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April 17, 2020
Roller coaster mood swings, raging arguments, risky sexual encounters, and the use of drugs and alcohol. These are hallmarks of a challenging adolescence. But what differentiates “typical teenage behavior” from something more serious?
Blaise Aguirre, MD, a child and adolescent psychiatrist and the founding medical director of McLean’s adolescent dialectical behavior therapy (DBT) program, said that borderline personality disorder (BPD) is marked by persistent, extensive difficulties in regulating emotions, thoughts, relationships, behaviors, and a sense of self. “While many teens display these types of behaviors,” Aguirre said, “they tend to have a different function in people with BPD. They use them as a way to deal with the struggles caused by intense emotions.”
Lyndsey Moran, PhD, a child psychologist and DBT expert at McLean’s adolescent program, said distinguishing between normative teenage behavior and pathological behavior involves observing its frequency, intensity, and severity.
“Sometimes such behavior has the same function it would for any teen, such as pursuing something rewarding without thinking through the potential consequences.” Other times teens engage in high-risk behavior to generate relief from intense emotion. “Self-injury can reduce the experience of intense emotion. Substance use may alter or numb unwanted experiences. Risky sex may temporarily reduce loneliness. Other times, high-risk behavior is an impulsive response to a high-intensity emotion. And other times, it may serve to cause an experience for people who feel emotionally empty.”
The experience of living with borderline personality disorder can be volatile. “Responses by someone with BPD during times of emotional distress can be erratic and unpredictable. So when there’s conflict in a relationship, the person with BPD can see the other person in very black-and-white ways. Or they may experience all-or-nothing thinking,” Aguirre said.
People with BPD can fear abandonment, even if abandonment isn’t threatened. They can have thoughts of ill-intent from other people, even if such thoughts aren’t on other people’s minds.
Those experiencing BPD can have emotions and behaviors that are overly reactive to situations. If something bad or unwanted happens, the negativity can impact the rest of the day. Then, if something good or desired happens, it can lead to an intense uplift in mood. The rapid and unpredictable swings between the ups and the downs can be tough to bear. Some express that it can feel like you’re being hijacked by your emotions. The variability in mood typically happens within the course of day or two, or even within hours or minutes, rather than days, weeks, or months.
According to the National Institute of Mental Health, 4 million U.S. adults live with BPD, and more than 6 million adolescents are affected by the condition.
Diagnosing personality disorders in younger people has been controversial because of the idea that adolescents’ personalities are still developing. But diagnosing teens is possible, and necessary, according to Aguirre and Moran. It allows young people to receive the help they need before they are faced with a crisis while also enabling families to learn how to be supportive of their loved ones.
Contrary to long-held beliefs that BPD is a chronic disorder, research suggests the condition is more treatable than previously thought. Effective evidence-based treatments exist that help teens learn to identify, understand, and regulate emotions in healthy ways.
When Moran works with families, she provides a metaphor of a fire breaking out in a room, in which the sensitive child is the only one who notices the flames. The child becomes increasingly agitated, begging the parent to leave the room. The parent may eventually relent, only because they see their child’s distress. “This type of interaction,” Moran said, “teaches the child that the environment is unlikely to respond to their needs until their behavior or communication escalates. The interaction doesn’t help kids better understand their emotions or what to do about them.”
Over time, Moran added, the behavior develops into a pattern. The child’s actions for soothing emotions (such as cutting) or for eliciting a caring response (for example, with a suicide attempt) can seem extreme to others. Often, these young people have experiences in which they’re described as manipulative. Such behaviors are often unconscious or reinforced by the environment. Use of the word “manipulative” is recognized as stigmatizing when associated with BPD.
When children’s emotions are regularly ignored or misunderstood, Moran said, they can begin to second-guess themselves. They may vary between intense escalating behavior and shutting down, numbing, or ignoring emotions because they think their emotions are wrong and they shouldn’t have them.
DBT was developed in the 1980s by psychologist and researcher Marsha Linehan, M. PhD, ABPP. It is a form of cognitive behavior therapy (CBT) that helps people who struggle with regulating emotional experiences. While CBT focuses on creating change in a patient’s life, DBT brings in the practice of acceptance. The term “dialectical” refers to the therapist’s and patient’s integration of the two opposing concepts of change and acceptance.
When Linehan developed DBT, she observed that patients who struggled with emotion dysregulation needed to make changes to identify and develop skills for what she termed “a life worth living.” She noticed focusing on just change was not enough. It was as important to learn how to validate emotions and accept aspects of their lives they could not actively change.
DBT has been effective in treating conditions including eating disorders, substance use disorders, and depression. For BPD, it is the gold-standard treatment.
DBT helps people cope with strong emotions by teaching them four different skills sets:
Patients learn DBT skills through individual therapy, group therapy, and real-time phone coaching with therapists. Aguirre, for example, is available 24/7 by phone. The idea of DBT is to be less theoretical than traditional counseling. “It’s very easy to sit in a room with a patient and go over what will happen that night if she’s out with her boyfriend, and he breaks up with her,” he said. “It’s much more difficult if it’s late in the evening, they’ve had a few drinks, and he’s actually breaking up with her.” At such times, Aguirre talks with patients while they are in the thick of a situation. “It’s not a therapy session,” he pointed out. “It’s about ten minutes, and over time, patients learn coping mechanisms and rely on their therapists less.”
Prospective DBT patients may struggle to access care. Aguirre says that 99% of people who need DBT use the outpatient model. In this model, individual counseling and group therapy combined can take up to 2.5 hours per week. In some cases, it can take even longer, as in the case of adolescents, who frequently need family therapy sessions.
Patients with more severe BPD symptoms may attend a partial hospital program that involves daily treatment for approximately 4-6 weeks or a more intensive residential program that involves the patient living at the facility for approximately 6-12 weeks.
Once patients receive DBT, though, the results are often striking.
A study by Linehan and her colleagues in 1991 showed that DBT significantly helped suicidal and self-injuring women with borderline personality disorder—a population formerly deemed untreatable. Since then, numerous studies have attested to the effectiveness of DBT in adults and teens with BPD.
A 2016 study in the Journal of the American Academy of Child and Adolescent Psychiatry showed DBT was more effective than usual care in improving borderline symptoms in adolescents after just 19 weeks of treatment, with improvements being maintained at one year after treatment.
A 2018 study authored by Moran, Aguirre, and colleagues on the effects of residential DBT treatment for teens found that DBT significantly reduced BPD symptom severity after one month of treatment.
Aguirre and Moran say that of the young people they treat with DBT, many feel it saved their lives.
“One thing I really appreciate about DBT is that it helps people better identify and understand nuances about their emotions and how their emotions may be helpful, not just painful or useless,” Moran said. “The idea of being able to identify and actually understand what you’re feeling, why you might be feeling it, and what to do about it is pretty big and would be helpful for everyone—not just for kids we see at McLean.”
The concept of biosocial theory suggests that personality is a result of biological predispositions that transact with environmental factors. All humans are born with a different sensitivity of emotion reactivity. Some people fall low on the scale, many land in the middle, and some have very reactive emotions. The spectrum of biological sensitivity brings diversity to the human experience. It gives people different strengths.
Aguirre pointed out that people at the reactive end of the spectrum simply have a wider range of emotional experience—and there’s nothing wrong with this. “Many therapists are biologically sensitive,” he said. “Many artists and actors are biologically sensitive. It’s almost like being a supertaster, or somebody who can tell nuances between different colors.”
Biologically sensitive people can develop BPD when they are immersed in an invalidating environment. Because of this, Moran and Aguirre work with families to help them better understand their children’s emotional experiences.
Moran said, “We often see kids with big emotions who happen to be in an environment that sends the message that these kids’ emotional experiences don’t make sense, they shouldn’t have them, or that they should be better at regulating them.”
Often, she said, these teens have a mismatch with caregivers who either don’t have the same emotional sensitivity as them or who have also not learned how to regulate emotions well. Many of the problems within BPD are attempts at trying to cope with big emotions or learned responses to this mismatch with their environment.