (e.g. a fight or a disappointment).

The adolescents in my practice recognize that they feel things "quicker" and with less apparent provocation than others their age.

They say they feel things more intensely than others their age.

They say that they are slower to return to baseline than others.

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! T hese 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 the young 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-IV-TR 

I frequently see these similarities in adolescents in my practice:

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 though the person doesn't identify him/herself 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 

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.

For more information, read the article, Teen Moodiness or Borderline Personality Disorder?, by Dr. Alec Miller.

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