Fortunately, at least in my case, as I’ve gotten older I’ve mellowed a bit in my old age. As a teenager though everything is more dire and intense. Not that things weren’t still EXTREMELY intense into my 20’s but I learned a little more control and self-awareness so I was able to mitigate some of the damage. That’s my experience though. I know that it’s not always the case though and for some it seems to just get worse and worse. Which is why early diagnosis, and the potential for earlier treatment can be especially important. So let’s get back into it….
Borderline Personality Disorder in Adolescents: Part 2
Issues in Diagnosis and Treatment
By Blaise Aguirre, MD | May 9, 2012
The dialectical behavioral therapy profile
From a dialectical behavioral therapy perspective, the symptoms of BPD have been divided into 5 areas of dysregulation:
• Emotional dysregulation: adolescents with BPD are highly reactive and can experience episodic depression, anxiety, and irritability; they also have problems with anger and anger expression.
I can only imagine how much greater my quality of life would have been if I had any idea how express myself appropriately or express my anger constructively…. Which I absolutely did not.
• Interpersonal dysregulation: relationships are chaotic, intense, emotional, and hard to give up; the fears of abandonment can be pronounced.
• Behavioral dysregulation: adolescents with BPD demonstrate dangerous, impulsive, and suicidal behaviors; self-injury, suicide attempts, dangerous drug use and unsafe sex are common behaviors
• Cognitive dysregulation: stressful situations and a history of trauma can lead to nonpsychotic loss of reality testing and may include depersonalization, dissociation, and delusions
• Self-dysregulation: adolescents with BPD frequently have little sense of self; they feel empty and struggle mightily with a sense of purpose
Yes. Yes. Yes. And Yes. What makes this especially traumatic is when you’re so young and so inexperienced you don’t understand what’s happening to you. You’ve never experienced this before, you don’t know that what you’re going through isn’t normal, you don’t know that what you’re experiencing is something that has a name or is treatable… you feel paranoid and alone. It can be terrifying and depressing and utterly isolating. When you’ve never experienced something before, you don’t know to ask for help. When you don’t feel you can trust anyone, you don’t believe there’s anyone you can turn to even if it did cross your mind.
The neuropsychological profile
Although the neuropsychological profile of BPD has not been described for adolescents, studies in adults have shown impairments in specific cognitive domains. One robust finding has been deficits in executive functioning, which suggests decreased frontal processing. Such deficits would explain many of the behavioral findings in BPD, including a poorer capacity to plan, impulsivity, and increased difficulty in emotion regulation.
Given that adolescents have developmentally determined deficits in executive functioning, adolescents with BPD present with even more impulsive and less planned behavior than a typically developing adolescent. The deficits in executive functioning manifest as substance abuse, impulsive aggression, and maladaptive strategies to deal with intense emotions.
The long-term outcome
Biskin and colleagues recently published a study on current diagnoses and functional status of women who had received a diagnosis of BPD in adolescence. They also looked at factors that might be associated with long-term outcomes.
Girls with BPD that was diagnosed before age 18 (n = 31) were compared with those who had other psychiatric diagnoses but not BPD (n = 16). Each group was assessed over 10 years. Study findings indicate that 4.3 years after the initial diagnosis, only 11 of the patients with BPD still met criteria for the disorder; BPD did not develop in any of the patients who did not initially have BPD. Those who did not have symptom remission were significantly more likely to have a current episode of major depression, to have a lifetime substance use disorder, and to self-report childhood sexual abuse. The researchers concluded that their findings supported the validity of an adolescent BPD diagnosis and that prognostically, in nearly two-thirds of cases of adolescent-onset BPD, remission could be expected within 4 years.
These findings are consistent with a prospective follow-up that also found a 60% remission rate. It is notable that the rate of recovery in adolescents parallels that seen over a similar period in adults with BPD.
What we are seeing challenges one of the historically entrenched myths about borderline personality disorders. Research now shows that BPD is not a lifelong condition and that most patients, adolescents and adults, can expect to improve over time.
Mary C. Zanarini, EdD, Professor of Psychology at Harvard Medical School, has been conducting an NIMH-funded study of the long-term course of BPD in adults for the past 19 years. In a personal communication, she reported that her findings show that patients with BPD have a substantially better prognosis than previously recognized; remissions are common and recurrences are relatively rare. She and Marianne Goodman, MD, of Mount Sinai School of Medicine, are conduct-ing a similar study among adolescents (aged 13 to 17) with BPD and a comparison group of emotionally healthy adolescents. Although the data are yet to be fully analyzed, their baseline data show strong similarities between adolescents and adults with BPD.
Not all good news
Prospective studies on the course of adult BPD show that the majority of patients have symptom remission, often within the first 4 years of follow-up. However, even though over time most patients with BPD no longer qualify for the diagnosis, follow-up studies in adults with BPD indicate that good psychosocial functioning is only attained in 60% of these patients. Vocational impairment is more frequently seen than social impairment.
These findings highlight the need to direct patients with BPD to specialized treatments at an early age, when there is more potential to provide them with the skills that are necessary for improved long-term functioning, particularly in the educational and vocational domains. Furthermore, a number of factors, such as childhood sexual abuse and substance abuse, adversely affect outcome in adults with BPD. Once again, lack of research means that much less is known about the factors that predict outcome in adolescents with BPD.
I think this is very rational, expected news. It would be unreasonable to expect 100% improvement in follow-up studies. Good psychological functioning in 60% of follow-up patients 4 years later is still a phenomenal percentage! 60% !!! That’s huge. All this indicates to me is that early detection is important and some people have more deeply ingrained trauma and maladaptive coping mechanisms than others and it may take some people a little longer to determine their best path to healing. There’s nothing wrong with that. Even without the label, teaching the DBT skills to adolescents that present as BPD is important and can help them achieve better vocational, academic, and social goals.
Several psychotherapies have been shown to lead to overall improvement in functioning in patients with BPD, although as with research in general, studies of psychotherapy in adolescents with BPD are few. Empirically validated therapies include dialectical behavioral therapy, mentalization-based treatment, schema-focused therapy, and transference-focused psychotherapy. Most of these treatments have not been studied in adolescents.
Various treatment options are available for adolescents with BPD. These include standard cognitive-behavioral therapy, individual psychotherapy, and substance abuse treatment. The best evidence-based treatment outcomes for adolescents with BPD come from dialectical behavioral therapy and cognitive analytic therapy.
The bottom line
BPD appears to be a neurodevelopmental disorder, influenced by the person’s genetics and brain development and shaped by early environment, including attachment and traumatic experiences. BPD also appears to remit in the majority of cases within 4 years of a formal diagnosis. Research and clinical experience underscore that a history of sexual abuse and alcohol (Drug information on alcohol) and other substance use disorders is associated with failure to remit; affective lability is also associated with continuation of BPD.
Given that there is little reluctance on the part of psychiatrists to diagnose other psychiatric disorders, such as bipolar disorder, in children and adolescents and given that there appears to be a good prognosis for adolescents with BPD, clinicians should no longer be reluctant to diagnose BPD in those younger than 18. The DSM does not preclude it, the prognosis is not negative, and as with many disorders, early diagnosis can lead to timely and targeted treatment for this previously underserved and under-recognized population.
Finally, given the advent of new and validated therapies that target BPD, it is imperative that the diagnosis be made as early as possible so that targeted interventions can be applied. However, because BPD has numerous symptoms that over-lap with other disorders and because of the enduring nature of the symptoms of all borderline personality disorders, clinicians should understand that some features of BPD are likely to be chronic and, as such, be prepared for a long-term treatment relationship.
So there you have it. A very recent and update opinion on the earlier diagnosis of adolescent BPD. That it can, and possibly should, be diagnosed earlier in adolescence. Not only that, but it shines a brand new light of hope on just how treatable the prognosis can be if it’s caught earlier rather than later. That doesn’t mean it will be an easier journey. It will still be a long one, with intensive, long-term therapy, but therapy with a very promising and lasting outcome.
What are your thoughts?