Emerging borderline personality disorder in adolescents

Introduction 

There is now a growing recognition that a lot of major mental health illnesses experienced by adults have their onset in mid-adolescence. Similarly, many mental health ailments such as psychosis, depression are accompanied by co-morbid disturbance of the personality makeup - therapy or treatment which may target the main diagnosis and not the underlying personality constructs often leads to limited or poor outcomes.

Borderline Personality Disorder (BPD) - Genesis

The research indicates there is no single cause for someone to end up with borderline personality traits. There is evidence to suggest some genetic predisposition although it may well be that successive generations were exposed to similar environmental/social difficulties. The stress experienced often leads to neurochemical changes which are known to be associated with BPD, one amongst many is the link between reduced serotonin and impulsive behaviours. These theories sit well with the notion that the seeds are usually sown early through any life events which may affect one's experience of attachment and bonding to significant others around you. Childhood trauma, disturbed early relationships, abuse from parent/carer will make a child feel insecure. The child has to deal with making sense of the discordance i.e. the caregiver is the nurturer (good) but also the perpetrator and in its defense, it learns to split the good and bad object which in later years afflicts many relationships. This insecure base leads to frantic reactions triggered by the slightest threat of real or perceived abandonment. Over time this pattern of maladaptive responses becomes entrenched leading to the emergence of BPD as described below.

Features of BPD

  1. Frantic efforts to avoid real or imagined abandonment.
  2. A pattern of unstable and intense interpersonal relationships characterised by an alternation between extremes of idealisation and devaluation.
  3. Identity disturbance - markedly and persistently unstable self-image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging, e.g. spending, sex, substance abuse, reckless driving or binge-eating
  5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
  6. Affective instability due to a marked reactivity of mood, e.g. intense episodic dysphoria, irritability or anxiety, which usually lasts for between a few hours and several days.
  7. Chronic feelings of emptiness
  8. Inappropriate, intense anger, or difficulty controlling anger, e.g. frequent displays of temper, constant anger or recurrent physical fights.
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

BPD and mental illnesses

The above behaviour pattern and responses to the stress put such a person at considerable risk of experiencing traumatic life events. This tends to be secondary to impulsive self-harm, reckless behaviours involving the use of drugs and indiscriminate sex. The underlying emotional frailty predisposes such a person for ending up with Post Traumatic Stress Disorder, Depression and at times Psychotic episodes. 

Treatment of emerging borderline personality disorder in adolescents

A range of psychological approaches is possible. Evidence suggests consideration be given to one of the following - 
  1. Dialectical Behaviour Therapy (DBT) - An integrative approach which pragmatically mixes cognitive behaviour therapy with mindfulness and learning skills (see an example of one such technique called thought diffusion) for distress tolerance and reducing self-harm. 
  2. Cognitive behaviour therapy - Where the focus is on the triangular relationship between thought-feeling-behaviour. Tweak one and the other two have to change.    
  3. Schema Focussed Therapy - Also integrates CBT with approaches such as Gestalt therapy 
  4. Mentalisation Behaviour Therapy - Focus is on enhancing the ability to infer personal and the other person's mental state - i.e. thoughts, feelings, etc
  5. Medication - SSRI drugs like Fluoxetine may be used to treat impulsivity or depression. Some adolescents affected by BPD display rapid mood fluctuations and may benefit from mood stabilisers. Others require the psychotic episodes to be treated with antipsychotic medication. 
  6. Inpatient treatment may be needed in those severely affected and posing a risk to their own or others life.