DSM and the adolescent clinical profile
DSM has 9 criteria for BPD and states that the diagnosis can be made in adolescents younger than 18 if the criteria have been present for more than a year. Integrating the clinical experience with DSM criteria yields the following profile: adolescents referred for treatment often report that symptoms started around puberty. BPD symptoms such as self-injury and impulsivity involving drugs, alcohol(Drug information on alcohol), and sex are far less common in younger children. The 9 DSM criteria are the following:
Efforts to avoid abandonment. The risk of suicide is increased in adolescents with BPD after a breakup with a romantic partner or problems with a roommate or friend. They experience a profound sense that someone essential to their well-being will never come back. The clinician must recognize that suicidal and other maladaptive behaviors are sometimes reinforced by loved ones and caregivers, in that the adolescent with BPD feels more cared for when in crisis and being attended to by compassionate caregivers.
Unstable relationships. Patients with BPD tend to have relationships that are either overidealized or devalued. Parents and friends can be categorized as being the best parent or friend in the world in one moment and then vilified in the next. This reflects all-or-nothing, or black-and-white, thinking, which is typical in adolescents with BPD. On hospital units, the adolescents can divide staff into good and bad staff—designations that can readily change. In an unprepared staff, this can lead to polarization and staff that either likes or dislikes the adolescent.
Unstable sense of self. This criterion is harder to define in adolescents with BPD because adolescence is a time of defining identity. Clinically, we see enduring self-loathing as a core symptom. Others describe feeling “porous” to others’ emotions.
Dangerous impulsivity. In younger adolescents with less access to cars and money, reckless driving and spending and are unusual. Indiscriminate and unprotected sex, drug abuse, eating problems, and running away from home are more common, and these behaviors are often used to regulate emotions. These mood regulation strategies are one of the key assessments that differentiate “typical” adolescent experimentation from the behavior of adolescents who have BPD.
Recurrent self-injury and suicidal behavior. Self-injury in the form of cutting is common; self-burning, head banging, punching walls, attempting to break bones, ingesting nonnutritive substances, and inserting foreign objects under the skin are other forms of self-injury. Although patients with BPD are at increased risk for completed suicide, cautious intervention is key because suicide attempts can be reinforced by the well-intentioned attention of caregivers.9
Affective instability/extreme mood reactivity. Adolescents with BPD recognize that they feel things “quicker” and with less apparent provocation than others, feel things more intensely than others, and are slower to return to their emotional baseline than others. Mood states tend to be in response to interpersonal and intrapersonal conflict and rarely last for more than a day, typically lasting only a few hours. This mood reactivity can be useful in differentiating BPD from Axis I mood disorders, in which mood states can last for many days or weeks.
Chronic feelings of emptiness. Adolescents with BPD tend to express that they are easily bored and do not like to sit quietly; the emptiness and boredom of being alone is intolerable. They find that the emptiness is temporarily relieved by risky or “intense” behaviors (intense relationships, sex, drugs).
Anger regulation problems. If there is physical aggression, it tends to occur most with those closest to the adolescent with BPD. The anger-fueled aggression can take the form of destruction of property, bodily violence, or hurtful verbal attacks.
Paranoia and dissociation. It appears that about 30% of hospital-based adolescent patients with BPD have experienced some form of abuse. Some present with co-occurring PTSD. In this subgroup, dissociation, depersonalization, and derealization are common.