Education, Understanding, and Early Professional Support

Borderline personality disorder (BPD) creates significant challenges for an adolescent with BPD and anyone who knows and loves them. For parents raising a teenager with BPD, the challenges multiply. The combination of a personality disorder with the radical changes that characterize adolescence often results in a volatile, disruptive, and stressful home environment.

BPD is often misunderstood, which makes supporting a teen with BPD difficult. Confusion and misunderstanding around BPD often revolve around three factors:

1. Symptoms of BPD overlap with the symptoms of several other mental health disorders, which complicates diagnosis. An inaccurate diagnosis can lea to the exacerbation, rather than the mitigation, of symptoms
2. BPD often co-occurs alongside disorders, including:
   1. Major depressive disorder (MDD)
   2. Bipolar disorder (BD)
   3. Anxiety disorders (GAD)
   4. Alcohol/substance use disorders (AUD/SUD)
   5. Eating disorders (ED)
3. Adolescents with BPD often take more than one psychiatric mediation, each of which may cause confounding side effects

For years, therapists treating BPD in adolescents and adults faced an uphill battle. Typical approaches to the treatment of mental health disorders were not always effective, which resulted in what one research team described as “therapeutic nihilism,” or a baseline skepticism or doubt that any type of treatment can offer full relief from BPD symptoms.

However, in the past several years, research efforts show that adults with BPD do respond to specific, targeted treatment. Dr. Carla Sharp at the University of Houston believes targeted treatment can work for adolescents, as well:

“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.”

This article addresses the latest approaches to the treatment of adolescent BPD and how parents can find support for their teen with BPD. First, however, we’ll make sure we’re all on the same page by sharing the official clinical definition of the disorder.

Borderline Personality Disorder: A Clinical Definition

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.”

There are nine primary symptoms associated with BDP:

1. Frantic efforts to avoid abandonment
2. Volatile relationships with friends and family. Relationship behavior may vacillate between:
   • Extremely positive and loving
   • Extremely negative, angry, and combative
3. Risky and impulsive behavior, including:
   • Alcohol use
   • Substance use
   • Dangerous driving
   • Disordered eating
   • Excessive spending
   • Gambling
4. Unstable/distorted self-image that affects:
   • Mood
   • Values
   • Goals
   • Relationships
5. Suicidal behavior/NSSI (self-harm)
6. Extreme mood swings:
   • Can last from several hours to several days
7. Persistent feelings of emptiness
8. Intense/disproportionate/inappropriate/uncontrollable anger
9. Dissociation:
   • Feeling cut off from one’s own body
   • Seeing oneself from outside one’s body
   • Stress-related paranoia, including psychotic episodes

Diagnosing BPD can be difficult, because BPD symptoms in teens may overlap and either be mistaken or mimic the symptoms of other mental health disorders. When a therapist identifies the presence of at least five of the nine primary symptoms, they may arrive at a BPD diagnosis. An accurate diagnosis of BPD requires, at minimum, a full biopsychosocial and psychiatric evaluation administered by a licensed, experienced mental health professional.

Now that we know what we’re talking about, we’ll offer the latest information on the causes of BPD.

Borderline Personality Disorder: Genes, Brain Structure, and Environment

The universal consensus among research scientists on the precise causes of BPD does not exist. Until recently, research showed the following factors play a role in the development of the disorder:

• Genetics. People with a family history of BPD may be at increased risk of developing BPD.
• Neurobiological/neurophysiological factors. Structural and functional abnormalities in brain areas related to emotional regulation and impulse and control impulses may increase the risk of developing BPD.
  • It’s unknown whether these structural and functional abnormalities in the brain are the cause or the result of BPD.
• Environmental factors. Research associates BPD with childhood trauma, including:
  • Physical abuse
  • Emotional abuse
  • Sexual abuse
  • Adverse childhood experiences
  • Exposure to violence

However, not everyone with those risk factors will develop BPD. And some people who develop BPD don’t have any of those risk factors. These default facts confound both diagnosis and treatment. That’s why two new studies on BPD in adolescents can help us. One focuses on psychological and behavioral factors present in childhood and early adolescence associated with escalation to BPD during adolescence, and the other focuses on effective treatment for adolescent BPD.

We’ll look at the article about childhood/early adolescent factors first.

Childhood/Early Adolescent Factors Associated with Teen BPD

Published early this year, the study A Systematic Review of the Factors Associated With the Course of Borderline Personality Disorder Symptoms in Adolescence presents a systematic review of existing scientific literature on how BPD manifests during the teen years.

The researchers initiated the review with two primary goals in mind:

1. Identify factors associated with the course of borderline personality disorder symptoms during adolescence
2. Identify existing symptoms and factors that might contribute to increases or decreases in BPD symptoms during adolescence.

In their review of 14 studies published over four decades, they found evidence associating the presence of the following childhood mental health factors with increased rates of BPD during adolescence:

• High (excessive) levels of emotionality
• High (excessive) levels of activity
• Low levels of sociability with peers
• Negative affect (low mood)
• Oppositional behavior
• Hyperactivity/impulsivity

In addition to the childhood mental health factors, they found evidence associating the presence of the following emotional and behavioral disorders during early adolescence with escalation to BPD or escalation of BPD symptoms during adolescence:

• Oppositional defiant disorder (ODD)
• Alcohol use disorder (AUD)
• Substance use disorder (SUD)
• Major depressive disorder (MDD)
• Anxiety (GAD)
• Attention deficit hyperactivity disorder (ADHD)

Based on their review of data available as of 2020, they developed a profile of a child or adolescent at risk of either developing BPD in adolescence or at risk of experiencing escalating BPD symptoms during adolescence. Here’s the profile.

Adolescent BPD: Escalation Risk Factors

• Difficult temperament/behaviors during childhood (as listed above)
• Comorbid mental health disorders, i.e. mental health disorders in addition to BPD (also listed above)
• Victimization/bullying/violence from peers
• Exposure to interpersonal violence at home
• Childhood trauma: emotional, sexual, and/or physical abuse

What this means is that parents of children with these characteristics should understand that their child may be at risk of developing BPD and seek professional help sooner rather than later. We’ll now look at the second study we mention above.

Treatment for Adolescent BPD: New Study Yields Promising Results

We can summarize the second study more quickly, because the news is straightforward, and, in contrast to most material we read about BPD, it’s both positive and encouraging.

In a study called The Course of Borderline Psychopathology in Adolescents with Complex Mental Health Problems: An 18 Month Longitudinal Follow-up, scientists examined the treatment records of 556 adolescents with BPD. Here’s our summary how they conducted the study, and what they found:

• Researchers recorded symptom severity at admission to an inpatient teen treatment facility
• They followed up on each teen at the following intervals:
  • Upon discharge
  • 6 months after discharge
  • 12 months after discharge
  • 18 months after discharge
• At all time periods post-treatment, they observed:
  • Significant reductions in externalizing symptoms, i.e. behavior
  • Significant reductions in internalizing symptoms, i.e. mood and emotion

Here’s their analysis of the results:

“This is the first study to show that adolescent borderline pathology follows a similar course after discharge from inpatient treatment previously demonstrated for adults.”

That’s good news for teens with BPD, parents of teens with BPD, and mental health professionals who treat teens with BPD.

Now let’s take a look at the evidence-based treatments available for teens with BPD.

Treatment for Teenagers with Borderline Personality Disorder: Approaches that Work

Experts in adolescent mental health agree that the most effective approach to treating BPD is a comprehensive, integrated treatment plan. The plan should include psychotherapy, peer support, family support, and in some cases, medication. In addition, treatment in an adolescent-focused facility with clinical staff experience in teen BDP increases the likelihood of treatment success.

• Psychotherapy: Talk therapy is the first-line treatment for BPD. Evidence shows Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), and Mentalization-Based Therapy (MBT) are effective in treating BPD.
• Medication: Teens with BPD and a comorbid mental health disorder such as depression or anxiety may be prescribed mood stabilizers, antipsychotics, antidepressants, or anti-anxiety medications.
• Peer and Family Support: People with BPD experience intense feelings of loneliness fears of abandonment. They also experience drastic mood swings and often have volatile relationships. Therefore, friends and family who understand teen BPD and are willing to offer compassion, patience, and acceptance can help improve treatment outcomes.

Here’s a mantra we espouse: the right treatment at the right time can save lives. Here’s another: the sooner a teen who needs treatment for a mental health disorder gets the treatment they need, the more likely they are to learn the skills to lead an independent, fulfilling, and productive life.

That’s the current treatment model: talk therapy first, medication if needed, family and social support if possible. While friends and family cannot manage the symptoms of BPD for a person with BPD, their love and unconditional support can make all the difference in the world.

How To Help to Your Teen With BPD

First, find them professional treatment using the information we provide below. Next, understand that teens with BPD can be extremely volatile, and typical approaches to parenting may not work. Here are three things to keep in mind as you help your teen manage the ups and downs of BPD:

1. Unconditional love and support first and always. Teens with BPD want empathy, understanding, and compassion more than anything. This can be hard when their behavior is volatile, angry, and aggressive. Nevertheless, lead with love always.
2. Don’t take behavior personally. A teen with BPD may lie, manipulate, throw tantrums, become violent and aggressive, and behave as if they have no memory of previous discussions or agreements. Do not take all this personally. These are all symptoms of BPD.
3. Logical argumentation does not work. A teen with BPD lives in a world of overwhelming, confusing, and chaotic emotions. When talking to a teen with BPD, explaining the logical consequences of their actions is unlikely to help. What they need is for someone to help them explore how they’re feeling, show compassion and empathy, and stay the course as their emotions rise and fade. Lead with love, not logic.

We will qualify this advice: a teen with BPD may experience extreme emotions that lead to aggressive behavior. If you feel they present an imminent danger to you or to themselves, enlist the support of professionals immediately. Call their therapist, call 911, or take them to a psychiatric hospital right away. Do not wait: your safety and their safety – grounded in your understanding of their disorder – comes first.

Signs of BPD in Teenage Girls vs Teenage Boys

The most notable difference between teen girls and boys with borderline personality disorder is their response to emotional distress.  While girls are more likely to express their emotions through self-harm, boys may act out aggressively or become violent toward others. Signs of BPD in teenage girl may manifest as more extreme mood swings, while  boys and be more prone to suicidal thoughts and behaviors.

Additionally, while teen girls with BPD may have a difficult time forming relationships, teen boys often have difficulty regulating their emotions and maintaining interpersonal connections.  All teenagers with borderline personality disorder are at risk of engaging in risky behaviors like substance abuse or impulsive spending, but girls may be more likely to have eating disorders than boys.

Fortunately, the tools available for teens with BPD work for all genders.  Boys and girls both typically benefit from teen DBT programs.  Teen and family therapy Teen and family therapy is also shown to be effective.

What Are the Biggest Symptoms of BPD?

Parenting a teenager with borderline personality disorder can be easier when parents recognize the most common symptoms of BPD.  Certainly any guide to supporting teens begins with understanding what BPD looks like.  Teenagers with borderline personality disorder experience intense emotions and have difficulty regulating them.  If your teen has Emotional outbursts, such as yelling, crying, or angry tantrums, that may be a warning sign.

Common signs of BPD in teenagers include a distorted self-image characterized by extreme highs and lows in self-esteem, quickly shifting moods, and difficulty managing relationships.  They may also demonstrate a fear of abandonment or rejection and also feelings of emptiness and detachment from others.  Some teenagers with borderline personality disorder engage in impulsive choices, such as gambling, shoplifting, or reckless driving.

At What Age Does BPD Start Showing?

Borderline personality disorder usually begins to show itself in adolescence or early adulthood. However, symptoms can start to appear as early as childhood and, if left untreated, can become increasingly severe. It is important to recognize the signs of BPD so that an individual can get the help they need before their behavior becomes more extreme. Experts can give parents tips for struggling teens  and even help your teen get happy.    The sooner you start with therapy, the better your child’s chances of success.

Finding Help for a Teen with BPD: Resources

If you’re seeking treatment for your teen with BPD, 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.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.