Teens
It all started when…
My daughter was such a happy, outgoing child, but during middle school, I could feel the changes. She became moody and withdrawn. I couldn’t get her to talk about what was going on.
By the time she got to high school, it seemed she was having very intense emotional reactions to every day things. Her friendships were blowing up and then she even starting cutting on herself. That’s when I realized she needed professional help.
“Many teenagers have a day or even a few days when they get upset and slam a door or curse at their parents. But teens with borderline personality disorder engage in more extreme behaviors — and more often — than the average teen, and these behaviors impair their social, school and working lives.”
Classic symptoms of borderline personality disorder in adolescents…
Fear of real or imagined abandonment - Adolescents sometimes come to therapy after a suicide attempt triggered by a profound sense that someone essential to their well-being will never come back. For example, a break-up with a close friend or romantic partner. What people with BPD want most is closeness. And the tragedy is that the disorder pushes people away.
Unstable relationships - Parents and friends can alternate between being the best parent/friend in the world and then being vilified. This all-or-nothing or black-and-white thinking is called "splitting" and is a fundamental trait of BPD.
An unstable sense of self - This criterion is harder to define in adolescents with BPD because adolescence is a time of defining identity. However, BPD adolescents have an enduring sense of self-loathing, which is a core symptom of BPD.
Dangerous impulsivity - This includes indiscriminate and dangerous sex, drug abuse, eating disorders, and running away from home. These "pain management" behaviors are often used to regulate emotions.
Recurrent suicidal behavior - By the time most BPD teens get to therapy, they have made at least one suicide attempt, generally by overdose. Self-injury in the form of cutting, burning, head banging, punching walls, and attempts to break bones are other presenting symptoms.
Mood instability - Notable about these mood states is that they tend to be in reaction to some conflict, such as a fight or a disappointment.
Chronic feelings of emptiness - These are intolerable states where the BPD adolescent feels that there is nothing of substance in their life. This is often expressed as boredom or loneliness.
Anger regulation problems - Fights occur most with those closest to the BPD adolescent and can take the form of destruction of property, bodily violence, or hurtful verbal attacks.
Psychotic symptoms or loss of touch with reality - Some BPD adolescents have been abused verbally, physically, and/or emotionally. This results in symptoms of post-traumatic stress disorder (PTSD). These symptoms can include dissociation and depersonalization. They can also experience paranoia and assume others have evil intentions.
“In order for someone to be diagnosed with borderline personality disorder, or BPD, they need to meet 5 of 9 criteria in the DSM-IV, the manual of mental disorders that health professionals use for diagnosis. ”
Other symptoms of BPD not in the DSM…
I frequently see these similarities in adolescents in my practice:
They sometimes see themselves as loathsome and evil or contaminated.
They appear to have a profound sense of hopelessness and self-hatred.
During intense moods, they appear to have a marked lack of time. One minute can feel like an hour and vice versa. If they feel miserable, even a moment of misery, can feel like an eternity.
Some have great difficulty in consistently performing at school despite their intelligence.
Intense same sex emotional relationships may lead to physical intimacy even though the person doesn't identify him/herself as gay.
They complain that they are universally misunderstood or that they don't feel they deserve to be understood.
They seemed to be remarkably attuned to non-verbal communication and, as such, seem to be expert mind-readers.
They appear to be very susceptible to other people’s emotions.
“ Adolescent BPD looks a lot like adult BPD. Their symptoms are a reflection of a skills-deficit, or incapacity to regulate their emotions, rather than simple stubbornness or so-called “acting out.” If they were capable of doing things otherwise, most would. Because of the skills deficit, we need to intervene as early as possible. This is true of most skills. If a child cannot talk or walk, we put them in early intervention in order to target the skills deficit. The same must be the case for emotion regulation deficits. Early treatment includes learning a new skill with the use of treatments like Dialectical Behavior Therapy to teach adolescents and parents about BPD. ”
DBT can be an effective treatment…
DBT can be an effective treatment for adolescents who have symptoms of Borderline Personality Disorder (BPD).
Dialectical behavior therapy (DBT)focuses on teaching teens with BPD to become mindful about their emotions and provides them with healthy skills for coping and building strong interpersonal relationships.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) published by the American Psychiatric Association provides criteria for adolescents with BPD.
Below are the criteria of BPD in Adolescents written by Blaise Aguirre, MD Medical Director of the Adolescent DBT Residential Program, McLean Hospital, Belmont, MA in a blog post titled, Stop Walking On Eggshells. Dr. Aguirre is also an instructor at Psychiatry Harvard Medical School.
1. EFFORTS TO AVOID REAL OR IMAGINED ABANDONMENT
Adolescents sometimes come to therapy after a suicide attempt triggered by a profound sense that someone essential to their well-being will never come back, for example, a break-up with a close friend or romantic partner. These are dramatic attempts such as severe overdoses, jumping in front of a truck, and shooting themselves with a gun. I am also seeing a new trend in break-ups involving technology (text-messaging, Facebook, etc.).
In some, cases the adolescents recognize that by making these suicide attempts, they get reassurance that they are loved. If the BPD adolescent gets tremendous attention ONLY during suicidal and self-destructive acts, these suicidal behaviors can be unintentionally reinforced by loved ones and caregivers.
Self-harming behavior and other borderline defense mechanisms often come off as "manipulative" to others. While it can FEEL that way, it doesn't meet the definition of manipulation which is, "Shrewd or devious management, especially for one's own advantage." Truly manipulative behavior is planned, while BPD behavior is impulsive. When something triggers BPD behavior, it happens right away.
Manipulation is done for some kind of gain: to ultimately increase someone's happiness because something wanted has been obtained. But are people with BPD satisfied? No! They're miserable--even the high functioning ones. Would anyone in their right mind plan to end up in a psychiatric facility or in a desperately unhappy relationship? What people with BPD want most is closeness. And the tragedy is that the disorder pushes people away.
When we feel manipulated, we mistakenly conclude that our BP loved one is acting this way on purpose to drive us insane. It's that kind of thinking--ascribing devious intentions to borderline loved ones--that does the most harm. It can make parents feel like they've done something wrong when they haven't. That can cause needless guilt.
2. UNSTABLE RELATIONSHIPS CHARACTERIZED BY OVER IDEALIZATION AND DEVALUATION
Parents and friends can alternate between being the best parent/friend in the world and then vilified. This all-or-nothing or black-and-white thinking is called "splitting" and is a fundamental trait of BPD.
When they get hospitalized, these adolescents can divide staff into "good" and "bad" and cause chaos on the unit. Staff has to be careful not to be too comfortable with being assigned as "good" or "bad" because these designations can change quickly and easily.
3. AN UNSTABLE SENSE-OF-SELF
This criterion is harder to define in adolescents with BPD because adolescence is a time of defining identity. However, BPD adolescents have an enduring sense of self-loathing, which is a core symptom of BPD.
Some patients are like chameleons, adapting to whatever group of friends or trend is current. Flexibility is a helpful trait, but in our BPD kids it is because they have little sense of who they are.
Similarly, there is a sense of what one of one of my young patients recently described as being "porous." She readily (but painfully) takes on the positive or negative emotions of people around her.
4. DANGEROUS IMPULSIVITY
This includes indiscriminate and dangerous sex, drug abuse, eating disorders, and running away from home. These "pain management" behaviors are often used to regulate emotions. However, older adolescents take risks with driving and spending similar to adults. At times, dangerous behaviors are mediated through the Internet, for example, meeting strangers on-line for sex or drugs.
5. RECURRENT SUICIDAL BEHAVIOR
Self-injury in the form of cutting is the most common presenting symptom in my practice.
I also see burning with matches or lighters, head banging, punching walls, and attempts to break bones. Most of my patients have made at least one suicide attempt -- generally by overdose. But more recently I am seeing patients with self-inflicted gun shots, who have tried to hang themselves, or who have jumped in front of moving automobiles.
As I mentioned earlier, suicidal and self-injurious behaviors can be reinforced by the well-intentioned attention of caregivers when the adolescents feel cared for by loved ones ONLY when they make such attempts.
6. AFFECTIVE OR MOOD INSTABILITY
Notable about these mood states is that:
Moods tend to be in reaction to some conflict (e.g. a fight or a disappointment).
The adolescents in my practice recognize that they feel things "quicker" and with less apparent provocation than others their age.
They say they feel things more intensely than others their age.
They say that they are slower to return to baseline than others.
Mood reactivity is on a continuum, low to high, based on how much it affects the person's life.
7. CHRONIC FEELINGS OF EMPTINESS
These are intolerable states where the BPD adolescent feels that there is nothing of substance in their life. This is often expressed as boredom. The emptiness can be temporarily relieved by risky or intense behaviors (intense relationships, sex, drugs), as the extreme behavior leads to intense feelings that help the adolescent feel connected. At other times adolescents express the emptiness as loneliness.
8. ANGER REGULATION PROBLEMS
Fights occur most with those closest to the BPD adolescent and can take the form of destruction of property, bodily violence, or hurtful verbal attacks. While the DSM specifies anger, other intense emotional states are also difficult to regulate - even positive ones! T hese can feel intolerable because high intensity emotions are anxiety provoking and lead to irritability.
9. PSYCHOTIC SYMPTOMS OR LOSS OF TOUCH WITH REALITY
Some BPD adolescents have been abused (verbally, physically, and emotionally). This results in symptoms of post-traumatic stress disorder (PTSD). These symptoms can include dissociation and depersonalization which means that the young person disconnects their emotional experience from the reality they are experiencing. They can also experience paranoia and assume others have evil intentions.
Some Key Points to Remember About Adolescent BPD
Adolescent BPD looks a lot like adult BPD. Their symptoms are a reflection of a skills-deficit, or incapacity to regulate their emotions rather than simple stubbornness or willfulness or so-called "acting out." If they were capable of doing things otherwise, most would.
Because of the skills deficit, we need to intervene as early as possible. This is true of most skills. If a child cannot talk or walk, we put them in early intervention in order to target the skills deficit. The same must be the case for emotion regulation deficits. Early treatment includes learning a new skill with the use of treatments like Dialectical Behavior Therapy to teach adolescents and parents about BPD.
For more information, read the article, Teen Moodiness or Borderline Personality Disorder?, by Dr. Alec Miller.
DBT Group for Teens
This VIRTUAL group is a safe and non-judgmental place where teens can connect with others and learn all of the DBT skills. The group will provide an opportunity to not only learn the DBT skills, but to practice them in session, so that they can be best applied in their daily lives.
MONDAYS 6 PM - 7:30
$75 for the 90 minute session
$545 for the 8-week package
Teenagers are typically reluctant and anxious to start a group program like this, but the vast majority are comfortable and enjoying themselves by the mid-way point of the first group session.
I strive to ensure the group environment is safe, non-judgmental and comfortable for everyone.