The dialectical behavioral therapy profile
From a dialectical behavioral therapy perspective, the symptoms of BPD have been divided into 5 areas of dysregulation:
• Emotional dysregulation: adolescents with BPD are highly reactive and can experience episodic depression, anxiety, and irritability; they also have problems with anger and anger expression
• Interpersonal dysregulation: relationships are chaotic, intense, emotional, and hard to give up; the fears of abandonment can be pronounced
• Behavioral dysregulation: adolescents with BPD demonstrate dangerous, impulsive, and suicidal behaviors; self-injury, suicide attempts, dangerous drug use and unsafe sex are common behaviors
• Cognitive dysregulation: stressful situations and a history of trauma can lead to nonpsychotic loss of reality testing and may include depersonalization, dissociation, and delusions
• Self-dysregulation: adolescents with BPD frequently have little sense of self; they feel empty and struggle mightily with a sense of purpose
The neuropsychological profile
Although the neuropsychological profile of BPD has not been described for adolescents, studies in adults have shown impairments in specific cognitive domains. One robust finding has been deficits in executive functioning, which suggests decreased frontal processing.10-12 Such deficits would explain many of the behavioral findings in BPD, including a poorer capacity to plan, impulsivity, and increased difficulty in emotion regulation.
Given that adolescents have developmentally determined deficits in executive functioning, adolescents with BPD present with even more impulsive and less planned behavior than a typically developing adolescent. The deficits in executive functioning manifest as substance abuse, impulsive aggression, and maladaptive strategies to deal with intense emotions.
The long-term outcome
Biskin and colleagues13 recently published a study on current diagnoses and functional status of women who had received a diagnosis of BPD in adolescence. They also looked at factors that might be associated with long-term outcomes.
Girls with BPD that was diagnosed before age 18 (n = 31) were compared with those who had other psychiatric diagnoses but not BPD (n = 16). Each group was assessed over 10 years. Study findings indicate that 4.3 years after the initial diagnosis, only 11 of the patients with BPD still met criteria for the disorder; BPD did not develop in any of the patients who did not initially have BPD. Those who did not have symptom remission were significantly more likely to have a current episode of major depression, to have a lifetime substance use disorder, and to self-report childhood sexual abuse. The researchers concluded that their findings supported the validity of an adolescent BPD diagnosis and that prognostically, in nearly two-thirds of cases of adolescent-onset BPD, remission could be expected within 4 years.
These findings are consistent with a prospective follow-up that also found a 60% remission rate.4 It is notable that the rate of recovery in adolescents parallels that seen over a similar period in adults with BPD.13
What we are seeing challenges one of the historically entrenched myths about borderline personality disorders. Research now shows that BPD is not a lifelong condition and that most patients, adolescents and adults, can expect to improve over time.14
Mary C. Zanarini, EdD, Professor of Psychology at Harvard Medical School, has been conducting an NIMH-funded study of the long-term course of BPD in adults for the past 19 years. In a personal communication, she reported that her findings show that patients with BPD have a substantially better prognosis than previously recognized; remissions are common and recurrences are relatively rare. She and Marianne Goodman, MD, of Mount Sinai School of Medicine, are conduct-ing a similar study among adolescents (aged 13 to 17) with BPD and a comparison group of emotionally healthy adolescents. Although the data are yet to be fully analyzed, their baseline data show strong similarities between adolescents and adults with BPD.