"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
Self-injury in the form of cutting is the most common presenting symptom on our unit.
We also see burning with matches or lighters, head banging, punching walls, and attempts to break bones. Most of our patients have made at least one suicide attempt -- generally by overdose. But more recently we are seeing patients with self-inflicted gun shots, who have tried to hang themselves, or have jumped in front of moving automobiles.
As I mentioned earlier, suicidal and self-injurious behaviors can be reinforced by the well-intentioned attention of caregivers when the adolescents feel cared for by loved ones ONLY when they make such attempts.
6. Affective or Mood Instability
Notable about these mood states is that:
- Moods tend to be in reaction to some conflict (e.g. a fight or a disappointment)
- The adolescents on our unit recognize that they feel things "quicker" and with less apparent provocation than others their age
- They say they feel things more intensely than others their age
- They say that they are slower return to baseline than others
- Mood reactivity is on a continuum, low to high, based on how much it affects the person's life
7. Chronic feelings of emptiness
These are intolerable states where the BPD adolescent feels that there is nothing of substance in their life. This is often expressed as boredom. The emptiness can be temporarily relieved by risky or intense behaviors (intense relationships, sex, drugs), as the extreme behavior leads to intense feelings that help the adolescent feel connected.
At other times adolescents express the emptiness as loneliness.
8. Anger regulation problems
Fights occur most with those closest to the BPD adolescent and can take the form of destruction of property, bodily violence, or hurtful verbal attacks. While the DSM specifies anger, other intense emotional states are also difficult to regulate-even positive ones! These can feel intolerable because high intensity emotions are anxiety provoking and lead to irritability.
9. Psychotic symptoms or loss of touch with reality
Some BPD adolescents have been abused (verbally, physically, and emotionally). This results in symptoms of post-traumatic stress disorder (PTSD). These symptoms can include dissociation and depersonalization which means that person disconnects their emotional experience from the reality they are experiencing. They can also experience paranoia and assume others have evil intentions.
Symptoms NOT in the DSM-IV-TR
We frequent see these similarities in adolescents on the unit:
- They sometimes see themselves as loathsome and evil or contaminated. This contamination, they believe, can transfer to others.
- They appear to have a profound sense of hopelessness and self-hatred without other symptoms that would indicate that they are depressed.
- During intense moods, they appear to have a marked lack of a sense of continuity of time. One minute can feel like an hour and vice versa. If they feel miserable, even a moment of misery can feel like an eternity.
- Some have great difficulty in consistently performing at school despite their intelligence.
- Intense same sex emotional relationships may lead to physical intimacy even the person doesn't identify themselves as gay.
- They complain that they are universally misunderstood or that they don't feel they deserve to be understood.
- They seemed to be remarkably attuned to non-verbal communication and, as such, seem to be expert mind-readers.
- They appear to be remarkably susceptible to others emotions and as such feel porous.
Some key points to remember are that:
- Adolescent BPD looks a lot like adult BPD. Their symptoms are a reflection of a skills-deficit, or incapacity to regulate their emotions rather than simple stubbornness or willfulness or so-called "acting out." If they were capable of doing things otherwise, most would.
- Because of the skills deficit, we need to intervene as early as possible. This is true of most skills. If a child cannot talk or walk, we put them in early intervention in order to target the skills deficit. The same must be the case for emotion regulation deficits. Early treatment includes learning a new skill with the use of treatments like Dialectical Behavior Therapy to teach adolescents and parents about BPD.
Borderline personality has its roots in the genes that a child carries, the temperament and personality traits the child exhibits and the environment that the child grows up in. Recognizing the symptoms is critical in getting a jump start on treatment.
The time is now for clinicians to make the correct diagnosis and for parents to demand scientifically based treatments for the disorder. As clinicians we can help reduce the stigma that we helped create by making this an "untreatable" condition.
And, as parents, we must insist on knowing how the proposed treatment approach will help reduce the often misery-inducing symptoms associated with this now better-understood condition.