Discussing the Controversy of Borderline Personality Disorder Traits in Adolescents

Over the past two weeks I have enjoyed writing about and sharing with you the diagnostic issues and parental fears surrounding Borderline Personality Disorder (BPD) and the possibility of adolescents being diagnosed with the disorder. Last week we discussed treatment options for adolescents exhibiting borderline personality traits (a diagnostic term and label that many of you were unfamiliar with and challenged). The week before that we discussed adolescents who exhibit strong symptoms or traits of the disorder. This week we will be discussing some of the issues that were brought to my attention on Facebook,Twitter, and Pinterest regarding the term “Borderline Personality Traits.” I will also mention some of the recent research and theories surrounding adolescent BPD and “challenge” you to give me your best counter-argument. Lets give it a shot!

As discussed over the past two weeks, borderline personality disorder has previously been well known as an “adult only” disorder due to the riskiness of the person with severe symptoms, emotional turmoil, intense fear(s) of abandonment, self-injurious behaviors and suicidal ideations, and relational chaos that characterizes the disorder. However, recent researchers such as Dr. Blaise Aguirre, MD and previous researchers such as Psychiatrist James Masterson, MD were extremely interested in adolescents who tended to exhibit the symptoms of BPD and encouraged other mental health professionals to open their minds to a possible diagnosis in adolescence. Dr. Masterson met with multiple cases of teens who exhibited strong patterns of BPD (i.e., Chronic Self-injurious behavior such as cutting or burning, multiple psychiatric hospitalizations or placements, extreme need for affirmation, physical or verbal aggressiveness, poor thinking and cognitive processing, emotional instability or switchable moods, roller-coaster moods or behaviors that keep others confused, difficulty maintaining stable relationships, stormy relationships (fast attachments, strong desire for emotional connection), extreme reactions to minor events, risky behavior (substance abuse, sexual indiscretion, gambling, driving fast or risk taking), rage or excessive anger, sensitivity (easily offended), over-reactivity, etc.) and found no real logical reasoning from his colleagues for why they did not diagnose BPD other than the fact that:

“putting the diagnosis off until age 18 allowed for the hopeful resolution of this adolescent turmoil until the parents could be absolved of any guilt or diagnosis” (p. 27).

But Dr. Aguirre poses a great question:

“What do these young people look like the day before they turn 18 and the day before that?

What does the number 18 have to do with anything? What happens that makes this number magical for people who are fearful of the diagnosis being applied to a teenager younger than age 18? Dr. Aguirre states that he is very used to seeing teens as young as 13 exhibit borderline personality traits. From my experience as a therapist, I tend to see many youngsters ages 12-17 diagnosed with major depressive disorder (MDD), Anxiety disorder, NOS (none-otherwise specified), or even bipolar disorder or Mood Disorder NOS because many mental health professionals would rather diagnose a child incorrectly and treat the child incorrectly than to diagnose a long-lasting label such as BPD. But it is important that we consider the pros and cons of delaying this diagnosis for the simple fact of “sustaining hope.”

Research currently suggests that the earlier a diagnosis can be made, the better the outcome or prognosis. While there are high rates of co-morbidity or co-occurrence with BPD, meaning that other disorders are often diagnosed with BPD, early treatment can reduce the overall intensity of all present symptoms. For example, lets imagine that the mental health field has decided to start diagnosing teens with BPD. A teenager diagnosed with major depressive disorder and BPD can have a better prognosis if the BPD symptoms are properly treated because the depression could be strongly driven by the BPD symptoms. It would not make too much sense to treat the depression (which would be like trying to apply a tiny bandaid to a burn) if the BPD is what makes the depression worse. A youngster in this scenario would suffer for years with symptoms and struggle with correctly identifying why the depression will not subside. Many kids today go through this very scenario and spend thousands of dollars seeing specialists, receiving treatments, and purchasing medications that DO NOT work or provide only temporary relief. By the time a young person is 18-years-old, the diagnosis of BPD is finally given and the teen can begin to work on the emotional emptiness, confusion, and relational turmoil that dominated their adolescent years. But for many young adults who finally receive the diagnosis, there is a grieving process that might include denial or rejection of the diagnosis because the young adult has already received multiple treatments that did not work and might believe nothing will ever work. Many young adults lose hope after years of searching for the “correct diagnosis” during adolescence. If only the teen were diagnosed sooner with the disorder might they have received the treatment that would give the hope for their future.

Now… I would like to hear from you in response to some of the current theories of the BPD traits in adolescence. Below I will list a few theories, comments, or questions for you to think about, discuss, and share your concerns about.

• Question: Why does diagnosing an 18 year old with BPD seem better to you than diagnosing a younger adolescent? What is it about this particular age that makes a BPD diagnosis more “fair?”
• Discussion: As a therapist who works with many adolescents struggling with relational chaos, emotional emptiness, suicidal attempts, self-injurious behaviors, and confusion, I see so many teens who could benefit from receiving the diagnosis of BPD early in their treatment. It feels almost unethical to treat a child for something you clearly know isn’t the true diagnosis just because society is more comfortable with waiting for the BPD diagnosis until age 18. For many psychiatrists across the nation, “borderline personality traits” is a label that is often applied to the diagnostic profile of the teen so that the diagnosis might be considered in the future. This, however, still does not prevent the “stigma” many are afraid of because the label is still listed on the diagnostic profile as “traits of borderline personality disorder.” So from my view, it seems that the teen is already labeled. Having “traits” of BPD doesn’t always mean the teen has the disorder, but it does suggest that there is a strong possibility. For those of you who are unfamiliar with the term “traits of borderline personality disorder,” psychiatrists and many mental health hospitals are beginning to use this label to alert other professionals to the possibility of a teen having this disorder.

What are your thoughts regarding this label? Have you seen this label or heard of it yet? Do you believe it promotes stigma or promotes early treatment?

• Comment: It is very important that we consider that early treatment is the most important reason for a teen being diagnosed with BPD early. It is not so much about stigma as it is about early treatment. You must keep in mind that the teen is more likely to be “stigmatized” (in school, in the home, and in the community) if symptoms become so profound, due to lack of treatment, that normal functioning is unlikely.

As always, feel free to share your thoughts. Lets keep learning together!

References

Aguirre, B. (2012). Borderline Personality Disorder. Psychiatric Times. Retrieved October 2, 2014, from http://www.psychiatrictimes.com/articles/borderline-personality-disorder-adolescents.

Aguirre, B. (2014). Borderline personality disorder in adolescents: what to do when your teen has BPD. Beverly, MA: Fair Winds Press.