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September 8, 2019
Do emotions seem to overpower you and control many of your actions? Do you spend a lot of time worrying about social situations? Do you act without thinking in ways that get you into trouble?
That might make you a typical teen. But if your behaviors are severe enough, you could have a mental health condition called borderline personality disorder (BPD). But how can you tell the difference between normal adolescent development and the onset of a mental health diagnosis?
You can’t self-diagnose with an article, but you can learn more about this condition to have a better understanding of normal teen behavior and behaviors that might cause you to seek help.
Borderline personality disorder is a complex mental illness marked by unstable moods, behaviors, and relationships. People with BPD may struggle with self-image problems, feelings of self-doubt, intense fear of abandonment, and low self-worth.
Individuals with BPD often have trouble controlling their emotional reactions. This can lead to self-harm and suicidal behaviors. It is common for people with BPD to have high rates of co-occurring disorders, such as substance use disorders, depression, anxiety disorders, and eating disorders.
Studies show that BPD is more common than schizophrenia and bipolar disorder. It affects an estimated 1.6% of U.S. adults. This number may be higher, however, because many people with BPD are misdiagnosed with PTSD, ADHD, bipolar disorder, or depression. Given the complexities of diagnosing adolescents with the condition, and the fact that a large number of those with BPD attempt suicide, the problem may be even more severe.
For many years, people misunderstood BPD. And, although the mental health community and the general public have gained greater insight in recent years, misconceptions remain, particularly as BPD relates to adolescents.
Misunderstandings developed because BPD can be difficult to diagnose. In the past, if a person displayed psychotic behavior—characterized by abnormal thinking and actions such as irrational beliefs or hallucinations—clinicians clearly understood that the individual had a serious disorder that needed to be addressed. Such a patient was treated with known methods. When a person displayed neurotic behavior, such as being worried or anxious, clinicians treated the patient for these symptoms.
But what if a person straddled the line between these behaviors? And what if the person seemed well at times but disintegrated into a state of anger and impulsiveness at other times, engaging in risky behavior and displaying no ability to manage their emotions?
For years, mental health professionals could not fit these individuals neatly in the psychotic category or the neurotic category. As a result, few clinicians had expertise managing these patients. The patients were considered difficult, and this perception became accepted, creating confusion and stigma. Worst of all, many people who needed help were not getting treatment.
“Borderline” personality behaviors were particularly confusing when displayed by adolescents. When faced with teenagers who abused drugs and alcohol, engaged in dangerous sexual encounters, or just “acted without thinking,” clinicians struggled to determine whether these behaviors were signs of BPD or simply the actions of a typical teenager.
Attempts to categorize these behaviors began nearly 90 years ago. For years, there was steady though slow progress diagnosing and treating BPD in adults. By the 1970s, studies at McLean Hospital directed by BPD pioneer John G. Gunderson, MD, led to worldwide acceptance of BPD as a condition with specific treatments leading to successful outcomes. But this acceptance only applied to adults.
Despite Gunderson’s work, clinicians remained reluctant to make the diagnosis in younger people for much of the 20th century. Nevertheless, an increasing volume of research has confirmed that BPD has its developmental roots in childhood and adolescence and that adolescents can indeed have BPD traits and require treatment.
To ensure that teens with BPD get the help they need, an understanding of the corresponding symptoms is needed. There are some major characteristics that indicate BPD in adolescents.
“Behavioral dysregulation” is displayed when a teen engages in self-injury, such as cutting or burning their skin or punching walls. Dangerous sexual behavior, substance misuse, and impulsivity are other forms of this dysregulation. For teens with BPD, these actions rarely represent a desire to get attention. Rather, they often provide a kind of relief from emotional pain.
Other signs of BPD include trouble with interpersonal relations (particularly a fear of being abandoned), and difficulty regulating emotions, which can be seen when a teen has trouble controlling their anger or swings quickly from angry or sad to calm. Those with BPD may also hold irrational or paranoid beliefs (known as cognitive dysregulation). Or they may show signs of self-dysregulation—feeling empty and lacking a sense of self.
It is difficult for clinicians—and parents—to look at these signs and know whether an adolescent has BPD or if the individual is simply going through a normal teenage phase. It can be more confusing for the teen. With this in mind, a teenager who displays any or all of the characteristics associated with BPD might look around and ask themselves: “Does it seem that other people can deal with things I can’t deal with?” or “Why aren’t others struggling like I am?”
It is difficult for clinicians—and parents—to look at these signs and know whether an adolescent has BPD or if the individual is simply going through a normal teenage phase. It can be more confusing for the teen.
For the adolescent, feeling things more intensely than others or feeling wronged or misunderstood could be signs of BPD. A teenager who feels strong emotions for longer periods than others or takes longer to get back to their emotional baseline may have the condition. Strong reactions to seemingly small provocations—a sense that minor issues feel like the “end of the world” and that behaviors like self-harm, drugs, or death seem to be the only way to make these stop—could be signs of a serious problem. Teens with these actions and reactions should seek help for their symptoms.
A significant way to determine whether a teen has BPD is for the clinician to carefully examine the function or reasoning behind the various behaviors. Clinicians seek to more fully understand why a teenager is engaging in risky behavior or acting irrationally.
For example, during late adolescence and early adulthood, many young people experiment with alcohol. For some, drinking is a way to bond with friends, have a new experience, and experiment. The behavior, while risky, does not alone indicate BPD. However, if the individual is drinking to change the way they fundamentally feel, it could be a sign of BPD. If the person drinks to avoid feelings and problems, it may be a sign of a significant issue.
Strange as it may seem, less dangerous behaviors may also indicate a problem. For example, an adolescent who constantly studies in their room for hours on end may be using this behavior as a way to avoid dealing with more serious concerns. It may not seem risky on the surface, but it may be a sign that the teenager cannot manage their emotions and is looking for a way out. The reasons behind a behavior are also important, beyond the behavior itself.
The key to understanding and diagnosing BPD is to examine behaviors in context instead of isolation. Many characteristics must be present, and they must be persistent. Clinicians assess interpersonal factors such as:
Despite the complexity of the condition and the misunderstandings that surround it, BPD is treatable. Teens and their families can find relief after establishing an accurate diagnosis because of evidence-based treatments.
After the condition is diagnosed, therapy begins. Dialectical behavior therapy (DBT) is a very effective form of therapy, targeting self-harm and suicidal behaviors, drug use, and other destructive behaviors. In treatment, clinicians often work with the teenager to break down behaviors and teach skills for handling difficult emotions and relationships.
Although not necessary for everyone, DBT is the gold standard treatment for BPD. DBT emphasizes the development of four skill sets: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. A combination of cognitive behavioral techniques and mindfulness principles are used to help people gain better control over their impulsive, self-destructive behavior and promote a different way of managing intense feelings.
DBT has been clinically tested for its effectiveness in teens and adults. It was first developed to treat suicidality in adults with BPD. It now is being used effectively in adolescents with similar self-harm behaviors and for other mental health conditions, such as depression and anxiety.
Other therapies used to treat BPD include mentalization-based treatment (MBT) and general psychiatric management (GPM). MBT focuses on helping people to differentiate and separate their own thoughts and feelings from those around them. GPM, developed by Dr. Gunderson, includes case management and education for patients and their families.
Though the stigma remains, there is hope for teens who struggle with BPD. Teens who are ready to work on managing their condition will find that there are plenty of clinicians who will work side by side with patients to help them on the path toward rewarding and productive lives.
Effective help is out there. Get it today.
Blaise Aguirre, MD, is the medical director of McLean Hospital’s 3East continuum of care, which provides treatment to teens with an array of mental health conditions such as BPD, anxiety, depression, PTSD, and more.
If you or a loved one needs treatment for BPD, McLean Hospital is here to help. Call us today at 877.372.3068 to learn more about BPD treatment options for teens and young adults.