Thursday, April 11, 2013

Borderline Personality Disorder in Adolescents: Part 1

Busy, busy, busy. Sorry my posting has been sporadic. Working overt time and trying to practice what I preach to maintain a stable balanced life means somethings get done more slowly, but you know what, I’ve been feeling better, though I feel a little selfish about that. Anyways. I want to talk about a topic today that I’ve talked about before, and that many of you have asked about. Borderline diagnosis in Adolescents. Typically it’s just not done before the age of 18. Our brains are still developing and you don’t really want to mess with that, however there can be exceptions, sometimes there should. Usually though, it’s for the best. Let’s take a look! It’s a long, long article so I’ll do it in two parts! Part 1:

Borderline Personality Disorder in Adolescents

Issues in Diagnosis and Treatment
By Blaise Aguirre, MD | May 9, 2012

Dr Aguirre is Medical Director of the Adolescent DBT Residential Program at McLean Hospital in Belmont, Mass, and Assistant Professor of Psychiatry at Harvard Medical School, Boston. He reports no conflicts of interest concerning the subject matter of this article.

Borderline personality disorder (BPD) is frequently encountered in a variety of clinical settings. On inpatient units, it is estimated that 20% of patients have comorbidity with BPD. In outpatient clinics, 11% of patients meet diagnostic criteria for BPD. Despite these statistics, BPD has neither the same level of public awareness nor the same level of research funding that other major psychiatric diagnoses have.

The American psychoanalyst Adolph Stern was the first to use the term “borderline” in describing a group of patients who had both neurotic and psychotic features. He considered these patients to be in the “border line group.” It was not until 1949, however, that the term was applied to children. Margaret Mahler used the term “borderline” to describe a group of children who displayed “low frustration tolerance, poor emotional differentiation from their mothers, and [who were] beset by a series of neurotic-like defenses.”

Since Stern, the amount of research on BPD in adults has grown exponentially. Research on BPD in children and adolescents has not kept pace despite increasingly strong evidence of developmental antecedents for the condition in adult BPD.

Although an extensive historical review of the diagnosis of BPD in children and adolescents would be interesting, it is beyond the scope of this article. However, it is increasingly clear that BPD progresses from a strict psychodynamically based construct to a neurodevelopmental disorder with roots in the genetics of the child, the child’s temperament, and the environment. BPD is marked by skills deficits in broad areas of developmental ability, including deficits in emotion regulation, distress tolerance, and interpersonal functioning.

Waiting for therapy

Although symptoms typically begin in adolescence, there has been a strong reluctance in the psychiatric community to diagnose BPD in anyone younger than 18. Even in adults with BPD, it remains a highly stigmatized disorder among physicians and mental health professionals. Although DSM clearly allows for the diagnosis to be made in patients who have had enduring symptoms for more than a year, clinicians tend to write “deferred” on Axis II, even when an adolescent meets sufficient diagnostic criteria. What this means is that in many adolescents, mood and other behavioral and psychiatric disorders are diagnosed, and often medication is prescribed for symptoms even when clinical criteria for disorders other than BPD are not met.

Because of the reluctance to make the diagnosis, BPD has been under recognized and underdiagnosed in adolescents and, as a consequence, has not been adequately studied. As such, its nature and course in adolescent populations are not well understood. Equally troubling is that studies show that treatment typically begins in early adulthood. It appears that from the onset of symptoms to the definitive diagnosis of BPD, treatment can lag for many years. The lack of early treatment can mean years of suffering and years of practicing maladaptive (although temporarily effective) and self-reinforcing behaviors (eg, self-injury for emotional regulation).

I agree that this is very unfortunate! I begin presenting with very clear symptoms when I was about 12. My parents and school counselors did try to get me to see a counselor though. However I did not give them an easy time of it and they quickly became discouraged and gave up. In retrospect I do wonder how much better things could have been for me if I had been able to receive to the help I needed. However with my depression, paranoia, and my trust issues I was not in a mental state to accept help.

Evidence suggests that BPD can be reliably diagnosed in adolescents; however, other studies show that the diagnosis is not always stable over the course of development. For instance, a prospective study undertaken by Chanen and colleagues found that only 40% of adolescents aged 15 to 18 with BPD met criteria for the disorder at 2-year follow-up.

Never underestimate the volatility of teenage hormones and teenage misery! I’m actually not kidding.

A community study looked at self-reported symptoms at 2- to 3-year intervals starting in early adolescence (age 14) and ending in early adulthood (age 24) in adolescent twins with BPD. The results showed a decrease in rates of the diagnosis over the study period, with significant reductions in symptoms at each study interval during the 10-year follow-up.

What is already known about borderline personality disorder (BPD) in children and adolescents?

 BPD in adolescents has been a controversial diagnosis. Research indicates that the presentation in adolescents is very similar to that in adults.

What new information does this article provide?

 DSM does not prohibit the diagnosis of BPD before age 18. The earlier the diagnosis, the earlier an empirically validated treatment can be applied. Furthermore, BPD may not be a lifelong condition.

What are the implications for psychiatric practice?

 Adolescents overwhelmingly find the diagnosis to be validating of their experience. An early diagnosis can mean an earlier targeted intervention that will help avoid multiple and unnecessary medication trials and adverse effects.

Another study looked at 407 adolescents with cluster B symptoms. The findings show that BPD and other cluster B symptoms tended to persist even when formal diagnostic criteria for cluster B on Axis II were no longer met.

DSM and the adolescent clinical profile

DSM has 9 criteria for BPD and states that the diagnosis can be made in adolescents younger than 18 if the criteria have been present for more than a year. Integrating the clinical experience with DSM criteria yields the following profile: adolescents referred for treatment often report that symptoms started around puberty. BPD symptoms such as self-injury and impulsivity involving drugs, alcohol (Drug information on alcohol), and sex are far less common in younger children. The 9 DSM criteria are the following:

If this is true I would have been diagnosable by the time I was 14 for sure. Maybe even by the time I was 13. Puberty is precisely when things started changing for me, and not just in the uncomfortable awkwardness of budding sexuality. By the time I was 13 I deep into depression, self-harm, I began drinking, I was bulimic, and had already attempted to kill myself multiple times, begun shop-lifting, and more!

Efforts to avoid abandonment. The risk of suicide is increased in adolescents with BPD after a breakup with a romantic partner or problems with a roommate or friend. They experience a profound sense that someone essential to their well-being will never come back. The clinician must recognize that suicidal and other maladaptive behaviors are sometimes reinforced by loved ones and caregivers, in that the adolescent with BPD feels more cared for when in crisis and being attended to by compassionate caregivers.

Check. My first real crisis was when I was 12 and my parents told me my best guy friend and I could not hang out the way we used to because we were getting too old for our usual sleepovers. I knew things would never be the same.

Unstable relationships. Patients with BPD tend to have relationships that are either over-idealized or devalued. Parents and friends can be categorized as being the best parent or friend in the world in one moment and then vilified in the next. This reflects all-or-nothing, or black-and-white, thinking, which is typical in adolescents with BPD. On hospital units, the adolescents can divide staff into good and bad staff—designations that can readily change. In an unprepared staff, this can lead to polarization and staff that either likes or dislikes the adolescent.

I feel like this is oversimplified. Even when I was a teenager it there was much more of a love-hate struggle. Wanting to love someone and hating the power or pull they had over me. Needing someone’s love, but not being able to forgive how they’d hurt me and the inability to find a grey area of resolve that allowed the two to exist together but fluxuating back and forth one or the other instead.

Unstable sense of self. This criterion is harder to define in adolescents with BPD because adolescence is a time of defining identity. Clinically, we see enduring self-loathing as a core symptom. Others describe feeling “porous” to others’ emotions.

            Very different for everyone I imagine.

Dangerous impulsivity. In younger adolescents with less access to cars and money, reckless driving and spending and are unusual. Indiscriminate and unprotected sex, drug abuse, eating problems, and running away from home are more common, and these behaviors are often used to regulate emotions. These mood regulation strategies are one of the key assessments that differentiate “typical” adolescent experimentation from the behavior of adolescents who have BPD.

I would also include things like eating disorders, shop lifting, vandalism, petty crimes, things like that…things that I was involved with that were all dangerous and impulsive.

Recurrent self-injury and suicidal behavior. Self-injury in the form of cutting is common; self-burning, head banging, punching walls, attempting to break bones, ingesting nonnutritive substances, and inserting foreign objects under the skin are other forms of self-injury. Although patients with BPD are at increased risk for completed suicide, cautious intervention is key because suicide attempts can be reinforced by the well-intentioned attention of caregivers.

Cutting, burning, punching walls/windows/doors/concrete/lockers, pins and needles through my skin, etc, etc.

Affective instability/extreme mood reactivity. Adolescents with BPD recognize that they feel things “quicker” and with less apparent provocation than others, feel things more intensely than others, and are slower to return to their emotional baseline than others. Mood states tend to be in response to interpersonal and intrapersonal conflict and rarely last for more than a day, typically lasting only a few hours. This mood reactivity can be useful in differentiating BPD from Axis I mood disorders, in which mood states can last for many days or weeks.

I feel like this is the same in adolescents as it is with adults. Though as an adult I’ve learned to control it much better where as an adolescent I simply reacted. I had no clue why I was reacting so strongly or so quickly all I knew was that I felt intensely, I felt attacked, and I needed to protect myself as quickly and as strongly as possible. Returning to that emotional baseline felt impossible for me. It’s much easier now though it can still take time and determined focus.

Chronic feelings of emptiness. Adolescents with BPD tend to express that they are easily bored and do not like to sit quietly; the emptiness and boredom of being alone is intolerable. They find that the emptiness is temporarily relieved by risky or “intense” behaviors (intense relationships, sex, drugs).

            I’m still not sure this will every go away.

Anger regulation problems. If there is physical aggression, it tends to occur most with those closest to the adolescent with BPD. The anger-fueled aggression can take the form of destruction of property, bodily violence, or hurtful verbal attacks.

Violently, violently angry to myself and pretty much everything around me. Not to friends so much, but definitely to myself and with my family and within the confines of my home.

Paranoia and dissociation. It appears that about 30% of hospital-based adolescent patients with BPD have experienced some form of abuse. Some present with co-occurring PTSD. In this subgroup, dissociation, depersonalization, and derealization are common.

I had paranoid trust issues, but I don’t think I had any form of PTSD at this point. Though I was emotionally repressed and possibly dissociative without understanding what this was. My memory of my non-traumatic feelings actually isn’t very good from my younger years. 

But wait! There’s more! Stay tuned! Tomorrow is usually my Lucid Analysis, but maybe I’ll just finish up this article instead. What do you think so far? 

1 comment:

  1. Excellent analysis and commentary. When I see updates to this blog in my RSS reader, I always get a little thrill. I "save" them as reading treats. Keep it up! And I'm glad to read that you're feeling better.


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