Borderline personality disorder (BPD) is part of a cluster of diagnoses called the personality disorders. Personality disorders are a group of psychiatric conditions that are characterized by enduring (long-term) patterns of inner experience and behavior that are significantly different from the experiences or behaviors of most other individuals in the patient's culture. These patterns are pervasive (stable over time), inflexible, have an onset in adolescence or early adulthood, and lead to distress or impairment.
The diagnosis of personality disorders and BPD in particular in adolescents is controversial, as there is evidence that personality continues to develop throughout adolescence and into young adulthood. Additionally, the reliability of the BPD diagnosis in adolescents has been called into question, in light of the finding that many adolescents with the disorder appear to 'outgrow' it. Nevertheless, expert consensus is that the BPD diagnosis has clinical utility in adolescent samples and can be applied when appropriate.
BPD is a psychiatric disorder that affects approximately 3 - 14% of adolescents.
BPD is characterized by a pattern of impulsivity and instability in interpersonal relationships, self-image, and affect, as indicated by five or more of the following symptoms:
Symptoms of BPD are often triggered or exacerbated by interpersonal stressors, including perceived rejection, neglect, or abandonment. Recurrent suicidal ideation is the reason that many individuals with BPD present for treatment and risk of completed suicide is elevated in individuals with this disorder. For BPD to be diagnosed, the symptoms must be present across a variety of contexts. Although the disorder is often chronic, many adolescents who meet criteria for the disorder will remit by early adulthood.
Because many adolescents experience some of these symptoms from time to time, BPD should be diagnosed only when these patterns persist for at least one year and cause clinically significant distress or impairment.
BPD severity can range from mild to debilitating. In severe cases, BPD can lead to severely impaired functioning at work or school and an inability to maintain successful interpersonal relationships. Self-injurious behaviors can lead to medical complications. Risk of attempted and completed suicide is elevated among individuals with this disorder.
Many people with BPD also have other psychiatric conditions, most notably bipolar disorder, other personality disorders, depression, anxiety, and substance use disorders.
The neurobiology of BPD is poorly understood, due in part to the heterogeneous nature of the disorder. However, some studies have suggested that abnormalities in brain regions related to impulsivity and affect regulation, including the anterior cingulate cortex, orbitofrontal and dorsolateral prefrontal cortices, the hippocampus, and the amygdala. Of note, there appear to be sex differences in the neurobiology of the disorder. In terms of psychosocial factors, a history of childhood sexual abuse is a significant risk factor for the disorder. The disorder appears to have a genetic component, although having a genetic predisposition to BPD does not necessarily mean that someone will develop BPD.
There are no published guidelines for treatment of borderline personality disorder in adolescents; however, published treatment guidelines for BPD in adults include those from the American Psychiatric Association, the Society of Clinical Psychology, the National Institute for Clinical Excellence, and the Agency for Healthcare Research and Quality. Published guidelines for the treatment of non-suicidal self-injury and suicidal behaviors in adolescents are available from the Society of Clinical Child and Adolescent Psychology.
Partial hospitalization or brief inpatient hospitalization may be necessary, particularly in the context of serious suicidal or self-damaging behaviors. This determination should ideally be made in consultation with a specialist.
Clinical research suggests that the following treatments are effective for individuals with BPD:
Pharmacotherapy is not recommended as a monotherapy for BPD due to limited evidence of efficacy and the potential risk of drug overdose in patients with a history of suicidal gestures. Additionally, pharmacotherapy is not usually recommended as an adjunctive treatment to psychosocial therapy. However, pharmacotherapy may be considered in the management of comorbid psychiatric disorders. The advantages of pharmacotherapy should be carefully weighed against the potential risks, particularly with respect to suicidality. In some cases, short-term (1 week or less) sedative medication can be considered to address crisis situations. In these cases, side effect profiles should be considered and the minimum necessary dose should be prescribed.
Additional Treatments to Consider
Preliminary evidence suggests that herbal therapies including yi-gan san, while not a substitute for the more well-validated treatments described above, might be considered.
Partial hospitalization or brief inpatient hospitalization may be necessary, particularly in the context of serious suicidal or self-damaging behaviors. This determination should ideally be made in consultation with a specialist.
Clinical research suggests that the following treatments are effective for individuals with BPD:
Pharmacotherapy is not recommended as a monotherapy for BPD due to limited evidence of efficacy and the potential risk of drug overdose in patients with a history of suicidal gestures. Additionally, pharmacotherapy is not usually recommended as an adjunctive treatment to psychosocial therapy. However, pharmacotherapy may be considered in the management of comorbid psychiatric disorders. The advantages of pharmacotherapy should be carefully weighed against the potential risks, particularly with respect to suicidality. In some cases, short-term (1 week or less) sedative medication can be considered to address crisis situations. In these cases, side effect profiles should be considered and the minimum necessary dose should be prescribed.
Additional Treatments to Consider
Preliminary evidence suggests that herbal therapies including yi-gan san, while not a substitute for the more well-validated treatments described above, might be considered.