Borderline Personality Disorder in Children and 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:

• Frantic efforts to avoid real or imagined abandonment, including efforts to avoid being left alone
• A history of intense and unstable personal relationships that are characterized by alternating extremes in how the other person in the relationship is perceived
• Significantly and persistently unstable self-image or sense of self
• Impulsivity in at least two potentially damaging areas (e.g., substance use, spending, sex, reckless driving, binge eating)
• Recurrent self-injury or suicidal behavior, gestures, or threats
• Significantly reactive mood leading to emotional instability (e.g., intense emotions that usually only last a few hours)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger
• Transient, stress-related paranoid thoughts or dissociation

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.

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.

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:

• Dialectical behavior therapy is generally considered to be the treatment of choice for individuals with BPD.  DBT is a longer-term cognitive-behavioral therapy that consists of skills training in interpersonal effectiveness, emotion regulation, mindfulness, and distress tolerance. Treatment usually lasts at least one year and can involve both individual psychotherapy and group-based skills training.
• Other psychotherapies, including mentalization-based treatment, schema-focused therapy, psychoanalytic-based partial hospitalization, and transference-focused therapy have also shown positive effects in randomized controlled trials.

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.