By: Thea Soleil “Nine” Dona
Borderline Personality Disorder is a complex, multifaceted psychiatric disorder typically characterized by emotional dysregulation, interpersonal complications, and identity disturbances. Whereas most prior research on BPD has focused on adults, there is a growing awareness that the onset of the disorder often occurs during adolescence. Diagnosis of adolescents with BPD poses special problems due to developmental issues, overlapping symptoms with other psychiatric disorders, and stigma. The following research overview discusses the diagnosis criteria for adolescents with BPD, challenges in differentiating BPD from other psychiatric conditions, and how early diagnosis affects the treatment outcome.
Diagnostic Criteria for Adolescents
The DSM-5 criteria for BPD can be applied to adolescents; however, practitioners must consider the developmental context (American Psychiatric Association, 2013). Adolescents often display transient emotional instability, impulsivity, and identity exploration that can complicate the differentiation of BPD symptoms from typical developmental behaviors. Research by Sharp et al. (2017) points out that the symptoms of BPD in adolescents need to be persistent and pervasive, and cause significant functional impairment for diagnosis to be warranted.
Challenges in Diagnosing Adolescents
Developmental Overlap
Adolescence is a time of emotional and behavioral turmoil, making it challenging to distinguish between what is normative and pathological. One study by Chanen and Kaess (2012) points out that clinicians may underdiagnose BPD in adolescents due to fears of labeling and stigma.
Symptoms overlap with Other Disorders
Most adolescents with BPD present with comorbid major depressive disorder, anxiety, and ADHD. Being able to differentiate the comorbid conditions from BPD itself is an important aspect of treatment planning. For instance, Zanarini et al. (2014) have discussed how the impulsivity of the adolescent with ADHD may sometimes look similar to BPD but does not demonstrate the interpersonal instability and identity issues of BPD.
Stigma and Misdiagnosis
Diagnosis is often avoided due to stigma in the labeling of adolescents with BPD. This delay in diagnosis may hinder early intervention and exacerbate symptoms over time (Fonagy & Luyten, 2016).
Importance of Early Diagnosis
Accordingly, the early identification and intervention of BPD among adolescents can be highly beneficial in changing the course of the long-term outcome. Evidence-based therapies, like Dialectical Behavior Therapy for Adolescents (DBT-A), aim at emotional regulation, distress tolerance, and interpersonal effectiveness, bringing about improved symptom management in adolescents (MacPherson et al., 2014).
Broader Implications
Family Dynamics
Research by Crowell et al. (2009) further supports the need to address family environments in the treatment of adolescent BPD. High levels of family conflict and invalidation are risk factors for BPD and can interfere with therapeutic improvement.
Suicide Risk
Overall, adolescents with BPD have higher chances of ideation and attempts to commit suicide than the average adolescent. According to Miller et al. (2018), timely, correct diagnosis, coupled with targeted interventions, will lower the risk of suicide.
Conclusion
Diagnosing adolescents with BPD requires a complex understanding of developmental psychology, symptomatology, and the wider psychosocial context. While there are challenges, early identification and evidence-based interventions bring optimism for better outcomes. Efforts to reduce stigma, increase clinician training, and engage families in diagnosis and treatment processes are essential steps in developing better care for adolescents with BPD.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Chanen, A. M., & Kaess, M. (2012). Developmental pathways to borderline personality disorder. Current Psychiatry Reports, 14(1), 45-53. https://doi.org/10.1007/s11920-011-0242-y
Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135(3), 495-510. https://doi.org/10.1037/a0015616
Fonagy, P., & Luyten, P. (2016). A multilevel perspective on the development of borderline personality disorder. Development and Psychopathology, 28(4pt2), 1333-1363. https://doi.org/10.1017/S0954579416000890
MacPherson, H. A., Cheavens, J. S., & Fristad, M. A. (2014). Dialectical behavior therapy for adolescents: Theory, treatment adaptations, and empirical outcomes. Clinical Child and Family Psychology Review, 16(1), 59-80. https://doi.org/10.1007/s10567-012-0126-7
Miller, A. L., Muehlenkamp, J. J., & Jacobson, C. M. (2018). Linehan’s dialectical behavior therapy for adolescents: Conceptualization and strategies for treating suicidal adolescents. Child and Adolescent Psychiatric Clinics of North America, 17(4), 731-746.
Sharp, C., Steinberg, L., Yaroslavsky, I., Hofmeyr, A., Dellis, A., & Rossouw, T. (2017). An item response theory analysis of the DSM-5 borderline personality disorder criteria in adolescents. Personality Disorders: Theory, Research, and Treatment, 8(2), 107-116.
Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2014). Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and Axis II comparison subjects: A 16-year prospective follow-up study.
American Journal of Psychiatry, 169(5), 476-483.
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