The Experts on Differentiating Between Adolescence and BPD

Q: How is the emotional instability of BPD differentiated from normal teenage unstable affect?

A Brief Summary of the Experts Quoted Below:

(1) Engaging in an unusual number of impulsive behaviors, not just drugs or alcohol

(2) Engaging in self-harm

(3) Do the teenagers cut once or twice (not enjoy it and quit) or do they report that it provided them with emotional relief? Or, in other words, do they engage in self-harm and impulsive behavior to regulate their emotions (a sign of BPD) or do they just do so to experiment?

(4) Do the problematic behaviors appear in the context of broader emotional problems?

(5) A hyperbolic temperament, extreme sensitivity, and extreme reactivity are universally considered to be signs of BPD, so such traits should be treated as potential BPD traits.

(6) For teenagers, failure to maintain stable relationships even with their friends is a worrying sign.

(7) Do they just whine that they hate themselves (their bodies, their social status, and so forth) or do they actually feel that they are toxic and should not be allowed in polite society?

(8) In the early teens the situation is more fluid, but by 16, 17, 18 if they are not moving along the developmental trajectory, are not acting a little less impulsively, are still unable to build stable relationships then these are causes for concern.

The Experts Say…

Dr. Brad Reich in a 2017 webinar for the Brain and Behavior Research Foundation entitled “Borderline Personality Disorder: Diagnosis, Course, and Treatment” (at 52 min)

 (1) If they are engaging in self-mutilation, engaging in multiple forms of impulsiveness (not just substance abuse, but maybe several different forms)….

(2) What runs through all the different theories is the hyperbolic temperament, the extreme sensitivity, the extreme reactivity, so if you see this it is a tip off that they may have BPD

(3) If they can’t maintain stable relationships even with friends that is a tip off

(4) It becomes clearer in later teens – in early teens the situation is more fluid, but by 16, 17, 18 if they are not moving along the developmental trajectory, are not acting a little less impulsively are still not able to build stable relationships then I would be worried.

(5) However, a lot of BPD individuals (who never even become patients) seem to get better on their own as long as they are not in an environment that is overwhelmingly stressful. That can really throw people off course.

Dr. Blaise Aguirre in BPD in Adolescents (pp. 59-66)

(1) Look at the function of the behavior – Is it for experimentation or to regulate and control emotions? (59)

(2) Do they just whine that they hate themselves (their bodies, their social status, and so forth) or do they actually feel that they are toxic and should not be allowed in polite society? [oral communication]

(3)Do they cut once or twice (not enjoy it and quit) or do they report that it provided them with emotional relief? (60)

(4) When behaviors (such as drug use) persist in adolescents in the context of broad emotional problems, clinicians need to recognize that BPD may be developing (66).

(5) By the age of eighteen normal teenagers begin to demonstrate  a greater ability to delay gratification and remain emotionally stable. They show increased concern for others and have longer intimate relationships (64).

Dr. Blaise Aguirre, “BPD In Adolescence: Early Detection and Intervention” (2011), uploaded at https://www.youtube.com/watch?v=q4KjxxPp3Ls

Gunderson admitted in private conversation that those who developed the notion of BPD with him are to blame for the misconception that you cannot diagnose before 18. All adult BPD patients I (BA) have spoken with recognize that they had symptoms in adolescence or even earlier. Other psychiatric conditions are diagnosed in adolescence, so why not personality disorders.

There are early indicators/patterns of behavior that will develop into BPD….

One patient: Cannot stand being in herself/self-loathing/no one likes her/can only get boys to like her if she has sex with them.

Imagine identical twin children doing the exact same things: How do you differentiate the BPD one from the other: for BPD sufferers the function of the behavior is to regulate how they feel in the moment.

The DSM-5 quite correctly points out the following for any diagnosis of BPD:

1.Impairments must be stable across time and consistent across situations.

2. Impairments must not be understood better as normative for the

individual’s developmental stage or socio-cultural environment (for example,

what is normal for a Meditteranean or Israeli temperament is not for a British or German one).

3. Impairments are not solely due to the effects of substance use or a

medical condition.