Friday, April 12, 2013

Borderline Personality Disorder in Adolescents: Part 2

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

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.

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.

Targeted interventions

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? 

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? 

Tuesday, April 9, 2013

Affirmations for Borderlines

Hello Dear Readers! I hope you are all doing incredibly well. Spring is sprung here and things are going really pretty well for me. I hope they’re going well for you too. We can all use some help though, and that help often needs to come from within when we have nowhere else to turn. Learning to change our Self-Talk is a powerful skill to develop in our personal arsenal toward healing.

Affirmations for Borderlines

Changing the Self-Talk Can Be a Powerful Ancillary to BPD Treatments

In the course of their illness, many people living with borderline personality disorder have convinced themselves that they are unlovable. Borderline brains are hard-wired for rejection. This sense of rejection is often reinforced by constant negative self-talk, and borderlines need to change that. Medications, therapy, and education are crucial in this process.

It’s true that many of us are convince that that we are unlovable, but I’m not sure that we have convinced ourselves. I think that we have been convinced. Perhaps it is because we are sensitized to rejection and have picked up on too many cues from our environment and the people in it, but it’s important to remember that many of us have an intense history of abuse and have had it literally and figuratively beat into us that we are unlovable at some point. However once we escape these circumstances, if we are lucky enough to escape these circumstances, yes we do reinforce this with constant negative self-talk.

One way in which the internal self-talk can be changed is through the use of affirmations. Every day, we think between 60,000 to 90,000 thoughts. Of these, roughly 95% are the same thoughts we pretty much think every day. Affirmations can change the direction a borderline's self-talk takes by adding concentrated doses of positive messages.

Affirmations are brief, positive statements with which we surround ourselves or otherwise bring to the fore of our minds.

There are many ways of using affirmations. You can write them down or print them out, then post them in places where you are bound to see them frequently: right on your bathroom mirror, around your PC monitor, on your car's rear view mirror. Get creative. If you have a long commute to work, why not record some affirmations to tape or CD? With sound mixing software like Audacity, you can even add soothing music to your affirmations. There are many websites that offer "podsafe" music, which can be downloaded for free under very generous licensing arrangements. At their simplest, affirmations can be repeated like mantras. In my own experience, I have found that a single affirmation can be repeated about 1,000 times in a space of 20 to 30 minutes. During that time, other thoughts tend to be pushed out of the mind. That's 20 or more minutes when the mind is filled with healing thoughts.

Affirmations are no substitute for medication and therapy, but under proper supervision, they can be a powerful ancillary.

What follows is a series of affirmations I have written for myself. Feel free to use them as you like:

I can tell the difference between my identity and my disease.

Healing is possible.

Today I choose to focus on healing.

My desire to heal is stronger than my pain.

I am my most powerful ally.

I choose to cultivate a healthy relationship with myself.

I choose to have healthy relationships with others.

I choose to stop and think before I act.

It is healthy to consider the consequences of my actions.

Life is worth living.

I choose to accept myself.

It is okay for others to accept and love me.

I draw my strength from my higher power.

I draw strength from solitude.

I am pleased to be in my own company.

I choose to be kind to myself and others.

I choose to refrain from hurting myself.

I choose to refrain from hurting others.

My sense of worth comes from within.

I only need validation from myself.

I choose to stop and think before I act out of anger.

I choose to investigate the feelings my anger is concealing.

I choose to pay close attention to how my actions affect others.

I choose to make amends.

It is okay to ask others how my actions have affected them.

I walk fearlessly through life.

I am safe.

I accept the generosity of the universe.

I deserve to be treated with kindness.

I am trustworthy.

I choose to love myself.

I choose to love others and I accept both, their virtues and their flaws.

I look forward to getting to know myself.

I love all of myself.


Now darling Readers. My homework for you should be obvious. I want you to write a handful of affirmations specific to you and your own situations. Or as many as you can think of. Don’t limit yourself. Feel free to borrow from above but come up with at least two that are specific to you, that highlight a quality that makes you feel good about you. And. And! Remind yourself of these things every day.

In fact. Right them down. Put them next to your bed at night. Read them before you go to bed at night. Make them the first think you do in the morning. Read them before you do anything in the morning. End your day with a positive thought about yourself. Begin your day with a positive thought about yourself.

No matter what happens during the day, the things you have written down won’t have changed. You’ll still be the same person capable of surviving the situation and being able to take care of yourself. Being able to pull your mind out of the abyss, however slowly, until it can finally see the light dawning and shining down on the healing life you want to be living, is one more way you can begin to turn your life around.

It’s not always easy. You may not always remember. But you can always try. I will not lie to you though. No amount of positive self-talk is going to help a soul-crushing heart break. Sometimes you have to bear down, grip your cat tight, and cry your guts out until your throat is so raw you don’t think you’ll ever be able to speak again…. But reminding yourself that you’re strong, you’re a survivor, that you’ve gotten through before and you can again… is an inner power that you should not allow yourself to forget. Even if you don’t feel strong in the moment, surviving is strength. If there’s one thing we are, it’s survivors. 
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