Psychiatric Times.
No. 5
BORDERLINE PERSONALITY DISORDER
Borderline Personality Disorder in Adolescents
Issues in Diagnosis and Treatment
By Blaise Aguirre, MD |
May 9, 2012
Dr Aguirre is Medical Director of the Adolescent DBT Residential Program at McLean Hospital in Belmont, Mass, and Assistant Professor of Psychiatry at Harvard Medical School, Boston. He reports no conflicts of interest concerning the subject matter of this article.
Not all good news
Prospective studies on the course of adult BPD show that the majority of patients have symptom remission, often within the first 4 years of follow-up.15,16 However, even though over time most patients with BPD no longer qualify for the diagnosis, follow-up studies in adults with BPD indicate that good psychosocial functioning is only attained in 60% of these patients. Vocational impairment is more frequently seen than social impairment.17
These findings highlight the need to direct patients with BPD to specialized treatments at an early age, when there is more potential to provide them with the skills that are necessary for improved long-term functioning, particularly in the educational and vocational domains. Furthermore, a number of factors, such as childhood sexual abuse and substance abuse, adversely affect outcome in adults with BPD.18 Once again, lack of research means that much less is known about the factors that predict outcome in adolescents with BPD.
Targeted interventions
Several psychotherapies have been shown to lead to overall improvement in functioning in patients with BPD, although as with research in general, studies of psychotherapy in adolescents with BPD are few. Empirically validated therapies include dialectical behavioral therapy, mentalization-based treatment, schema-focused therapy, and transference-focused psychotherapy.19-23 Most of these treatments have not been studied in adolescents.
Various treatment options are available for adolescents with BPD. These include standard cognitive-behavioral therapy, individual psychotherapy, and substance abuse treatment.24 The best evidence-based treatment outcomes for adolescents with BPD come from dialectical behavioral therapy and cognitive analytic therapy.25,26
The bottom line
BPD appears to be a neurodevelopmental disorder, influenced by the person’s genetics and brain development and shaped by early environment, including attachment and traumatic experiences. BPD also appears to remit in the majority of cases within 4 years of a formal diagnosis. Research and clinical experience underscore that a history of sexual abuse and alcohol(Drug information on alcohol) and other substance use disorders is associated with failure to remit; affective lability is also associated with continuation of BPD.
Given that there is little reluctance on the part of psychiatrists to diagnose other psychiatric disorders, such as bipolar disorder, in children and adolescents and given that there appears to be a good prognosis for adolescents with BPD, clinicians should no longer be reluctant to diagnose BPD in those younger than 18. The DSM does not preclude it, the prognosis is not negative, and as with many disorders, early diagnosis can lead to timely and targeted treatment for this previously underserved and underrecognized population.
Finally, given the advent of new and validated therapies that target BPD, it is imperative that the diagnosis be made as early as possible so that targeted interventions can be applied. However, because BPD has numerous symptoms that over-lap with other disorders and because of the enduring nature of the symptoms of all borderline personality disorders, clinicians should understand that some features of BPD are likely to be chronic and, as such, be prepared for a long-term treatment relationship.27
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