Clinical Features of Borderline Personality Disorder in Adolescents

Aim. Identification of the features of primary and comorbid signs of borderline personality disorder (BPD) in teenagers.

Design. Open-label cohort study.

Materials and methods. A pilot clinical evaluation was performed for a full cohort of teenagers admitted to psychiatric in-patient clinic in 2021–2022, the condition of which corresponded to the International Classification of Diseases, revision 11, BPD criteria. The study included 74 teenagers aged 11–17 years old, of which 72 were females. The mean age was 16.6 years old.

Results. All 74 patients had comorbid disorders; complex comorbidities were observed in 31 (41.9%) patients. Forty-seven (63.5%) patients had a history of bullying. Anxiety and post-stress disorders preceded clinical manifestations of the BPD symptoms in 64 (86.5%) cases. Self-harm and attempted suicide were recorded in 58 (78.4%) patients; problems with self-identification, including gender preferences, were observed in 56 (75.7%) patients, problems with interpersonal relationships — in 64 (86.5%) patients, and dissociative symptoms — in 41 (55.4%) patients. Multiple personality disorder identification as “we”, “multiple personalities”) was observed in 12 (16.2%) cases. Clinically significant signs of various eating disorders were diagnosed in 16 (21.6%) patients. After being treated in an in-patient clinic, 65 (87.8%) teenagers demonstrated significant improvement. Most challenging was the management of patients with substantial dissociative symptoms, persistent “gender identity disorder” and trends to use abnormal psychological defence mechanisms.

Conclusion. Interim data show that manifestation of symptoms and comorbidities, as well as a short-term response to therapy in teenagers differ from those in adults with BPD, favouring BPD with adolescent onset as a relatively separate sub-type and justifying a dimensional approach for the search and optimisation of early therapeutic interventions in teenagers with BPD.

1. Kernberg O. Technical considerations in the treatment of borderline personality organization. J. Am. Psychoanalyt. Assoc. 1976;24: 795–829.

2. Torgersen J. Epidemiology. In: Oldham J., Skodol A.E., Bender D.S. Textbook of personality disorders. Washington, DC: American Psychiatric Publishing; 2005: 129–41.

3. Blashfield R.K., Intoccia V. Growth of the literature on the topic of personality disorders. Am. J. Psychiatry. 2000;157(3):472–3. DOI: 10.1176/appi.ajp.157.3.472

4. Bach B., First M.B. Application of the ICD-11 classification of personality disorder. BMC Psychiatry. 2018;18(1):351. DOI: 10.1186/s12888-018-1908-3

5. Skodol A.E., Stout R.L., McGlashan T.H., Grilo C.M. et al. Co-occurrence of mood and personality disorders: a report from the Collaborative Longitudinal Personality Disorders Study (CLPS). Depress. Anxiety. 1999;10(4):175–82.

6. Reed G.M., First M.B., Kogan C.S., Hyman S.E. et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry. 2019;18(1):3–19. DOI: 10.1002/wps.20611

7. Bernstein D., Cohen P., Velez C., Schwab-Stone M. et al. Prevalence and stability of the DSM-III-R personality disorders in a community based survey of adolescents. Am. J. Psychiatry. 1993;150(8): 1237–43.

8. Cailhol L., Pelletier É., Rochette L., Laporte L. et al. Prevalence, mortality, and health care use among patients with cluster B personality disorders clinically diagnosed in Quebec: a provincial cohort study, 2001–2012. Can. J. Psychiatry. 2017;62(5):336–42. DOI: 10.1177/0706743717700818

9. Ørts Clemmensen L., Olrik Wallenstein Jensen S., Zanarini M.C., Skadhede S. et al. Changes in treated incidence of borderline personality disorder in Denmark: 1970–2009. Can. J. Psychiatry. 2013;58(9):522–8. DOI: 10.1177/070674371305800907

10. Becker D.F., Grilo C.M., Edell W.S., McGlashan T.H. Diagnostic efficiency of borderline personality disorder criteria in hospitalized adolescents: comparison with hospitalized adults. Am. J. Psychiatry. 2002;159(12):2042–7. DOI: 10.1176/appi.ajp.159.12.2042

11. Cailhol L., Gicquel L., Raynaud J. Borderline personality disorder. In: Rey J.M., ed. IACAPAP e-Textbook of child and adolescent mental health. International Association for Child and Adolescent Psychiatry and Allied Professions. Chapter H 4: 18.

12. Miller A.L., Muehlenkamp J.J., Jacobson C.M. Fact or fiction: diagnosing borderline personality disorder in adolescents. Clin. Psychol. Rev. 2008;28(6):969–81. DOI: 10.1016/j.cpr.2008.02.004

13. Grilo C.M., Becker D.F., Anez L.M., McGlashan T.H. Diagnostic efficiency of DSM-IV criteria for borderline personality disorder: an evaluation in Hispanic men and women with substance use disorders. J. Consult. Clin. Psychol. 2004;72(1):126–31. DOI: 10.1037/0022-006X.72.1.126

14. Zanarini M.C., Horwood J., Wolke D., Waylen A. et al. Prevalence of DSM-IV borderline personality disorder in two community samples: 6,330 English 11-year-olds and 34,653 American adults. J. Pers. Disord. 2011;25(5):607–19. DOI: 10.1521/pedi.2011.25.5.607

15. Chabrol H., Montovany A., Chouicha K., Callahan S. et al. Frequency of borderline personality disorder in a sample of French high school students. Can. J. Psychiatry. 2001;46(9):847–9. DOI: 10.1177/070674370104600909

16. Sharp C., Fonagy P. Practitioner review: borderline personality disorder in adolescence — recent conceptualization, intervention, and implications for clinical practice. J. Child Psychol. Psychiatry. 2015;56(12):1266–88. DOI: 10.1111/jcpp.12449

17. Iliffe S., Williams G., Fernandez V., Vila M. et al. Treading a fine line: is diagnosing depression in young people just medicalising moodiness? Br. J. Gen. Pract. 2009;59(560):156–7. DOI: 10.3399/bjgp09X407081

18. Sharp C., Vanwoerden S., Wall K. Adolescence as a sensitive period for the development of personality disorder. Psychiatr. Clin. North Am. 2018;41(4):669–83. DOI: 10.1016/j.psc.2018.07.004

19. Chanen A.M., McCutcheon L. Prevention and early intervention for borderline personality disorder: current status and recent evidence. Br. J. Psychiatry Suppl. 2013;54:S24–9. DOI: 10.1192/bjp.bp.112.119180

20. Kaess M., von Ceumern-Lindenstjerna I.A., Parzer P., Chanen A. et al. Axis I and II comorbidity and psychosocial functioning in female adolescents with borderline personality disorder. Psychopathology. 2013;46(1):55–62. DOI: 10.1159/000338715

21. Hopwood C.J., Newman D.A., Donnellan M.B., Markowitz J.C. et al. The stability of personality traits in individuals with borderline personality disorder. J. Abnorm. Psychol. 2009;118(4):806–15. DOI: 10.1037/a0016954

22. Haltigan J.D., Vaillancourt T. Identifying trajectories of borderline personality features in adolescence: antecedent and interactive risk factors. Can. J. Psychiatry. 2016;61(3):166–75. DOI: 10.1177/0706743715625953

23. Skodol A.E., Gunderson J.G., Pfohl B., Widiger T.A. et al. The borderline diagnosis: psychopathology, comorbidity, and personality structure. Biol. Psychiatry. 2002;51(12):936–50. DOI: 10.1016/s0006-3223(02)01324-0

24. Ruggero C.J., Zimmerman M., Chelminski I., Young D. Borderline personality disorder and the misdiagnosis of bipolar disorder. J. Psychiatr. Res. 2010;44(6):405–8. DOI: 10.1016/j.jpsychires.2009.09.011

25. Zimmerman M., Lena Becker L. The hidden borderline patient: patients with borderline personality disorder who do not engage in recurrent suicidal or self-injurious behavior. Psychol. Med. 2022;29:1–8. DOI: 10.1017/S0033291722002197

26. Wolke D., Schreier A., Zanarini M.C., Winsper C. Bullied by peers in childhood and borderline personality symptoms at 11 years of age: a prospective study. J. Child Psychol. Psychiatry. 2012;53(8): 846–55. DOI: 10.1111/j.1469-7610.2012.02542.x

27. Belsky D.W., Caspi A., Arseneault L., Bleidorn W. et al. Etiological features of borderline personality related characteristics in a birth cohort of 12-year-old children. Dev. Psychopathol. 2012;24(1): 251–65. DOI: 10.1017/S0954579411000812

28. Bo S., Vilmar J.W., Jensen S.L., Jørgensen M.S. et al. What works for adolescents with borderline personality disorder: towards a developmentally informed understanding and structured treatment model. Curr. Opin. Psychology. 2021;37:7–12. DOI: 10.1016/j.copsyc.2020.06.008

29. Widiger T.A., Oltmanns J.R. Neuroticism is a fundamental domain of personality with enormous public health implications. World Psychiatry. 2017;16(2):144–5. DOI: 10.1002/wps.20411