Adolescence can be a turbulent time for many individuals, as many who’ve lived to survive it – not to mention those currently parenting teens – will readily attest. But for a small percentage of teens, this emotional turbulence can be especially intense, confusing, and painful, signaling the beginning of what may become a chronic and hellish disorder known as Borderline Personality Disorder (or BPD for short).
As a parent, trying to determine what’s normal and what’s not when it comes to your teen’s behavior and emotions. This brief guide is designed to help you identify the signs and know what steps to take if you believe your teen has borderline personality disorder.
Adolescent borderline personality disorder – statistics and facts
- An estimated 1 in 3 teens with BPD who end up hospitalized have a history of sexual, physical, or other abuse
- Posttraumatic stress disorder (PTSD) co-occurs in a significant percentage of individuals with BPD
- Although borderline personality disorder usually begins in adolescence treatment rarely starts until adulthood
- As many as 3% of adolescents are affected by BPD
- Although suicidal gestures and attempts may be or appear to be manipulative in nature, many individuals with BPD (an estimated 10%) end up dying by suicide
- Many adolescents and adults who have BPD are misdiagnosed with and / or treated for other symptoms and disorders, such as depression or bipolar disorder
Early diagnosis of and intervention for BPD is crucial. These two things will have three major benefits for your child:
- validate his or her experience (which others often find very frustrating and difficult to understand)
- reduce the risk and frustration of ineffective treatments due to misdiagnosis (e.g. countless medication trials)
- give him or her the tools and skills (via proper therapy) to more effectively handle the multiple challenges of living with BPD
Looking for and Recognizing the Signs of Borderline Personality Disorder
Knowing what to look for and recognizing the symptoms of borderline personality disorder in teens can be challenging for parents. Part of the problem with personality disorders is that the symptoms often slowly develop over a lengthy period of time, as opposed to a relatively brief period as is usually the case with major depression or bipolar mania, for example.
Another challenge with identifying borderline personality disorder is the fact that some of the signs and symptoms of BPD aren’t that uncommon in teens, such as identity issues, intense reactions to rejection, and moodiness. However, with borderline personality disorder, the symptoms will be more intense and a fairly distinct pattern will appear over weeks and months, as opposed to brief or occasional displays.
Signs to watch for:
- Rocky relationships with family and close friends (e.g. often has intense falling out with friends and significant others; frequent changes in friends)
- All-or-nothing thinking / seeing everything in extremes
- Idealizing someone one moment and hating them the next
- Self-loathing (e.g. seeing themselves as inherently “bad”)
- Very low frustration tolerance
- Intense fear of being abandoned or rejected; over-reaction to perceived or actual abandonment
- Being a “chameleon” (e.g. readily adapting to whatever or whomever is currently influencing them, such as a new friend or group of friends)
- Highly susceptible to the emotions of others
- High level of impulsivity, often resulting in risky or reckless behavior (e.g. running away, reckless driving, having unprotected sex, spending sprees, using drugs)
- Recurrent suicidal gestures or acts of self-harm / self-mutilation (e.g. cutting is a frequent form of self-harm in adolescents with BPD; other examples of self-harm include burning, head-banging, and inserting things under the skin)
- Self-harm and suicide attempts after being rejected by a friend or break-up with a romantic partner
- Extreme moodiness and intensely felt emotions; mood episodes are usually brief (a few hours to a day) and often triggered by rejection or conflict
- Chronic sense of emptiness – in adolescents they’re often restless or bored, especially if they’re alone (this often leads to the risky, impulsive behavior mentioned above)
- Anger outbursts, which may lead to verbal or physical aggression or destruction of property
- Paranoid thoughts (e.g. assuming others have evil or bad intentions)
- Brief dissociative episodes, especially during times of extreme stress
- Disordered eating
- Difficulty tolerating being alone or feeling lonely
- Frequent problems at school – socially and / or academically
- Complaints of feeling misunderstood
- Deep sense of hopelessness (separate from other symptoms of depression)
Knowing the First Steps to Take
If you believe your teen is exhibiting signs of borderline personality disorder, there are three initial steps to take to help him or her:
1 – Talk to your teen. Let your teen know that you’re concerned about the things you’ve noticed, that you want to help in any way you can, and that you’re there if he or she needs to talk – about anything.
Ask your teen if there’s something going on that’s troubling him or her. Don’t pressure, though. If the lines of communication with your teen haven’t been very open, he or she may refuse to talk, give you the “everything’s fine” brush off, or accuse you of over-reacting.
2 – Set up an appointment for an evaluation. With personality disorders, it’s better to have your teen evaluated by a clinical psychologist or psychiatrist than a regular medical doctor.
A medical evaluation by your family doctor or child’s pediatrician can help rule out any underlying medical issues that may be causing some of the symptoms you’ve noticed. However, he or she isn’t a mental health professional.
If you can find a psychologist or psychiatrist who specializes in treating children and adolescents, that would be the ideal place to start. They have the experience and training to detect and understand the subtle nuances of adolescent psychiatric disorders. Borderline personality disorder is inherently complex, and even mental health professionals are hesitant to diagnose it in teens.
3 – Get your teen into treatment. Once your teen has been evaluated, getting him or her into treatment is the next step.
The primary treatment for borderline personality disorder is talk therapy. Medication may be used to treat symptoms of co-occurring disorders, such as depression or anxiety, which aren’t uncommon with BPD. However, medication has limited effectiveness with BPD itself and is not recommended as a primary treatment. Medications that are most likely to be prescribed for individuals with BPD are mood stabilizers, antidepressants, and antipsychotic medications.
DBT – Dialectical Behavior Therapy is one of the most well-researched, effective, and widely used therapies for the treatment of borderline personality disorder in adolescents. DBT is a highly-structured therapy with practical applications that teens can readily apply to their day to day life. It focuses on three area that are a major struggle for individuals with BPD:
- Emotional regulation (e.g. learning to deal with intense emotions)
- Interpersonal relationships
- Stress management
Other types of therapy that may be helpful in the treatment of BPD include:
- Cognitive behavioral therapy
- Mentalization-based therapy
- Interpersonal group therapy
- Transference focused psychotherapy
- Schema-focused therapy
Family therapy can also be very beneficial to help address conflict and stress that may be exacerbating your child’s symptoms and help everyone learn the best ways to respond to and support him or her.
Supporting and Encouraging Your Teen
It can be particularly difficult knowing how to support and encourage a teen with BPD. Following are some helpful tips:
- Educate yourself about borderline personality disorder so you’ll have a better understanding about what your child is experiencing
- Talk to your child’s therapist or psychiatrist regarding the best way to respond to self-harm behaviors and suicide gestures or attempts. With BPD, these behaviors can be inadvertently reinforced by the attention they get from their parents and others
- Make yourself available (and willing) to listen and let your teen know you’re there for him or her
- Encourage your teen to use the skills he or she is learning at home
- Understand that BPD isn’t something your teen can simply overcome with sheer willpower or merely a phase of adolescence
- Actively participate in your teen’s treatment and consult with his or her treatment provider regarding concerns and questions
- Strive to create and maintain a low-stress, safe, and structured home environment to help support your teen’s treatment and overall emotional health
- Avoid getting into power-struggles with your teen
- Strive to remain calm when your child is acting out or lashing out
- Focus on keeping your teen in therapy and minimizing things that disrupt his or her treatment (e.g. skipping appointments or frequent hospitalizations)
- Recognize that your child is doing the best he or she can; that learning to manage intense emotions and other BPD symptoms requires new skills that he or she doesn’t yet have (but can learn in therapy)
- Respect your child’s experience. Understand that the internal world of your teen is often experienced as painful, bleak, confusing, and overwhelming
- Be genuinely supportive in both your words and actions
- Frequently check-in with your child to see how he or she is doing, whether treatment is helping, and to see if there is anything you can do that would be helpful
What to Do When Things Escalate
It’s very common with borderline personality disorder for things to escalate – and quickly. Therefore, proper and consistent treatment, such as DBT, is so crucial for adolescents with BPD. However, even with proper treatment there are times when emergency measures are necessary. Your teen may become suicidal or engage in serious (but non-suicidal) self-harm, physically aggressive, or erratic. If alcohol or drugs are part of the picture, it can make things much worse and far more unpredictable. Reach out for help if things escalate. You can:
- Contact your teen’s treatment provider (DBT programs have a structured protocol to help de-escalate and manage emergency situations)
- Enlist the help of a close friend or family member
- Take your child to the nearest hospital emergency room (if you can do so safely)
- Call 911
A brief psychiatric or medical hospitalization may be necessary to keep your teen and others safe, treat a self-inflicted injury or suicide attempt, or stabilize the symptoms of a co-occurring disorder.
When Individual Therapy isn’t Enough
Sometimes individual therapy isn’t adequate to treat a teen with borderline personality disorder. If your child is:
- Threatening or actively planning suicide
- Making suicide gestures or attempts
- Frequent or serious forms of self-harm (e.g. deep vs. superficial cutting or scratching)
- Having intense anger outbursts that involve physical aggression or property destruction
- Abusing alcohol or drugs
- Engaging in any behavior that endangers self or others (e.g. high risk or reckless behavior)
then it’s time to consider a more intensive level of treatment. This may involve:
- Intensive outpatient treatment (IOP) / Psychiatric day treatment
- Residential treatment
- Dual diagnosis treatment
- Inpatient psychiatric treatment
Intensive outpatient treatment or psychiatric day treatment can vary in terms of the amount of time spent in treatment and how often (e.g. twice a week, 5 days a week) your teen is required to go. These programs are the next step up from regular outpatient treatment (i.e. an hour of therapy once or twice a week).
Residential treatment involves having your teen stay at a non-hospital treatment facility that specializes in treating adolescents with mental health disorders. Residential treatment typically lasts between 30 to 180 days, depending on the disorder and its severity.
Dual diagnosis treatment is recommended for adolescents who have both BPD and a substance use disorder. Many teens with BPD start using alcohol or drugs to alleviate intense, painful emotions, cope with feelings of boredom, or as part of the reckless behavior commonly seen in BPD.
Inpatient psychiatric treatment is the highest and most intensive level of treatment for adolescents with borderline personality disorder. It involves admitting your teen to an adolescent psychiatric hospital unit where medical staff is on hand to monitor him or her around the clock. With BPD, hospitalizations tend to be brief (i.e. no more than a few days). However, in more complex or severe cases inpatient treatment may be longer. It’s most often used for teens who are an imminent danger to themselves or others. For BPD, residential treatment is generally recommended over inpatient treatment if possible.
Each of these intensive levels of treatment typically provides daily therapy in a variety of formats. Therapy may include both group and individual, as well as a combination of different types, such as psychotherapy, art therapy, music therapy, equine therapy, etc.
Taking Care of Yourself
Parenting a teen with BPD can be challenging and exhausting. You’ll likely have times when you feel like pulling your hair out in frustration. Taking care of yourself and learning to manage your own stress and negative emotions will enable you to keep your sanity and give your teen the emotional support and guidance he or she needs. Following are some things that can help:
- Surround yourself with as much support as possible – therapy, online or local support groups, your church, and family and friends can all provide much needed support and encouragement
- Find healthy ways to effectively manage your own stress
- Take care of your physical health by getting sufficient rest and eating a healthy diet
- Make time for yourself
A diagnosis of BPD for your teen can be devastating, especially since the disorder is often misunderstood and stigmatized. With proper treatment, your teen can learn invaluable skills that will benefit him or her in all areas of life and have a worthwhile and fulfilling future.