Borderline personality disorder (BPD) is characterized by a “pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image.”1 The impact of BPD is formidable and results in a high burden on family and caregivers, high utilization of healthcare resources, and high costs of treatment.1
BPD is classically diagnosed in adults and its diagnosis in adolescents is controversial.1 And yet a significant body of research suggests that signs and symptoms of BPD appear long before adulthood, often in younger children, and that adolescents can display the full range of symptoms that qualify for a diagnosis of BPD.
To shed light on this ongoing controversy and its therapeutic implications, Psychiatry Advisor interviewed Carla Sharp, PhD, professor and director of clinical training in the Department of Psychology at the University of Houston, Texas. Dr Sharp is the co-editor of the Handbook of Borderline Personality Disorder in Children and Adolescents2 and the co-founder of the Global Alliance for Early Prevention and Intervention for Borderline Personality Disorder (GAP) Initiative.
Psychiatry Advisor: What is the controversy surrounding the diagnosis of BPD in adolescents?
Dr Sharp: Ever since the first descriptions of BPD and specification of its diagnostic criteria in the DSM [Diagnostic and Statistical Manual of Mental Disorders], there was no restriction placed on diagnosing it in adolescents. Nevertheless, in our training programs, we were taught that one does not make a personality disorder diagnosis before age 18 years, even though the DSM allows for it.
One of the major arguments raised against diagnosis prior to age 18 is that, since the personality is still forming and identity is still being consolidated, a personality disorder cannot be accurately diagnosed.
A strong research base2 has been mounting, especially in the past 10 years, supporting the concept of a diagnosis of BPD in teens. It has been found that personality traits are as stable in children and adolescents as they are in adults. In other words, we have overestimated the stability of personality traits in adults. We used to see them as fixed and stable and postulated that they would be less stable in children and adolescents. But in reality, this is not the case. Traits wax and wane in both age groups.
Psychiatry Advisor: Adolescence is often a time of angst, stormy emotions, moodiness, and confusion. How do BPD traits differ from those of normal adolescence?
Dr Sharp: The first clue that a teenager may not be experiencing “normal” adolescent angst is that these traits likely began before adolescence and even in childhood. Children come into the world with a given temperament, and in the case of these children, they are unusually sensitive. I compare this type of child to a burn victim. When you touch the skin of a burn victim, he or she experiences pain that is far greater than the pain that might be experienced by an ordinary person from the same type of touch.
Marsha Linehan’s biosocial theory3,4 suggests that a person with BPD has grown up in an invalidating environment. It is important to recognize parents are not to blame. They have done the best they could, but most parents do not necessarily have the time, resources, or understanding to recognize what their child needs and how to help the child modulate anxiety and regulate emotion. For example, parents might tell their children that they are overreacting and should just “pull up their socks.” But for the child with this type of sensitive temperament, that response is seen as invalidating. The environment is unable to meet the temperament.
Psychiatry Advisor: How do these early traits develop into BPD during adolescence?
Dr Sharp: When the environment does not match the child’s temperament, he or she begins to be on a trajectory of atypical development in terms of self- and other-relatedness. These children’s view of themselves, their identity, and the trustworthiness of others becomes unstable. So as these children age into adolescence, when they are supposed to consolidate identity, they experience huge confusion and feel lost. Many start engaging in high-risk behaviors, such as substance abuse or self-harm, to help deal with the emptiness. The picture of BPD begins to emerge.
Psychiatry Advisor: How does BPD intersect with other psychiatric conditions in adolescents?
Dr Sharp: I do not see BPD as a discrete disorder, especially in young people. What it denotes is personality pathology in general. In our treatment of adolescents, we tend to neglect that domain of psychopathology. When youngsters start having trouble with relationships, peers, romance, or parents or severe emotional regulation problems of difficulty finding themselves, we tend to write it off as developmental or we look for depression, anxiety, or conduct disorders. BPD is highly comorbid with these conditions, but it is a personality disorder and should be treated together with the other disorders.
Psychiatry Advisor: Are there red flags that parents or mental health clinicians should look for?
Dr Sharp: I think the most important flag would be intense emotional dysregulation. The child does not bounce back from a difficult emotional experience as other children might. Other clues would include statements that seem age-inappropriate or disturbing—for example, pseudopsychotic or weird statements such as “I see dots.” Statements such as “I don’t want to live” or “I feel empty” are also strong clues. In our work, we have heard children as young as 9 say they do not want to live anymore, or they feel as if nothing is inside them. Some describe dissociative experiences where they say they are not in the room or not in their bodies. These symptoms, combined with what we call externalizing behaviors—angry outbursts or oppositionality—are very suggestive.