This article primarily focuses on adolescents with borderline personality disorder (BPD).
- Adult prevalence of BPD is estimated to be between 0.7% and 2.7%.
- Ten years after the initial diagnosis, 85% of adults with BPD will "remit," i.e. no longer meet the DSM-5 BPD criteria. (5)
- In adolescents, 0.9 - 1.4% meet diagnostic criteria for BPD by age 16 years; cumulative prevalence by age 22 is around 3.2% (5)
BPD is a severe mental disorder that is characterized by a pervasive pattern of
- instability in affect regulation,
- impulse control,
- interpersonal relationships, and
Individuals with BPD have severe difficulties with emotional regulation with significant affective instability. They show pronounced sensitivity to environmental stress, are highly emotionally reactive; their reactions tend to be extreme, and the time taken to return to their baseline affective state is often considerably longer than for individuals without the condition. The DSM-5 requires 5 out of 9 criteria in order to make the diagnosis
Such traits are strongly predictive of adult personality disorders and are associated with increased long-term impairment, morbidity, and mortality. (1)
Diagnosis in Adolescents
BPD in adolescents was not commonly diagnosed in the past due to the belief that the personality is not fully formed until late adolescence or early adulthood. However the level was disability and dysfunction seen in many adolescents who meet criteria for BPD lead many clinicians and, increasingly, researchers to recognize it as a legitimate diagnosis in teenagers. (2) There is substantial evidence that the diagnosis of BPD in adolescents in reliable and valid; furthermore, effective early intervention supports the need for prompt diagnosis. (5)
"Early Intervention" for BPD is gaining increasing recognition. Specifics of each program vary, but they all involve
- assertive case management,
- active engagement of families,
- integration of inaptient and crisis-care,
- social recovery for patients, and
- supervision and support for staff.
Some examples of these programs include Helping Young People Early (HYPE), emotion regulation training program (ERT), and Adolescent Risk-taking and Self-harm behaviors (AtR!Sk). (5)
Dialectical Behavioral Therapy (DBT), a comprehensive, multimodal outpatient treatment, is widely used for treatment of adults with BPD, but had not been studied extensively in adolescents.
- In the first randomized controlled trial of DBT for adolescents with BPD, the treatment included parents in weekly skills training groups, and added new skills module to address common skill deficits in teens with emotion dysregulation and their families. (3)
- Compared to "treatment as usual," 5-mo long DBT program reduced frequency of self-harm, severity of suicidal ideation, and depressive symptoms, with large effect sizes for outcomes.
Treatment of adolescents with suicidal behaviors and BPD was studied using the mentalization-based therapy (MBT), a psychodynamic-based approach.
- MBT is a year-long, manual-based treatment with individual and family sessions. The focus is on increasing the adolescent’s and family’s capacity to understand action in terms of thoughts and feelings, which in turn is hypothesized to augment self-control and regulation of affect. The impact of MBT on self-harm was mediated by a decrease in avoidant attachment and an increase in self-reported ability to mentalize. (1,4)
1. Apter, Alan. Adolescent Self-Harm: New Horizons? J Am Acad Child Adol Psychiatry, 2014; 53:10, 1048 - 1049
2. Westen, D., DeFife, J.A., Malone, J.C., and DiLallo, J. An empirically derived classification of adolescent personality disorders. J Am Acad Child Adolesc Psychiatry. 2014; 53: 528–549
3. Mehlum, L., Tørmoen, A., Ramberg, M. et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014; 53: 1082–1091
4. Rossouw, T.I. and Fonagy, P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012; 51: 1304–1313 e3
5. Kaess, M., Brunner, R. Borderline Personality Disorder in Adolescence. Pediatrics 2014;134:782–793