BPD in Adolescentsor“Adolescence with a Vengeance” Blaise Aguirre, MD Medical Director 3East Residential Clinical Instructor in Psychiatry Harvard Medical School
Quick Points The idea that we have to wait until 18 to diagnose a personality disorder makes very little sense to me. In my clinical experience almost every patient with BPD has recognized the evolution of symptoms starting in adolescence. Does not make sense that personality is not present in children. Parents often recognize that their children can have very different personalities from each other. Psychiatry has been comfortable diagnosing most other DSM conditions in younger people.
BPD-A Case "Tammy” is a 17yo junior in HS SWF who lives at home with parents. Multiple (at least 12) previous psychiatric hospitalizations for depression, suicidal ideation and self-injury. Despite high IQ, has had poor grades since middle school. She feels that others do not and cannot possibly like her. Has few friends. Has traded sex for drugs and alcohol on multiple occasions. Also feels that sex with boys “is the only way” to get them to like her. Many of the brief sexual relationships have been abusive, including rape. Feels she “deserves” abusive relationships. Acknowledges that drug, alcohol, sex and self-injury frequently are used to regulate how she feels in the moment. Most intolerable is her sense of self-loathing. She cannot stand herself and "feels like crawling out of my skin " when not high. Feels intense shame and guilt about what she does and some relief from the intensity by doing what she knows best. She is remarkably attuned to non-verbal communication especially with female peers. Says she knows that someone doesn't like her because of the way they look at her.
Historically many clinicians saw BPD symptoms in adolescence as either an extreme variant of normal functioning, or solely as a reflection of poor parenting. “Blame condition.” Sadly we still see parents and kids being blamed. Today we can apply DSM-IV BPD Criteria to Adolescents:
Efforts to Avoid Abandonment Hospitalized for suicide attempt after a break-up with a romantic partner, or burn-out of a room mate or friend. Recently we have seen severe overdoses, jumping in front of a truck and gun-shot wounds. New techniques for breakup is by text-messaging, or posting on Facebook. A profound sense that someone essential to their well-being will never come back. Suicidal and other maladaptive behaviors are sometimes reinforced by loved ones and caregivers.
Unstable Relationships Parents and friends alternate between being best parent/friend in the world and then vilified. A reflection of all-or-nothing or black-and-white thinking. Validation of the adolescent’s experience of their parents can get the therapist into trouble when the kid changes their opinion! On hospital units, divide staff into good and bad staff. Good/Bad designations can easily change. These designations appear to be mood dependent.
Unstable Sense of Self This criterion is harder to define in adolescents with BPD . Adolescence a time of defining identity. We see tremendous and enduring self-loathing as a core symptom in many of the kids we work with. Some are chameleon-like (porous) -- adapt readily to whatever group of friends or trend or emotion or even psychiatric symptom is current. Recognize that others have a better sense of who they are than they do.
Dangerous Impulsivity In younger adolescents with less access to cars and money reckless driving and spending and are unusual. Indiscriminate sex (I don’t like the word “promiscuity”), drug abuse, eating problems, and running away from home are more common-often used to regulate emotions. Older adolescents take risks with driving and spending, similar to adults. Some adolescents “hook up” with much older adolescents/adults. At times dangerous behaviors are mediated through the Internet.
Recurrent Suicidal Behavior Self-injury in the form of cutting is the most common presenting symptom on our unit. We also see burning, head banging, punching walls, attempts to break bones and “insertions”. Most patients have made at least one suicide attempt (generally OD but more recently, gun shots, hanging, jumping in front of automobile). Behaviors can be reinforced by the well-intentioned attention of caregivers.
Affective Instability/Extreme Mood Reactivity Feel things “quicker” and with less apparent provocation than others. Feel things more intensely than others. Slower return to baseline than others. Mood reactivity is on a continuum. How much does it affect the person’s life?
Chronic Feelings of Emptiness In adolescents this is often expressed as boredom. Temporarily relieved by risky or “intense behaviors” (intense relationships, sex, drugs). Sometimes expressed as feeling “lonely” or alone.
Anger Regulation Problems Fights occur most with those closest to the BPD adolescent “Fights” can take the form of destruction of property, bodily violence, or hurtful verbal attacks. The DSM specifies anger but it is not only anger but other intense emotional states that are difficult to regulate Using anger only as a criterion can lead to not having enough criteria!
Paranoia and Dissociation Some BPD adolescents have been abused. Some suffer co-occurring PTSD. Dissociation, depersonalization and derealization are common in the group with trauma. Paranoia can manifest as the assumption of evil or bad intention by another.
Non-DSM Criteria in BPD Adolescents See themselves as loathsome, evil or contaminated and that they will end up contaminating others. Profound sense of hopelessness and self-hatred without other vegetative symptoms (not just depression). Marked lack of a sense of continuity of time. Great difficulty in consistently performing at school despite cognitive ability. In relationships there is a tendency to connect emotionally rather than simply by gender or physically. More same sex romantic relationships. Complain that they are universally misunderstood or that they don’t feel they deserve to be understood. Remarkably attuned to non-verbal communication. Remarkably susceptible to others emotions.
Final Thoughts Adolescent BPD looks a lot like adult BPD certainly in the young women we see. Their symptoms tend to be based on skill deficits rather than intentional “acting out”. Rethink manipulation!!!! Early treatment includes habilitation vs. rehabilitation and psychoeducation. We must persist in ongoing efforts to increase public awareness of BPD.