Psychiatry Advisor: Are there other reasons why BPD might go undiagnosed by mental health professionals?
Dr Sharp: Even in adults, BPD is a highly stigmatized disorder. Often, healthcare professionals are the ones who stigmatize it the most: “Oh, that patient is just borderline, you don’t have to take her complaints seriously.” Some clinicians refuse to work with patients with BPD. So there is a concern that diagnosing BPD in younger people can be even more stigmatizing, as if you are hanging this diagnosis around a teenager’s neck and he or she will be labelled early in mental health services.
We argue the opposite. We have a duty as mental health professionals to challenge this idea of BPD as a death sentence. We argue that it is a serious public health concern and we should identify it thusly so children and their families can receive appropriate treatment.
Psychiatry Advisor: What types of interventions are helpful in adolescents with BPD?
Dr Sharp: Dialectical behavior therapy for adolescents (DBT-A) has a strong evidence base. DBT-A is adapted from adult DBT (dialectical behavior therapy) and is a 16-week behavioral treatment consisting of weekly individual therapy and multifamily skills groups, as well as family therapy as needed.2 It teaches adolescents various skills focused on improving their emotion regulation and reducing impulsive behaviors. A body of literature supports the utility of DBT-A in the treatment of BPD pathology and its proposed underlying mechanisms (ie, emotion dysregulation and impulsivity) in adolescent outpatients with subthreshold or threshold BPD.5
Mentalization-based therapy (MBT) is another well-researched intervention for adults with BPD, and it has been adapted for adolescents (MBT-A). It is a psychoanalytic treatment that focuses on the enhancement of mentalization, which is the ability to understand and reflect upon one’s own and others’ internal states and their relationship to behaviors.2 The goal of MBT is to strengthen the person’s ability to mentalize when experiencing the stress caused by attachment activation. Although MBT does not directly target emotional dysregulation or impulsivity-enhanced mentalization, it can help increase emotion regulation and behavioral control.
Transference-based psychotherapy (TFP) is a promising approach with an emerging evidence base. It is a manualized, psychoanalytically oriented psychotherapy that focuses on interpersonal dynamics in the patient’s life that can cause emotional dysregulation. The transference toward therapist is used to help patients with their self-perception and issues that arise in relationships.
Psychiatry Advisor: What is the potential role of medication in the treatment of adolescents with BPD?
Dr Sharp: Before a determination can be made regarding the utility of medication, a thorough neuropsychiatric assessment is necessary so that attention-deficit/hyperactivity disorder (ADHD) can be ruled out. If it is not present, then there is no need for medication, as mood stabilizers are not supported by a strong evidence base in BPD, which is best treated through relationally oriented psychotherapy or adapted DBT. I have seen adults with BPD who have been treated with a variety of medications since childhood, sometimes because they are treated symptomatically to stabilize moods and sometimes because they have been diagnosed with bipolar disorder. Many have been on all sorts of drug cocktails for as many as 10 years. Once a diagnosis of BPD has been established, they can begin to get effective treatment. A well-done neuropsychiatric evaluation can save years of unnecessary and potentially harmful medications and a delay in effective treatments. If these therapies are not sufficiently effective, it might be appropriate to consider a trial with mood stabilizers or other medications.
Psychiatry Advisor: What suggestions do you have for practicing psychiatrists and other healthcare professionals who may be presented with these patients?
Dr Sharp: It is critically important to assess children and adolescents presenting with symptoms suspicious of BPD to assess for personality problems. The youth’s actual behaviors, verbal and nonverbal, in the interaction with the examiner are valuable sources of information.2 The Personality Assessment Interview (PAI) is a useful tool.
If evidence of BPD is found, I would not refer to it as a “disorder” prior to age 12. We do not have enough data to make that type of definitive diagnosis. I would suggest explaining to parents that these can be early signs of maladaptive traits, meaning that the child is engaging in behaviors that could develop into a personality disorder in the future. I would recommend age-appropriate DBT group or emotional regulation-focused work. MBT is particularly helpful for little ones because it makes use of the therapeutic relationship.
For a child older than age 12, I would explain to parents that their child meets criteria for BPD. I would emphasize that this does not necessarily point to a lifetime disorder and that it waxes and wanes like depression and anxiety. It important to name and destigmatize the disorder and to direct parents to appropriate therapies.
Educating the family about the nature of BPD is critical, especially emphasizing that the child is very sensitive. I find that this is what parents struggle with the most. It is relatively easy for a parent to empathize with a depressed or anxious child. But children with BPD are sensitive and anxious, but they often respond by getting angry. It is difficult for parents to continue feeling and expressing empathy. Once we explain that the child does not only experience anxiety but also a combination of internalizing and eternalizing features, parents can more easily remember that the child is actually very sensitive and can slow down interactions, take things one step at a time, and try to see things from the child’s perspective while continuing to set clear boundaries, which is very important.
Psychiatry Advisor: Where can psychiatrists find out more about working with children with BPD?
Dr Sharp: The National Educational Alliance for Borderline Personality Disorder (NEABPD) is a helpful organization to educate both laypeople and healthcare professionals about BPD. Under the auspices of NEABPD, I co-developed the GAP Initiative with Andrew Chanen, MD. We offer an extensive library on all publications published on BPD in childhood and adolescence, which can provide education about assessment and treatment. We also offer Sunday evening call-in programs to facilitate extra education and more interaction with clinicians.
- Kaess M, Brunner R, Chanen A. Borderline personality disorder in adolescence. Pediatrics. 2014;134(4):782-793.
- Sharp C, Tackett JL, eds. Handbook of Borderline Personality Disorder in Children and Adolescents. New York, NY: Springer Science and Business Media; 2014.
- Linehan M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press; 1993.
- Crowell SE, Beauchaine TP, Linehan MM. A biosocial developmental model of borderline personality: elaborating and extending Linehan’s theory. Psychol Bull. 2009;135(3):495-510.
- Klein DA, Miller AL. Dialectical behavior therapy for suicidal adolescents with borderline personality disorder. Child Adolesc Psychiatr Clin N Am. 2011;20(2):205-216.
- Selzer MA, Kernberg P, Fibel B, Cherbuliez T, Mortati SG. The Personality Assessment Interview: preliminary report. Psychiatry. 1987;50(2):142-153.