And why it's now being diagnosed and treated in #teenagers

Caroline Miller

What You'll Learn

- What is #borderlinepersonalitydisorder (#BPD)?
- What are the signs of #BPD?
- How is #BPD treated?

- Quick Read
- Full Article
- What is #BPD?
- Emotional dysregulation
- Self-destructive #behavior
- Criteria for diagnosing #BPD
- Diagnosing #teenagers
- Why early diagnosis is crucial
- Treatment for #BPD

People with #borderlinepersonalitydisorder (#BPD) experience extreme emotions. Once a powerful emotion is triggered, it is very hard for them to calm down. Because of this, they often have unstable relationships. They also engage in self-destructive #behavior, including #suicideattempts.

In the past, traditional therapy hasn’t been very effective in helping people with #BPD. But there is now new understanding of the disorder and more effective treatments available. With the right support. most people with #BPD can learn to manage overwhelming emotions and improve their lives.

Another important change is that #BPD is now diagnosed and treated in #teenagers. When #kids get the right treatment, sooner, they’ll do better in the future.

Some #kids with #BPD have a history of abuse or neglect. But the disorder can also occur in ordinary, loving families when #parents ignore or minimize kids’ big emotional reactions. This might seem like a normal part of parenting, and in most cases, it is. But highly sensitive or emotional #kids can end up feeling painfully alone. When these children’s big feelings are brushed off by #adults, they often fail to learn the important skills they need to control their emotions.

People with #BPD are often overwhelmed by anger and feelings of abandonment, shame and self-loathing. These feelings take a toll on relationships. Small problems easily become big blow-ups, causing fights with friends, #parents and partners. Problems with friends or breakups with partners can trigger self-harm or #suicideattempts. Other dangerous #behaviors can include substance abuse, risky sex, and recklessness.

The gold-standard treatment for #BPD is called #dialecticalbehavioraltherapy, or #DBT. The treatment helps #patients practice more effective ways to manage and respond to their feelings, and it is very successful in treating this disorder.

#Borderlinepersonalitydisorder (#BPD) is a diagnosis that has historically been difficult to understand, and even more difficult to treat successfully. The symptoms associated with it are a painful mix of emotional turmoil, unstable relationships and self-destructive #behavior, including #suicideattempts.

But new insights into the disorder, leading to new, more effective treatments, have made the prognosis for someone with #BPD much more promising. With the right support, most people with #BPD can successfully learn to regulate their overwhelming emotions, stop self-destructive #behavior and improve their lives.

“It used to be that receiving a #BPD diagnosis felt like a life sentence of misery,” said Alec Miller, PsyD, an expert in treating #adolescents with #BPD. “But research now shows that the chances of functioning better and even dropping the diagnostic label are very high.”

Another important change is that #BPD is now diagnosed and treated in #teenagers. Until recently #mentalhealthprofessionals were reluctant to give the diagnosis to anyone under 18, despite the fact that symptoms become prominent in #adolescence, or even earlier. Now experts stress that treating #BPD as early as possible leads to better long-term outcomes, as well as lowering the risk of  dangerous or suicidal #behavior.

What is #BPD?

Experts call #BPD a biosocial disorder, meaning that it starts with a biological (or temperamental) inclination which is exacerbated by the social environment. People who develop #BPD are by temperament highly emotionally sensitive and reactive, feeling things more immediately and more intensely than most people. And once a powerful emotion is triggered, it takes them longer to return to their emotional baseline.

 #BPD develops when one of these emotionally vulnerable people is confronted with an environment that doesn’t validate her feelings — that is, acknowledge them, make her feel understood, and help her handle them. In many cases, kids who develop #BPD have been abused or neglected. But the disorder can also come about in #children whose loving, well-meaning #parents minimize or discount their emotional reactions, because they seem exaggerated or inappropriate.

Dismissing what seems like an overreaction is a fairly typical parental response. But for highly reactive kids, the chronic sense of not feeling understood or supported leads them to feel painfully alone and disconnected, explains Blaise Aguirre, MD. Dr. Aguirre is the founding medical director of 3East, a continuum of care using #dialecticalbehaviortherapy (#DBT) to treat borderline personality disorder at Boston’s McLean Hospital. Friends and family members don’t understand why people with #BPD have huge reactions to small things. For Dr. Aguirre, author of #BorderlinePersonalityDisorder in #Adolescents, #BPD is something like a peanut allergy; the reaction may not be typical of most people, but it’s no less real.

Emotional dysregulation

When a child’s powerful feelings aren’t validated by the #adults in her life, it becomes difficult for her to learn to manage them in a healthy way.  #Adults help us name and identify what we’re feeling; by soothing us they teach us how to soothe and calm ourselves down.

“Take a person with extremely strong, intense emotions, who is constantly told that she’s overreacting, she shouldn’t feel the ways she feels,” explains Jill Emanuele, PhD, clinical psychologist and director of the Mood Disorders Center at the #ChildMindInstitute. “As a result, she doesn’t learn how to regulate and modulate her emotions. “

People with #BPD are often overwhelmed by intense anger and feelings of abandonment, emptiness, shame and self-loathing.

These feelings tend to destabilize relationships for people with #BPD, who are hypersensitive to social cues from others, and more likely than others to interpret things negatively. Minor slights — or things misinterpreted as slights — are taken as evidence of abandonment, and the reaction can be swift and intense, causing rifts with friends, #parents, partners. They go from “I love you” to “I hate you” in a heartbeat, Dr. Aguirre explains. Or they become so frantic asking for reassurance that they are loved — incessant texting, calling, begging, clinging —that they drive partners away.

Rifts with friends or breakups with partners are often the trigger for self-harm or #suicideattempts, he notes.

Self-destructive #behavior

Why does #BPD lead to self-destructive #behavior?

Without the skills to manage painful feelings in a more effective way, people with #BPD  often find unhealthy alternatives, including substance abuse, risky sex, reckless thrill-seeking.

Self-injury is very often one of these #behaviors:  #Teenagers use things like cutting, scratching and opening wounds to alleviate emotions they find intolerable. “In fact it can work as an emotional regulation strategy,” notes Dr. Miller, cofounder and clinical director of Cognitive and #Behavioral Consultants in Westchester and New York City. “The problem is that if it works, they’re more likely to use it again to cope with negative emotions. To reduce self-harm we need to acknowledge what it’s doing for them, and try to give them some safer replacement strategies.”

One dangerous misunderstanding about #BPD is that the emotional drama and the self-destructive #behaviors, including #suicideattempts, are manipulative pleas for attention.

“Historically, people with #BPD have been viewed as purposely manipulative,” explains Dr. Emanuele, “using extreme measures to get things, gaming people around them. But that’s not it at all. These people are in intense pain, and feel they can’t get what they need.”

In fact, Dr. Aguirre notes, suicidal feelings are almost universal in people with #BPD, and reflect a desperate need to escape extreme emotional distress.

Criteria for diagnosing #BPD

These are the criteria #mentalhealthprofessionals use to diagnose #borderlinepersonalitydisorder:

- Frantic efforts to avoid abandonment, real or imagined
- A pattern of unstable and intense relationships
- An unstable self-image or sense of self
- Dangerous impulsivity such as unsafe sexual encounters, substance abuse
- Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
- Emotional instability due to high reactivity
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoia or severe dissociative symptoms

Diagnosing #teenagers

In the past, #mentalhealthprofessionals were reluctant to diagnose anyone under 18 with #BPD, even though symptoms usually develop during the #teen years. That was, in part, because emotional intensity and impulsive risk-taking are to some extent characteristic of #adolescence itself. Typical #teenage #behavior, it was thought, could be confused with #BPD.

But even if the #behavior looks similar, the reasons for it are different in typical #adolescents and those with #BPD, Dr. Aguirre notes. Typical #teens experiment with #alcohol and sex out of curiosity and impulsivity, while people with #BPD use them to escape acutely painful feelings. They may seek out sexual encounters, for instance, because they feel abandoned, and crave closeness, rather than sex itself. They may take dangerous risks because “in that moment of desperation the need to change how they feel makes the #behaviors feel like the right thing to do.”

Another reason for not diagnosing #BPD in #teens was to avoid labeling them with a severe illness that didn’t respond well to treatment. But as the treatment picture has changed, so has the aversion to diagnosis in #adolescence. One large study called the McLean Study of #Adult Development, which followed #BPD #patients for 12 years, found that 74 percent of participants had no active symptoms after 6 years, and only 6 percent relapsed in the following 6 years.

The lead author of the study, Mary Zanarini, began to call #borderlinepersonalitydisorder a “good-prognosis diagnosis,” and those who are treated while they’re still #teenagers have even more optimistic outcomes.

Why early diagnosis is crucial

If #BPD is understood as a lack of emotional regulation skills, it’s crucial to get someone who develops symptoms into treatment as soon as possible, Dr. Aguirre says, “before patterns of maladaptive #behavior have set in.”

This is particularly important as young people are developing their identity and sense of self, which is made incredibly difficult for young people with #BPD symptoms. “When your environment doesn’t reflect back what your experience is,” Dr. Aguirre says, “it’s hard to know who you are, what your values are.”

Another reason experts urge earlier diagnosis of #BPD is to lessen inaccurate diagnosis of more common disorders like #ADHD, #depression and #bipolar disorder. Sometimes these are co-occurring disorders, but often they are misdiagnoses. As a result, these teenagers are given medications that aren’t effective, including mood stabilizers and antipsychotics.

“I’ve seen kids with #BPD who were on extensive drug cocktails because the clinicians didn’t know what was happening,” adds Dr. Emanuele. “They’re just going after the symptoms. And no medication is going to correct the invalidation that these people feel.”

#BPD #patients who are admitted to Dr. Aguirre’s unit often come in “zombie-like,” he reports, because they are on so many medications. When they are discharged, he says, half are on no meds at all.

#JamesDonaldson notes:

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Having gone through a recent bout of #depression and #suicidalthoughts myself, I realize now, that I can make a huge difference in the lives of so many by sharing my story, and by sharing various resources I come across as I work in this space.  #http://bit.ly/JamesMentalHealthArticle

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Treatment for #BPD

There are a number of specialized psychotherapies that have been developed to treat #BPD, but the gold standard treatment — the one with the most evidence for its effectiveness — is called #dialecticalbehavioraltherapy, or #DBT. The reason it’s called “dialectical” is that it involves two things that might seem to be in opposition but are both important: the need for acceptance and the need for change.

First, a patient’s feelings need to be validated, or accepted without judgment, in order for her to learn more effective ways for her to manage and respond to them.

“It’s basically ‘I’m doing the best I can’ on the one hand,” explains Dr. Miller, “and at the same time ‘I need to do better’ on the other.”

Validation, which is the first step in #DBT, means recognition and acceptance of another person’s feelings as being real.  It doesn’t mean agreeing with the thoughts or feelings. When people feel accepted and understood, it has a calming effect and allows them to learn skills to regulate emotions and develop safer, more effective alternatives to the self-destructive #behaviors they have been using.

“It’s essentially a skills-based approach which says that if our #patients could do better, they would, but they’re lacking skills,” explains Dr. Miller, who is the author of Dialectical Behavioral Therapy with Suicidal #Adolescents. “It’s so easy for us to tell people to stop problematic #behaviors but it’s better to teach them new skills.”

#DBT skills are very effective for getting #patients to stop self-injury and suicidality, Dr. Aguirre notes. It’s tougher to change the self-loathing and self-hatred that can become fused with a borderline person’s identity.

He also notes that availability of #DBT and other treatment for #BPD is limited, which means that a lot of #teenagers who should get treatment aren’t getting it. “The number of people with emotion regulation problems is outstripping the number of #DBT providers,” he says, “and we know that because #suicide rates in #adolescents continue to go through the roof.”

Dr. Miller stresses the urgency of getting #teens with #BPD into treatment: “If you throw yourself into treatment, you can be a very successful, highly functional #adult.”

Dr. Emanuele adds that she’s seen many #patients dramatically improve their lives. “Over the years, I have repeatedly seen DBT give participants the hope and reality of a ‘life worth living,’ ” adds Dr. Emanuele. “And that’s something they had not been able to imagine or experience before.”

Caroline Miller

Caroline Miller is the editorial director of the #ChildMindInstitute. She is a veteran magazine, newspaper and website editor … Read Bio
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