"Tammy" has been hospitalized for depression, thoughts of suicide and self-injury at least a dozen times. The few friends she has get burned out by her mood swings and neediness. She can go from loving her friends to hating them in seconds. She uses drugs and self-injury to stem her self-loathing.
Tammy trades sex for drugs and alcohol, and thinks that sex is the only way to get males to like her. Many of her sexual encounters have been brief and unrewarding; some have been abusive. But she feels she deserves abusive relationships because she is a terrible person and deserves to be punished.
Now, if Tammy were 25 or 30 years old, most clinicians would recognize she has a classic case of borderline personality disorder. But in reality, Tammy is only 16--unable, according to some, to have BPD.
But do a few years really that much of a difference? The stakes are high. If Tammy gets diagnosed and into the right treatment program right away, she has a better chance to have a life worth living. If not, she could bounce around in the mental health system for years at great emotional and financial cost.
A Jump Start on Treatment
As the medical director of McLean's Adolescent Dialectical Behavior Therapy Program, every day I work with teenagers who have been misdiagnosed with bipolar, conduct disorders, and other conditions because they're "too young" to have BPD. As a result of this misdiagnosis, not only are they not getting the right treatment, they're often on medications that may do no good, or in some instances, made things worse.
For instance some have been treated on high doses of atypical antipsychotic medications, like the medication Zyprexa. These were prescribed as mood stabilizers. However, not only did they not work, but the adolescents put on significant amounts of weight.
Recognizing BPD in adolescents means that we can get the wounded person into the right treatment immediately to end or mitigate this devastating illness. For this to happen, we need to get the latest information from the American Psychiatric Association's Diagnostic and Statistical Manual into the hands of clinicians (more about that later). The need is urgent: those with BPD are more likely to pass along the disorder to their own children.
Children Display Temperaments Early
For decades, clinicians have been very reluctant to make the BPD diagnosis in people younger than 18 on the basis that their personality is not yet "fixed." Yet any parent can tell you that even very young children have personalities-especially those who have more than one child.
"Joan" and "John Smith," for example, have two grade school children whose personalities are polar opposites. "Kevin" is the outgoing one. He has lots of friends, tends to be the leader in his group of friends, and loves being outdoors.
"Franny," his sister, loves to read. An introvert, she is happiest at home playing quietly with her parents. She has one best friend and is satisfied with that. Two children and yet two very different temperaments.
Also, psychiatry has been comfortable diagnosing most other psychiatric conditions like bipolar and depression in younger people. So why the reluctance with diagnosing BPD?
The DSM Diagnostic Criteria for Adolescents
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) published by the American Psychiatric Association provides criteria for adolescents with BPD. I've described these below along with some discussion on how borderline adolescents behavior in our DBT unit.
1. Efforts to avoid real or imagined abandonment:
Adolescents sometimes come to us after a suicide attempt triggered by a profound sense that someone essential to their well-being will never come back-for example, a break-up with a close friend or romantic partner. These are dramatic attempts such as severe overdoses, jumping in front of a truck, and shooting themselves with a gun. We are seeing a new trend in break-ups involving technology (text-messaging, Facebook, etc.).
In some, cases the adolescents recognize that by making these suicide attempts, they get reassurance that they are loved. If the BPD adolescent gets tremendous attention ONLY during suicidal and self-destructive acts, these so suicidal behaviors can be reinforced by loved ones and caregivers.
Self-harming behavior and other borderline defense mechanisms often come off as "manipulative" to others. While it can FEEL that way, it doesn't meet the definition of manipulation: "Shrewd or devious management, especially for one's own advantage." Truly manipulative behavior is planned, while BPD behavior is impulsive. When something triggers BPD behavior, it happens right away.
Manipulation is done for some kind of gain: to ultimately increase someone's happiness because something wanted has been obtained. But are people with BPD satisfied? No! They're miserable--even the high functioning ones. Would anyone in their right mind plan to end up in a psychiatric facility or in a desperately unhappy relationship? What people with BPD want most is closeness. And the tragedy is that the disorder pushes people away.
When we feel manipulated, we mistakenly conclude that our BP loved one is acting this way on purpose to drive us insane. It's that kind of thinking--ascribing devious intentions to borderline loved ones--that does the most harm. It can make parents feel like they've done something wrong when they haven't. That can cause needless guilt.
2. Unstable relationships characterized by over idealization and devaluation
Parents and friends can alternate between being best parent/friend in the world and then vilified. This all-or-nothing or black-and-white thinking is called "splitting" and is a fundamental trait of BPD.
When they get hospitalized, these adolescents can divide staff into "good" and "bad" and cause chaos on the unit. Staff has to be careful not to be too comfortable with being assigned as "good" or "bad" because these designations can change quickly and easily.
3. An unstable sense-of self
This criterion is harder to define in adolescents with BPD because adolescence is a time of defining identity. However, BPD adolescents have an enduring sense of self-loathing, which is a core symptom of BPD.
Some patients are like chameleons, adapting to whatever group of friends or trend is current. Flexibility is a helpful trait, but in our BPD kids it is because they have little sense of who they are.
Similarly, there is a sense of what one of one of my young patients recently described as being "porous." She readily (but painfully) takes on the positive or negative emotions of people around her.
4. Dangerous Impulsivity
This includes indiscriminate and dangerous sex, drug abuse, eating disorders, and running away from home. These "pain management" behaviors are often used to regulate emotions. However older adolescents take risks with driving and spending similar to adults. At times, dangerous behaviors are mediated through the Internet, (for example meeting strangers on-line for sex or drugs).
5. Recurrent Suicidal Behavior
