Borderline personality disorder is common among adolescents. It’s associated with long-term harm to a young person’s mental health and relationships. Adolescents with BPD are also some of the most likely people to have a BPD diagnosis as adults, with BPD traits that persist stably through time.
Early diagnosis matters because it facilitates access to appropriate and timely treatment, supporting young people to recover from BPD. These interventions prevent much of the social and psychological harm that follows from BPD during adolescence and make it less likely that BPD features will persist into adulthood.
This blog explains why early diagnosis is so important for young people with BPD. It also touches on the concept and practice of early intervention and the treatments available for BPD among adolescents.
How Common Is BPD Among Adolescents?
Borderline personality disorder is common among adolescents. Data suggests that around 3% of young people in the general population may meet the criteria for a BPD diagnosis, with some studies suggesting the prevalence is even higher.
BPD diagnoses among adolescents are as reliable as among adults – and clearly identifiable in clinical practice. The disorder also has a similar structure, aetiology, and stability as it does in adulthood.
Why Does Early Diagnosis Matter?
One of the most persuasive arguments for diagnosing and treating BPD in adolescence (or when it first appears) is that many children or adolescents with BPD traits and symptoms continue to show the same traits as adults.
Research has found that personality disorder symptoms in children and adolescents are the strongest predictors of a personality disorder in adulthood. In a community sample, young people with a BPD diagnosis were at a much higher risk than others of having the same diagnosis two years later. This means that BPD symptoms or diagnosis during adolescence is a significant (and possibly the most significant) predictor of a BPD diagnosis during adulthood.
During the period from which BPD traits emerge in adolescence and a diagnosis in adulthood, young people can experience a range of adverse consequences, including incidents of self-harm, the onset of other mental health conditions, and obstructions to normal psychosocial development. Early diagnosis and timely intervention during adolescence can prevent this harm, facilitating a reduction in BPD traits and (earlier) recovery.
What Are the Psychosocial Consequences of BPD Among Adolescents?
Adolescents with BPD experience serious psychosocial challenges. A community study found that 11-21-year-olds with BPD had the broadest range of functional impairments of any personality disorder, including problems at school and work, other mental health disorders, and anti-social behaviour.
BPD also affects adolescents’ relationships with friends, family relationships, and their ability to practice self-care. Adolescents with BPD tend to have less enduring friendships, a lack of confident or romantic partners, and fewer social activities.
What Are the Longer-Term Consequences Linked to BPD in Adolescence?
BPD symptoms and traits during adolescence can disrupt and inhibit developmental processes, even if symptoms later reduce. Adolescence is a key period of personality development and the acquisition of emotional and social skills. BPD during adolescence is linked to negative consequences over the next two decades of a young person’s life.
For example, BPD symptoms in adolescence are associated with a range of mental health disorders during adulthood, especially mood disorders.
The social consequences of BPD also continue into young adulthood. One study found that undergraduates with BPD features experienced more interpersonal difficulties than others and, at the two-year follow-up, continued to have interpersonal and academic problems. Moreover, BPD symptoms at age 22 are associated with a lower quality of life at age 33 – almost 11 years later.
Understanding Early Intervention for Sub-Threshold BPD
In conversations about treatment for BPD in under 18s, people often speak about ‘early intervention’. Here, early intervention is defined as when treatment and other interventions begin in the early stages of a disorder when symptoms still have not met (or have only just met) the threshold for a diagnosis.
However, some young people experience a diagnosable disorder during adolescence and before the age of 18. While they may start treatment earlier in their life, they’re more likely to benefit from interventions for diagnosable BPD rather than early interventions. This means that it’s important to match treatment to the traits of each young person’s disorder rather than with their age.
According to the DSM-V, a diagnosis of BPD requires that a young person meets at least five BPD criteria. Sub-threshold BPD is when three or four criteria are met.
Importantly, young people experience significant changes in their health-related quality of life and psychological distress well before they meet the criteria for a full diagnosis. Subthreshold BPD is associated with higher mental health service use and poorer functioning, even where only one BPD criterion is met.
By the time five criteria have been met, adolescents are likely to have already experienced harm to important development processes that affect their outlook for the future.
This means that starting treatment in the earliest stages of the disorder is crucial for young people’s development and health during adolescence and into adulthood. Some experts recommend using a meta-diagnostic tool (known as CHARMS) to identify symptoms and features of various mental health disorders (including BPD) that result in a young person experiencing significant distress despite not meeting the threshold criteria for any single diagnosis.
Treatment Interventions for Adolescents with BPD
Diagnosing BPD among adolescents facilitates access to treatment, enabling quicker recovery and preventing short- and long-term harm to a young person’s life. While randomised controlled trials among adolescents with BPD are still limited, several studies have found various treatment methods to effectively treat the disorder.
These include:
- Dialectical behavioural therapy -A
- Adolescent identity therapy
- Mentalisation based treatment
- Emotional regulation therapy
- Cognitive analytic therapy
Early Intervention for Adolescents
Early intervention programs offer treatment and support for young people even before they have met the criteria for a diagnosis. This might be when they first show signs of BPD traits or the disorder. Early intervention programs tend to target the broader range of negative consequences associated with BPD traits and symptoms rather than only those contained in the definition of the disorder.
Early intervention programs may use a range of approaches to address the first presentations of BPD or sub-threshold BPD. These include adaptations of cognitive analytic therapy and emotional regulation therapy.
Encouraging Early Diagnosis
Despite overwhelming evidence that BPD is at least as common – if not more common – among adolescents as adults, many clinicians are still reluctant to diagnose BPD in under-18s. This reluctance is largely based on misconceptions about how young brains and personalities develop and what may be considered a ‘normal’ trajectory. It’s also connected to the stigma surrounding BPD and fears about how a diagnosis may affect a young person’s employment and other opportunities in the future.
However, diagnosing BPD in under-18s is really important. Timely treatment during adolescence is fundamental to preventing further harm to a young person’s life, both in the present and in the future. Diagnosing BPD facilitates access to appropriate and effective treatment for young people with the disorder.
