Our Changing Understanding of the Course and Outcomes for Adolescents with Borderline Personality Disorder

New Insight on Trajectories for Adolescents With BPD

Adolescent borderline personality disorder (BPD) is one of the most challenging mental health disorders we know about. For decades, clinicians avoided diagnosing teens with BPD for fear of misinterpreting typical adolescent turmoil as atypical behavior. They feared pathologizing typical behavior, which can lead to inappropriate and potentially harmful treatment. One study called adolescent BPD the “he who must not be named” of adolescent psychiatry. This perspective led to misdiagnoses of schizophrenia, bipolar disorder, or major depressive disorder in adolescents, when the real disorder was, in fact, BPD.

The prevailing opinion was that the prognosis for anyone diagnosed with BPD was poor, that treatment outcomes were variable, and in most cases, treatment was ineffective. The implication, which trickled down into our mainstream concept of BPD, was that treating BPD might be a waste of time and energy. Therefore, as recently as the 1980s, many therapists avoided BPD patients because limited evidence supported therapeutic success.

That left people with BPD and their friends, families, and loved ones out in the cold, as it were. Treatment appeared ineffective, finding a therapist willing to offer support was difficult, and the origins and risk factors for the disorder were all but unknown. Then, in the 1980s, Dr. Marsha Linehan developed a technique called dialectical behavior therapy (DBT), which incorporated elements of cognitive behavioral therapy with elements of mindfulness. She and her team published studies demonstrating the effectiveness of DBT for patients with BPD and other disorders characterized by high emotional reactivity and volatile patterns of behavior.

Over the past three decades, the overall concept of BPD among mental health treatment professionals has evolved. Evidence shows that “the condition that shall not be named,” once viewed by treatment professionals with an attitude described as therapeutic nihilism, responds to targeted techniques that can produce favorable outcomes.

Therapeutic Progress: New Hope for BPD Treatment

We won’t sugar coat this. BPD is a challenging diagnosis. Treatment is not easy. Living with BPD is not easy for adolescents or their families. However, the nihilism – a.k.a. the idea that treatment doesn’t work so why even bother – is slowly fading from our collective concept of and approach to BPD. According to a study published the University of Houston, the prognosis for adolescents diagnosed with BPD now, in 2022, is far different than it was ten, twenty, or thirty years ago:

“Like adult BPD, adolescent BPD appears to be not as intractable and treatment resistant as previously thought. That means we should not shy away from identifying BPD in adolescents and we shouldn’t shy away from treating it.”

That’s a major step in the right direction. It’s good news for teens with BPD and their families. It’s an indication that our understanding of the course and outcomes of teen BPD changes as we learn more about the disorder.

Another misconception about BPD – aside from it being untreatable in general and undiagnosable in adolescents – is that it’s a very rare condition. Research estimates the prevalence of BPD as follows:

  • General population: 1.6-5.9% (around 12-13 million people)
  • Adolescents: 3% (around half a million)
  • Adolescents receiving outpatient mental health treatment: 11%
  • Adolescent patients receiving inpatient mental health treatment 50%
  • Adolescent patients hospitalized for suicidality: 78%

That’s more common than diagnoses like schizophrenia and psychosis, for instance. The last two bullet points are what we want to pay attention to here, though. They tell us that BPD is serious, sometimes requires inpatient hospitalization, and is often related to suicidal behavior. In addition, BPD is also associated with increased risk of self-harming behavior, which is called non-suicidal self-injury (NSSI).

Before we describe the latest research on the course and outcomes for adolescents with BPD, we should clear up any confusion about what BPD is, what the primary symptoms are, and how clinicians arrive at a diagnosis of borderline personality disorder in teens.

Teen BPD: Definition, Symptoms, and Diagnosis

The National Institute of Mental Health (NIMH) defines BPD as:

“A mental illness marked by a pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with BPD may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days.”

 The primary symptoms of teen BPD are:

  • Frantic and extreme efforts to avoid or prevent abandonment
  • Rocky, volatile relationships with friends, family, and peers. Interactions may vary between extremely loving and extremely angry
  • Impulsive behavior, e.g., alcohol/drug use, binge spending, reckless driving, gambling, binge eating.
  • An unrealistic, unstable self-image that interferes with mood, behavior, and relationships.
  • Suicidal behavior/NSSI, e.g., suicidal ideation, suicide attempts, and self-harming behavior (NSSI)
  • Extreme mood swings that may persist for hours, and in some cases, for days
  • Constant emptiness/depressed mood
  • Angry outbursts and tantrums that seem out of context in relation to the events that trigger them
  • Dissociation, e.g., feeling cut off from their body, feeling they’re watching themselves from outside their body, and stress-related psychotic episodes or paranoia

Those symptoms show why BPD is a challenging diagnosis, and explain why mental health professionals avoided patients with BPD and rarely diagnosed BPD in teens. They’d avoid patients because of the challenges, and shy away from diagnosing BPD in teens because the symptoms of BPD overlap not only with the radical changes of puberty, but also with other mental health disorders.

But that was before we knew what we know now. Now we have a clear, evidence-based idea about how teen BPD may develop, and that various risk factors that increase risk for teen BPD. In 2020, a group of researchers created a profile of teens at highest risk of developing BPD.

Factors Common to Teens Who Develop Borderline Personality Disorder

  • Challenging childhood behaviors, including:
    • Excessive emotional reactivity
    • Excessive levels of physical activity/reactivity
    • Undeveloped or poor social skills
    • Depressed mood
    • Oppositional behavior
    • Hyperactivity
    • Impulsivity
  • The presence of mental health disorders, including:
    • Major depressive disorder (MDD)
    • Anxiety (GAD)
    • Attention deficit hyperactivity disorder (ADHD)
    • Oppositional defiant disorder (ODD)
    • Alcohol/drug addiction (AUD/SUD)
  • Experiencing physical or psychological bullying from peers
  • Witnessing violence at home
  • Adverse childhood experiences (ACEs), including:
    • Neglect
    • Emotional abuse
    • Sexual abuse
    • Physical abuse

The creation of this profile was a significant milestone in teen BPD treatment. Like the recognition that BPD is treatable and not as intractable as previously thought, this profile helps our understanding of the course and outcomes of teen BPD because it will help clinicians give teens with BPD and accurate diagnosis. An accurate diagnosis and ensure appropriate treatment, which can save time, energy, and resources.

That brings us to the subject of treatment. We’ll spend the rest of this article talking about effective treatments for teen BPD. We’ll also discuss the latest evidence on long-term outcomes for people diagnosed with BPD at an early age. In fact, we’ll talk about long-term outcomes first, because there’s new data to share on the subject.

Teen BPD: Long-Term Outcomes

There’s no other way to say it: we have good news and not-so-good news. We’ll start with the not-so-good news, but remind parents of teens with BPD that within the context of this very challenging diagnosis, there is hope.

With that said, let’s get to the data. A review published in 2021 called Borderline Personality Disorder: Course and Outcomes Across the Lifespan gives “an overview of our changing understanding of BPD in terms of age of onset and prognosis over time.” We can cut to the chase, in a manner of speaking, and offer two primary takeaways from this paper:

  1. Contrary to the earlier beliefs we describe above, remission of symptoms is common for people diagnosed with BPD. Evidence from various studies show the following rates of remission. Note: remission means absence of symptoms. Here’s what they found:
      • 60% of adults with BPD experience remission
      • The earlier BPD is diagnosed, the higher the likelihood of remission
      • When BPD is diagnosed early – in the pre-teen or teen years – remission rates are higher than when BPD is diagnosed during adulthood
      • Rate of remission for teen diagnosis is 73%
  1. Remission is not synonymous with recovery. Remission means absence of symptoms. Real recovery is known as functional recovery, wherein improvement in life functioning accompanies symptom remission. This is the not-so-good Although many people with BPD experience remission of symptoms, the data on those who achieve functional recovery is not as favorable as the data on remission of symptoms.

Researchers in this review describe the results of a study that examined data from adolescents with BPD symptoms diagnosed at 12 years old and then re-assessed at 18 years old. The study shows these adolescents were significantly more likely to experience a wide range of problems.

Teens with BPD: Problems After Long-Term Follow Up

Compared to teens with no BPD diagnosis, teens diagnosed with BPD at age 12 and reassessed at age 18:

  • Have difficult, challenging, and volatile personalities
  • Have significant mental health issues, including:
    • Conduct disorder (CD)
    • Suicidal behavior, including:
      • Suicidal ideation
      • Suicide attempts
    • Self-harming behavior (NSSI)
  • Experience and/or participate in the following:
    • Low educational attainment
    • Risky sexual behavior
    • Criminal activity
  • Become victims of violence, including experiencing:
    • Maltreatment
    • Neglect
    • In-person peer bullying
    • Online bullying

What this means is that while people with BPD often show a remission of symptoms, they do not always achieve functional recovery. Based on the information presented above, the authors of the review conclude the following:

  • BPD most often follows this trajectory:
    • It begins in early to late adolescence, peaks in late adolescence and early adulthood, with symptoms declining over time
  • In the big picture, BPD has more positive prognosis than traditionally accepted. However, issues that persist into adulthood include:
    • Emotional dysregulation
    • Unstable relationships
    • Anger issues
    • Attachment issues, meaning the extreme attachment insecurity that characterizes BPD may not fade over time
  • Rates of functional improvement are low, in comparison to other mental health disorders, and in comparison to remission of BPD symptoms

However, this does not mean that functional recovery is impossible. Furthermore, remission of symptoms is, to put it simply, a big deal. It’s the first step toward functional recovery. To temper the information above, we can report that in a study of over 500 adolescents with BPD who received targeted inpatient treatment, all teens showed:

  • At all time periods post-treatment, they observed:
    • Reduced behavioral symptoms at 6,12, and 18 months after discharge
    • Reduced emotional symptoms at 6,12, and 18 months after discharge

With that in mind, let’s take a look at the type of treatments that are effective for adolescents diagnosed with BPD.

Teen BPD: Evidence-Based Treatment for Remission of Symptoms

Data shows the best treatment for adolescent BPD follows the comprehensive, integrated treatment model. The integrated model means that a course of treatment for a teen with BPD should include psychiatry/psychotherapy, family engagement in treatment, peer/community support, and, when applicable, psychiatric medication. Adolescents experience the most favorable outcomes when they receive treatment in a facility designed for teens, with a clinical staff that has extensive practical experience supporting teens with BPD:

Psychotherapy/Counseling/Psychiatry

Evidence shows Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), and Mentalization-Based Therapy (MBT) help teens with BPD achieve symptom remission.

Psychiatric Medication

When a teen with BPD has an additional mental health disorder such as depression or anxiety, they may receive a prescription for medications used to stabilize mood, reduce psychotic episodes, and relieve anxiety.

Family Engagement in Treatment and Community/Peer Support

Teens diagnosed with BPD report intense feelings of loneliness and extreme fears of abandonment by the people they love. Many have severe mood swings and unstable relationships with family and friends. When the people they know and love also know and understand the details of BPD, they can learn to handle the volatility that often accompanies the diagnosis. In addition, participation in support groups with other teens with BPD can help them learn they’re not alone, and that it’s possible to learn to manage their disorder.

The top-line takeaway from this article, and the long-term review study of BPD outcomes across the lifespan of a person with BPD, is that remission of symptoms is common, and specific therapies, such as dialectical behavior therapy (DBT), can help teens manage BPD over time. However, long-term, functional recovery will remain a challenge. The best outcomes for long-term remission of symptoms and functional recovery are achieved when two things happen:

  1. A teen receives an early, accurate diagnosis of BPD
  2. A teen receives appropriate, evidence-based treatment

That’s our mantra: the right treatment at the right time can make all the difference. That’s true for common disorders like depression and anxiety, and the latest evidence shows it’s also true for a traditionally problematic diagnosis like borderline personality disorder.