Treatment of Borderline Personality Disorder in Adolescents

[David Baxter PhD]

What Therapy Is Recommended for Borderline Personality Disorder in Adolescents?
August 9, 2005
by Mary E. Muscari, PhD,RN,CRNP,APRN,BC, CFNS
Professor, Director of Forensic Health, University of Scranton, Scranton, Pennsylvania; Pediatric Nurse Practitioner, Psychological Clinical Specialist, Forensic Clinical Specialist, Lake Ariel, Pennsylvania

Question
In adolescents (13-17 years of age), what is the recommended treatment for borderline personality disorder?

Borderline personality disorder (BPD) is a complex psychiatric disorder characterized by unstable personal relationships, intense anger, feelings of emptiness, and fears of abandonment. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) allows BPD to be diagnosed in adolescents when maladaptive traits have been present for at least 1 year, are persistent and all-encompassing, and are not likely to be limited to a developmental stage or an episode of an Axis I disorder.^[1,2] However, the personality of adolescents is still developing; therefore, the diagnosis of BPD should be made with great care in this population.^[3]

Borderline pathology in children refers to a syndrome characterized by a combination of disruptive behavioral problems, mood and anxiety symptoms, and cognitive symptoms. Follow-up studies of these children show that they have a tendency to develop a wide range of personality disorders, not just BPD. Although borderline pathology in childhood is not necessarily a precursor to BPD in adulthood, evidence suggests that both have strikingly similar risk factors, which may indicate a common etiology. These risk factors include family environments characterized by trauma, neglect, and/or separation; exposure to sexual and physical abuse; and serious parental psychopathology, such as antisocial personality disorder and substance abuse.^[4]

Characteristics of BPD
Adolescents with BPD have disturbed thinking patterns and always seem to be in crisis. They can be rational and calm one moment, and then explode into inappropriate anger in response to some perceived rejection or criticism the next. The disorder occurs in all races, is prevalent in females (female-to-male ratios as high as 4:1), and typically presents by late adolescence.^[4] Signs and symptoms of BPD may include significant fear of real or imagined abandonment; intense and unstable relationships that vacillate between extreme idealization and devaluation; markedly and persistently unstable self-image; significant and potentially self-damaging impulsivity (spending, sex, binge eating, gambling, substance abuse, and reckless driving); repeated suicidal behavior, gestures, or threats; self-mutilation (carving, burning, cutting, branding, picking and pulling at skin and hair, biting, and excessive tattooing and body piercing); affective instability and significant reactivity of mood (intense dysphoria, irritability, or anxiety that lasts for a few hours or days); persistent feelings of emptiness; inappropriate anger or trouble controlling anger; and temporary, stress-related severe dissociative symptoms or paranoid ideation.^[1]

Comorbidities are common with BPD. These disorders, which include mood disorders, substance-related disorders, eating disorders (notably, bulimia), posttraumatic stress disorder, other anxiety disorders, dissociative identity disorder, and attention-deficit/hyperactivity disorder, can complicate both diagnosis and treatment. Depression is particularly common in patients with BPD.^[3] Other personality disorders have also been documented as comorbid with BPD. A study of 138 adolescents and 117 adults with BPD showed a significant occurrence of schizotypal and passive-aggressive personality disorders in the adolescent group and antisocial personality disorder in the adult group. The researchers suggested that BPD may represent a more diffuse range of psychopathology in adolescents than adults, because adults had comorbidity only with another Cluster B disorder, whereas adolescent comorbidity encompassed aspects of Clusters A and C.[5] (A brief explanation of the clustering system in personality disorders is available at the National Mental Health Association Web site.

Treatment Issues
Due to the complex nature of this disorder, psychiatric nurse practitioners (NPPs) should consider the following when developing a treatment plan^[6]:

• Chronic depression: Depression results from ongoing feelings of abandonment. Although the depression of BPD is intense and pervasive, the NPP must rule out major depression or consider it as a comorbid disorder.
• Inability to be alone: Chronic fear of abandonment also leads to these adolescents having little tolerance for being alone. This results in a constant search for companionship, no matter how unsatisfying.
• Clinging and distancing: Relationships tend to be disruptive due to the adolescents' alternating clinging and distancing behaviors. When clinging, they may exhibit dependent, helpless, childlike behaviors. They overidealize the person they want to spend all their time with, constantly seeking that person out for reassurance. When they cannot be with their chosen person, they exhibit acting-out behaviors, such as temper tantrums and self-mutilation. Distancing is characterized by anger, hostility, and devaluation, usually arising from discomfort with closeness.
• Splitting: Splitting arises from the adolescents' inability to achieve object constancy and is the primary defense mechanism in BPD. They view all people, including themselves, as either all good or all bad. If the NPP is supportive, the NPP will be idealized. If the nurse-patient relationship is threatened (eg, the NPP goes on vacation), the caregiver's image changes from beneficent caregiver to cruel persecutor.
• Manipulation: Separation fears are so intense that these adolescents become masters of manipulation. They will do just about anything to achieve relief from their separation anxiety, but their most common ploy is to play one individual against another, including pitting their primary care nurse practitioner (NP) against their NPP.
• Self-destructive behaviors: Self-mutilation is characteristic of BPD. The behaviors are typically manipulative gestures, but some acts can prove fatal. Suicide attempts are not uncommon and usually take place in relatively safe places, such as swallowing pills at home while reporting the deed to another person on the telephone. Other self-destructive behaviors include cutting and burning (eraser burns, a burnlike lesion resulting from rubbing the skin with a pencil eraser, are common in adolescents).
• Impulsivity: Poor impulse control can lead to substance abuse, binge eating, reckless driving, sexual promiscuity, excessive spending, or gambling. These behaviors can occur in response to real or perceived abandonment.

Treatment
Treatment studies on adolescents with BPD are virtually nonexistent. Although treatments effective in adults would be expected to be efficacious, research that demonstrates this efficacy is needed.^[3] Overall, treatment planning should address BPD, as well as any existing comorbid disorders, and must be flexible to respond to the changing characteristics of the adolescent over time. The NPP, adolescent, and family need to realize that treatment will take an extended amount of time.

Psychotherapy is the primary treatment of BPD. Extensive therapy is required to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning. Long-term dialectical behavior therapy (DBT) appears to be the most effective. DBT is a type of cognitive behavioral therapy that focuses on coping skills, so patients learn to better control their emotions and behaviors. This may be complemented with symptomatic psychopharmacology to address affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior. Psychoanalytic/psychodynamic therapies have also proven effective.^[7]

NPPs can use guidelines on the treatment of BPD from the American Academy of Psychiatry, although they need to realize that these recommendations are not adolescent-specific^[7]:

• Consider the treatment setting to ensure that outpatient treatment is warranted over hospitalization:
  • Partial hospitalization -- dangerous impulsive behavior, deteriorating clinical picture, complex comorbidities, symptoms unresponsive to outpatient therapy;
  • Brief inpatient hospitalization -- serious suicidal ideation or attempt, imminent danger to others, symptoms unresponsive to partial hospitalization; and
  • Extended inpatient hospitalization -- persistent suicidal ideation, nonadherence to other therapies, life-threatening comorbid Axis I disorder, continued risk of assaultive behavior, severe symptoms that interfere with living.
• Establish a strong therapeutic alliance that includes empathic validation of the patient's suffering and experience.
• Coordinate and collaborate with the treatment team. Be aware of and manage splitting problems, and assist the adolescent in integrating both positive and negative aspects of self and others.
• Provide education to the adolescent and the family on BPD.
• Manage intense feelings produced by both the patient and the NPP. The use of supervision and consultation is strongly recommended.
• Help patient take responsibility for his/her own actions, and promote reflective rather than impulsive behaviors.
• Consider pharmacologic treatment for selected symptoms, but realize that data are lacking on their use with adolescents, and be aware of the US Food and Drug Administration's (FDA's) warning on suicidality in children and adolescents treated with antidepressants^[8]:
  • Affective symptoms: Initially treat with a selective serotonin reuptake inhibitor (SSRI), the treatment of choice for disinhibited anger occurring with affective symptoms. Mood stabilizers (lithium, valproate, and carbamazepine) are a second-line or augmentation treatment.
  • Impulsive behaviors: SSRIs are the treatment of choice. Valproate, carbamazepine, and atypical neuroleptics are also used, despite limited data. For additional information on atypicals and BPD, see "Atypicals in Borderline Personality Disorders.^[9]" Treatment failure may warrant the use of clozapine.
  • Cognitive-perceptual symptoms: Low-dose neuroleptics are the treatment of choice, but clozapine may be useful for patients with severe, refractory psychotic-like symptoms.
• Treat substance abuse. Drug counseling may be warranted.
• Address violent and antisocial behaviors. Monitor carefully for impulsive and violent behavior because these are hard to predict. Address abandonment and rejection issues. Arrange for appropriate coverage when away; carefully communicate this to the adolescent; and document it. Take action to protect self and others if the patient makes threats.
• Address trauma and posttraumatic issues and dissociative (depersonalization, derealization, and loss of reality testing) features.
• Explore and address psychosocial stressors. Most adolescents with BPD are very sensitive to psychosocial stressors, particularly interpersonal ones.
• Consider cultural factors. Avoid cultural bias related to sexual behavior, emotional expression, and impulsivity.

Managing adolescents with BPD can be challenging at best. But with careful planning, collaboration, and supervision, NPPs can assist these adolescents in reaching their optimal potential.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association; 2000.
2. Becker D, Grillo C, Edell W, McGlashan T. Diagnostic efficiency of borderline personality disorder criteria in hospitalized adolescents: comparison with hospitalized adults. Am J Psychiatry. 2002;159:2042-2047.
3. American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. 2004. Available at: Page Not Found Accessed July 6, 2005.
4. Finley-Belgrad E, Davies J. Personality disorders: borderline. eMedicine. May 20, 2005. Available at: Medscape: Medscape Access Accessed July 6, 2005.
5. Becker D, Grillo C, Edell W, McGlashan T. Comorbidity of borderline personality disorder with other personality disorders in hospitalized adults and adolescents. Am J Psychiatry. 2000;157:2011-2016.
6. Townsend M, Psychiatric Mental Health Nursing: Concepts of Care. 4th ed. Philadelphia, Pa: FA Davis; 2003:700-701.
7. American Psychiatric Association. Treating Borderline Personality Disorder: A Quick Reference Guide. 2001. Available at: The Practice Guidelines have moved! Accessed July 6, 2005.
8. US Food and Drug Administration (FDA). FDA Public Health Advisory: Suicidality in children and adolescents being treated with antidepressant medications. October 15, 2004. Available at: http://www.fda.gov/cder/drug/antidepressants/SSRIPHA200410.htm Accessed July 6, 2005.
9. Schulz SC. Atypicals in borderline personality disorders. June 15, 2004. Available at: Medscape: Medscape Access Accessed July 6, 2005.

Suggested Readings

• American Academy of Child & Adolescent Psychiatry. Available at: American Academy of Child & Adolescent Psychiatry Accessed August 1, 2005.
• American Psychiatric Association. Available at: American Psychiatric Association Accessed August 1, 2005.
• Borderline Personality Today. Available at: Borderline Personality Disorder Today Accessed August 1, 2005.
• BPD Central. Available at: Homepage - Stop Walking on Eggshells Accessed August 1, 2005 (Web site coming soon).
• BPD World. Available at: BPDWORLD - Support and Information Accessed August 1, 2005.
• Lambert MT. Suicide risk assessment and management: focus on personality disorders. Curr Opin Psychiatry. 2003;16:71-76. Available at: Medscape: Medscape Access Accessed August 1, 2005.

 

[Daniel E.]

Borderline Personality Disorder in Adolescents | Psychology Today

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.