Adolescence can be a turbulent time. Anyone who lived to survive it – including those who are now parents of teens – know about the social, emotional, and physical rollercoaster that often characterizes the teen years. For a small percentage of teens, the emotional turbulence is especially intense, confusing, and painful. For some teens, emotional upheaval during adolescence signals the beginning of a severe emotional disorder known as borderline personality disorder  (BPD).

As a parent, it’s difficult to discern typical teen behavior from atypical teen behavior. This brief guide is designed to help you identify the signs and know what steps to take if you think your teen has or may be developing BPD.

Adolescent Borderline Personality Disorder

BPD Facts and Statistics: Adolescents

  1. Experts estimate 3% of adolescents meet criteria for BPD diagnosis
  2. People with BPD have high rates of co-occurring disorders. Data published by the National Institutes of Health (NIH) show:
    • 80% to 96% have mood disorders, e.g. depression
    • 88% have anxiety disorders, e.g. post-traumatic stress disorder (PTSD)
    • 64% have substance abuse disorders
    • 53% have eating disorders
    • 10% – 30% have attention deficit hyperactivity disorder (ADHD)
    • 15% have bipolar disorder
  3. Around 33% of teens with BPD have a history of physical, sexual, and/or emotional abuse
  4. The symptoms of BPD typically appear first during adolescence, but most people with BPD rarely receive treatment before adulthood
  5. An estimated 10% of people with BPD die by suicide
  6. Adolescents with BPD are often initially misdiagnosed with 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 their experience
  • Reduce the risk and frustration of ineffective treatments due to misdiagnosis
  • Give them the tools and skills to manage the multiple challenges of BPD

Recognizing the Signs of Borderline Personality Disorder

Knowing what to look for and recognizing the symptoms of borderline personality disorder in teens can be a challenge for parents. Symptoms often develop slowly, over time, as opposed to appearing quickly, over a brief period, as is often the case with other mental health disorders. This makes recognizing the warning signs difficult.

Another challenge with identifying borderline personality disorder is the fact that some of the signs and symptoms of BPD are common in teens. Anyone who remembers their teen years knows adolescents can experience identity issues, feel intense emotions around to rejection, and have up and down moods. However, with borderline personality disorder, these typical teen emotions and behaviors are far more intense and follow a pattern that develops over weeks and months, whereas typical teens brief or occasional displays.

BPD Warning Signs

  • Rocky relationships with family and close friends
  • All-or-nothing thinking / seeing everything in extremes
  • Idealizing someone one moment and hating them the next
  • Self-loathing
  • Very low tolerance for frustration or disappointment
  • Intense fear of being abandoned or rejected
  • Over-reaction to perceived or actual abandonment
  • Being a chameleon: rapid, unpredictable changes in behavior, mood, personality, or appearance to please others
  • High sensitivity to the emotions of others
  • High impulsivity, often resulting in risky or reckless behavior: running away, reckless driving, risky sexual activity, spending sprees, excess drug and alcohol use
  • Recurrent/frequent suicidal ideation
  • Self-harming behavior, a.k.a. non-suicidal self-injury (NSSI): self-mutilation, cutting, burning, branding, head-banging, inserting objects under skin
  • Self-harm and suicide attempts after being rejected by a friend or following a romantic breakup or disappointment
  • Extreme moodiness
  • Intense emotional episodes: emotional episodes may be brief, volatile, and triggered by rejection, conflict, or perceived rejection/conflict
  • Chronic sense of emptiness: adolescents with BPD often say they’re restless/bored, especially when alone, which can lead to the risky, impulsive behavior mentioned above
  • Intense anger, which may lead to verbal aggression, physical aggression, or destruction of property
  • Paranoid thoughts: assuming others bad or evil intentions
  • Brief dissociative episodes during times of extreme stress
  • Disordered eating
  • Difficulty tolerating being alone or feeling lonely
  • Frequent academic and/or social problems at school
  • Frequent feelings of being misunderstood by everyone
  • Intense feelings of hopelessness

Do not ignore suicidal thoughts or behavior. Don’t assume they’re being dramatic or manipulative. If your teen, you, or your family is in immediate danger, call 911, go to a hospital emergency room, or call the National Suicide Prevention Lifeline: (800) 273-8255

Know the First Steps to Take

If your teen shows warning signs of borderline personality disorder, there are three initial steps to take to help:

1. Talk to them.

Let them know you’re concerned about their behavior, that you want to help in any way you can, and that you’re there for them to talk about anything. Ask if there’s anything troubling them. Don’t pressure them, though. If communication with your teen is rocky, they may shut down, tell you everything is fine, or tell you that you’re overreacting.

2. Schedule an appointment for a full assessment with a mental health professional.

With a personality disorder like BPD, a full biopsychosocial assessment administered by a clinical psychologist or psychiatrist is essential. An accurate diagnosis – as soon as possible – will give your teen the best chance at getting appropriate treatment, which gives them the opportunity to develop the skills needed to manage the symptoms of BPD.

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, most pediatricians and/or primary care providers are not mental health professionals.

3. Get your teen into treatment.

 Once your teen has been evaluated, getting them 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.

Evidence-Based Treatment for BPD

The NIH indicates the most effective treatment for BPD is dialectical behavior therapy (DBT).

What is Dialectical Behavior Therapy (DBT)?

DBT 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. DBT therapists focus on three areas individuals with BPD need the most help:

  • Emotional regulation
  • Interpersonal relationships
  • Stress management

The following therapeutic approaches are also effective in treating adolescent BPD:

  • Cognitive behavioral therapy (CBT)
  • Mentalizing-based therapy (MBT)
  • Interpersonal group therapy
  • Transference focused psychotherapy (TFP)

Family therapy can also help teens and families address conflict and stress that may exacerbate BPD symptoms. Family therapy helps loved ones and caregivers learn the best ways to respond to and support and adolescent with BPD.

To find treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

Treatment for BPD Can Work

Research indicates that treatment for BPD helps teens manage symptoms. A study of close to 300 people with BPD showed the following rates of remission:

  • 35% remission after 2 years
  • 91% remission after 10 years
  • 99% remission after 16 years

The treatment journey for a teen with BPD is not easy. Managing BPD symptoms will likely be a lifelong process, but professionals treatment and support is essential. Treatment helps people with BPD learn to create the balance and stability necessary for a productive and functional life.

How to Support and Encourage Your Teen

It can be particularly difficult knowing how to support and encourage a teen with BPD. Here are some helpful tips:

  • Educate yourself about borderline personality disorder so you have a better understanding about what your teen is experiencing
  • Talk to their therapist or psychiatrist regarding the best way to respond to self-harming behaviors and suicidal ideation.
  • Listen and let your teen know you’re there for them, no matter what
    • A teen with BPD needs to know you love them unconditionally
  • Encourage them to apply the skills they learn during treatment when they’re at home
  • Understand that BPD your teen cannot simply overcome BPD by force of will.
    • A teen with BPD needs professional support
  • Participate in their treatment. Ask their therapist/counselor/psychiatrist/treatment team about concerns and questions you have
  • Create and maintain a low-stress, safe, structured, and predictable home environment
  • Do not get into power struggles with a teen with BPD
  • Remain calm if they act out/lash out
  • Keep them in treatment and minimizing treatment disruption
    • Do not skip appointments
    • Stick to the treatment plan
    • Stay consistent
  • Recognize they’re doing the best he or she can. Learning to manage intense emotions and other BPD symptoms requires new skills that may take time to implement effectively in day-to-day life
  • Respect their experience. Understand the internal world of a teen with BPD is often painful, bleak, confusing, and overwhelming.
  • Always lead with empathy and compassion
  • Be Supportive in word and action
  • Check-in with them. Ask whether treatment is helping, and ask if there’s anything you can do to help

What to Do If Things Escalate

It’s common for things to escalate – and quickly. Therefore, appropriate, consistent treatment – with an approach like DBT – is crucial for adolescents with BPD. However, even with proper treatment there are times when emergency measures are necessary. Your teen may become suicidal. They may engage in serious self-harm, become physically aggressive, or display troubling erratic behavior. If alcohol or drugs are involved, it can make things much worse and far more unpredictable. Reach out for help if things escalate. You can:

  • Contact their 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
  • Call 911

A brief psychiatric or medical hospitalization may be necessary to keep everyone 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. Intensive therapy above and beyond individual psychotherapy may be necessary if your teen:

  • Threatens or actively plans suicide
  • Makes suicide gestures or attempts
  • Engages in frequent or serious forms of self-harm, e.g. deep vs. superficial cutting or scratching)
  • Has outbursts of anger that involve physical aggression or destruction of property
  • Abuses alcohol or drugs
  • Engages in any behavior that endangers themselves or others

More intensive levels of treatment may include:

  • Intensive Outpatient Programs (IOP)
  • Partial Hospitalization Programs (PHP)
  • Residential Treatment Centers (RTC)
  • Inpatient Pyshciatric Hospitalization

Here are the details about these levels of care:

Intensive Outpatient Programs (IOP)

This level of treatment is a step above weekly therapy or counseling. The amount and timing of treatment depends on the program. Teens typically participate in treatment 3 times a week for 3 hours per session, live at home, and attend school during an intensive outpatient program.

Partial Hospitalization Programs (PHP)

This level of treatment is a is a step up from intensive outpatient treatment. As with IOP treatment, the amount and timing of treatment depends on the specific program. Adolescents go to treatment daily, usually for 4 hours per day, and attend school at least part time. Most teens in PHP programs for mental health disorders continue to live at home.

Residential Treatment Centers (RTC)

Residential psychiatric treatment, also often referred to as inpatient psychiatric treatment, involves having your teen live full time at a non-hospital treatment facility. This intensive level of treatment may last from 30 to 120 days, depending on your teen’s treatment needs and clinical progress. In addition to receiving full-time psychiatric treatment, one of the greatest advantages of residential psychiatric rehab is being in an environment that is designed specifically for teenagers with mental health disorders. This enables them to focus one hundred percent on recovery, without worrying about other factors in their life such as school, family, and peer relationships.

Inpatient Psychiatric Hospitalization

Hospitalization may be necessary if your teen is a danger to themself or others (e.g. if they become suicidal or physically aggressive), or in need of 24/7 medical monitoring. Medical monitoring may be recommended for teens who are a danger to themselves or others due to suicidal ideation, suicidal behavior, or severe depression.

More About Levels of Care

These levels of care – excluding psychiatric hospitalization, during which immediate safety and psychiatric stability are the primary goals – typically involve some combination of the following therapeutic approaches:

  • Individual therapy and counseling
    • Once a week or more, depending on the treatment center and treatment plan
  • Group therapy and counseling
    • This typically happens every day
  • Family therapy and counseling
    • Family therapy commonly occurs once a month, and in some cases, once a week
  • Experiential activities such as exercise, mindfulness, music, or art
    • These activities often happen every day, with longer experiences on weekends
  • Community support

The exact combination of treatment depends on the treatment center and the level of care your teen needs.

What You Can Do for Yourself

Borderline personality disorder can be challenging for everyone. The success of treatment and course of the disorder – even with treatment – can vary significantly from one individual to the next.

In addition to doing everything above to help your child, it’s vitally important that you take care of yourself throughout this process. This may include therapy, taking proactive steps to manage your stress and anxiety, reaching out for support to family, friends, support groups, and organizations such as the National Alliance on Mental Illness (NAMI).

Your teen will look to you for hope, encouragement, and guidance – so be sure you attend to your own emotional and physical well-being as you strive to do everything you can to help them. Together – with teamwork, commitment, and hope for the future – you can help your teen heal, grow, and live a full and productive life.