Identifying and Treating Adolescent Borderline Personality Disorder

Borderline personality disorder (BPD) is estimated to affect approximately 3% of the adolescent population, but is a common association in more severe mental illnesses or psychiatric-related events; up to three-fourths of adolescents with suicidality attended to in emergency departments are diagnosed with BPD.

This mental illness is a critical challenge of care at a pivotal time of development in its patients—and it’s often hard to derive who’s the affected adolescent, and what their pathway of care should be.

In an interview with HCPLive during the American Psychiatric Association (APA) 2022 Annual Meeting in New Orleans this week, Lois Choi-Kain, MD, MEd, Director of the Gunderson Personality Disorders Institute at McLean Hospital, highlighted the convergence of “new life experiences” in adolescents who may begin to show signs of BPD.

“Socially, there’s more demands and complexity, and in terms of academics and extracurricular activities, there’s more pressure,” Choi-Kain said. “So, adolescents are naturally trying to navigate social and emotional processes on their own without parents. I think it’s an important time period for developing your sense of self, and that takes a lot of consistency and clarity about how you’re going to manage something based on who you are, what you’re like.”

Some children are at greater risk of sensitivity to stressors; adolescence can exacerbate the matter. The features of adolescent BPD can become difficult to ascertain: emotional dysregulation, impulsivity, and confusion about oneself, Choi-Kain said.

“But the things that distinguish teens that are more likely go on to have borderline personality disorder from other teens is that they tend to have more self-destructive behavior, as well as more dependency on others,” she explained. “It’s this very uncomfortable combination fo needing others very badly, but then getting very angry at them and do things that aren’t likely to promote the relationship.”

Choi-Kain said everything from genetics to their childhood upbringing, developing life stressors and social factors may perpetuate adolescent BPD. Often through no fault, parents and guardians may struggle to interpret the mental illness as the cause of burden on young patients.

“I think it’s shocking how much you think what it’s like to be that age by the time you’re a parent,” Choi-Kain said. “They are set by something and they manage it in their own way, but most kids don’t obsess or ruminate, even if something’s really upsetting. Some people do, and when they are doing that, that becomes something like a smoke signal.”

On the subject of response, Choi-Kain stressed that adolescents require more “identified safe spaces,” noting that parents and guardians, or even teachers, may address the issues brought on BPD from an interventional approach that could be derived as disciplinary rather than caregiving. Even clinicians could improve in their approach to adolescent BPD.

“I think the problem is even psychiatrists are afraid of these patients, and they’re afraid to upset them and talk to them honestly,” Choi-Kain said. “Most clinical professionals have good health care skills, but there’s something about the symptoms of BPD that elicits a certain “walking on eggshells” attitude toward them.”

Lastly, Choi-Kain reviewed treatment strategies and goals for adolescents with BPD, calling current regimens “too complex and intensive” to be feasibly considered for use in general community settings.

“There’s an absolute inadequacy of supply compared to demand, and the intensity and rigors of these treatments make other people feel less incentivized to use them,” she said.

Rather, she and her team are focused on building “steps of care” that incrementally improve adolescent’s management of their symptoms without altering their standard of living.

“People with BPD need more predictability—and I think people misunderstand it, because those with BPD have a more unstable sense of self-direction,” Choi-Kain said. “While I do think people with BPD have special needs, I think that there’s also a phenomenon where people try to make life too easy for them…so they don’t learn how to cope in a constructive environment.”