Abstract
Purpose of Review
We review recent research concerning the diagnosis and treatment of borderline personality disorder (BPD) in young people. We examine evidence for the need to define an appropriate age for detection, and the suitability of current classification methods and treatment.
Recent Findings
Evidence supports early detection and intervention for subsyndromal borderline pathology or categorical BPD across an extended developmental period. A range of structured treatments are effective for BPD in young people, although the role of treatment components in successful outcomes is unclear. Substantial evidence suggests that a stronger focus on functional outcomes, especially social and vocational outcomes, is warranted.
Summary
Effective treatments for BPD are rarely available internationally. There is a need to assess whether less complex interventions might be developed that are scalable across health systems. A clinical staging model should be considered, addressing clinical distress and co-occurring psychopathology, as well as diagnosis.
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References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Chanen AM, Thompson KN. The age of onset of personality disorders. In: de Girolamo G, McGorry PD, Sartorius N, editors. Age of onset of mental disorders: Etiopathogenetic and treatment implications. Cham: Springer International Publishing; 2019. p. 183–201.
• Álvarez-Tomás I, Ruiz J, Guilera G, Bados A. Long-term clinical and functional course of borderline personality disorder: a meta-analysis of prospective studies. Eur Psychiatry. 2019;56:75–83 This meta-analytic review of long-term outcomes in BPD describes significant remission and symptom reduction in adults with the disorder.
Fok ML-Y, Hayes RD, Chang C-K, Stewart R, Callard FJ, Moran P. Life expectancy at birth and all-cause mortality among people with personality disorder. J Psychosom Res. 2012;73(2):104–7.
•• Chanen AM, Sharp C, Hoffman P. Global Alliance for Prevention and Early Intervention for Borderline Personality Disorder. Prevention and early intervention for borderline personality disorder: a novel public health priority. World Psychiatry. 2017;16(2):215–6 This article highlights the importance of early detection and intervention for BPD, outlining key clinical, research and policy priorities.
Thompson KN, Jackson H, Cavelti M, Betts J, McCutcheon L, Jovev M, et al. The clinical significance of subthreshold borderline personality disorder features in outpatient youth. J Personal Disord. 2018;32:1–11.
Thompson KN, Jackson H, Cavelti M, Betts J, McCutcheon L, Jovev M, et al. Number of borderline personality disorder criteria and depression predict poor functioning and quality of life in outpatient youth. J Personal Disord. 2019;28:1–14.
Feenstra DJ, Hutsebaut J, Laurenssen E. The burden of disease among adolescents with personality pathology: quality of life and costs. Personal Disord. 2012;26(4):593–604.
Malla A, Iyer S, McGorry P, Cannon M, Coughlan H, Singh S, et al. From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people. Soc Psychiatry Psychiatr Epidemiol. 2016;51(3):319–26.
McGorry PD, Mei C. Early intervention in youth mental health: progress and future directions. Evid Based Ment Health. 2018;21(4):182–4.
Laurenssen EMP, Hutsebaut J, Feenstra DJ, Van Busschbach JJ, Luyten P. Diagnosis of personality disorders in adolescents: a study among psychologists. Child Adolesc Psychiatry Ment Health. 2013;7(1):3.
Dahl RE, Allen NB, Wilbrecht L, Suleiman AB. Importance of investing in adolescence from a developmental science perspective. Nature. 2018;554(7693):441–50.
Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet Child Adolesc Health. 2018;2(3):223–8.
Arnett JJ, Žukauskienė R, Sugimura K. The new life stage of emerging adulthood at ages 18–29 years: implications for mental health. Lancet Psychiatry. 2014;1(7):569–76.
Newton-Howes G, Clark LA, Chanen A. Personality disorder across the life course. Lancet. 2015;385(9969):727–34.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602.
Chanen AM. Borderline personality disorder in young people: are we there yet? J Clin Psychol. 2015;71(8):778–91.
Lawrence KA, Allen JS, Chanen AM. Impulsivity in borderline personality disorder: reward-based decision-making and its relationship to emotional distress. J Personal Disord. 2010;24(6):786–99.
Scalzo F, Hulbert CA, Betts JK, Cotton SM, Chanen AM. Substance use in youth with borderline personality disorder. J Personal Disord. 2017;9:1–16.
Thompson KN, Betts J, Jovev M, Nyathi Y, McDougall E, Chanen AM. Sexuality and sexual health among female youth with borderline personality disorder pathology. Early Interv Psychiatry. 2019;13(3):502–8.
Kramer U, Temes CM, Magni LR, Fitzmaurice GM, Aguirre BA, Goodman M, et al. Psychosocial functioning in adolescents with and without borderline personality disorder. Personal Ment Health. 2017;11(3):164–70.
Westen D, Betan E, Defife JA. Identity disturbance in adolescence: associations with borderline personality disorder. Dev Psychopathol. 2011;23(1):305–13.
Johnson JG, Cohen P, Kasen S. Age-related change in personality disorder trait levels between early adolescence and adulthood: a community-based longitudinal investigation. Acta Psychiatrica. 2000;102(4):265–75.
Stepp SD, Pilkonis PA, Hipwell AE, Loeber R, Stouthamer-Loeber M. Stability of borderline personality disorder features in girls. J Personal Disord. 2010;24(4):460–72.
Conway CC, Hipwell AE, Stepp SD. Seven-year course of borderline personality disorder features: borderline pathology is as unstable as depression during adolescence. Clin Psychol Sci. 2017;5(4):742–9.
Chanen AM, Jovev M, McCutcheon L, Jackson H, McGorry P. Borderline personality disorder in young people and the prospects for prevention and early intervention. Curr Psychiatr Rev. 2008;4(1):48–57.
Sharp C, Wall K. Personality pathology grows up: adolescence as a sensitive period. Curr Opin Psychol. 2018;21:111–6.
Winograd G, Cohen P, Chen H. Adolescent borderline symptoms in the community: prognosis for functioning over 20 years. J Child Psychol Psychiatry. 2008;49(9):933–41.
Cohen P, Crawford TN, Johnson JG, Kasen S. The children in the community study of developmental course of personality disorder. J Personal Disord. 2005;19(5):466–86.
Cohen P, Chen H, Kasen S, Johnson JG, Crawford T, Gordon K. Adolescent cluster a personality disorder symptoms, role assumption in the transition to adulthood, and resolution or persistence of symptoms. Dev Psychopathol. 2005;17(02):549–68.
Kaess M, Fischer-Waldschmidt G, Resch F, Koenig J. Health related quality of life and psychopathological distress in risk taking and self-harming adolescents with full-syndrome, subthreshold and without borderline personality disorder: rethinking the clinical cut-off? Borderline Personal Disord Emot Dysregul. 2017;4:7.
Zimmerman M, Chelminski I, Young D, Dalrymple K, Martinez J. Does the presence of one feature of borderline personality disorder have clinical significance? Implications for dimensional ratings of personality disorders. J Clin Psychiatry. 2012;73(1):8–12.
Ellison WD, Rosenstein L, Chelminski I, Dalrymple K, Zimmerman M. The clinical significance of single features of borderline personality disorder: anger, affective instability, impulsivity, and chronic emptiness in psychiatric outpatients. J Personal Disord. 2016;30(2):261–70.
Zimmerman M, Chelminski I, Young D, Dalrymple K, Martinez J. Is dimensional scoring of borderline personality disorder important only for subthreshold levels of severity? J Personal Disord. 2013;27(2):244–51.
McGorry PD. Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry. Schizophr Res. 2010;120(1–3):49–53.
McGorry PD, Hartmann JA, Spooner R, Nelson B. Beyond the “at risk mental state” concept: transitioning to transdiagnostic psychiatry. World Psychiatry. 2018;17(2):133–42.
Chanen AM, Berk M, Thompson K. Integrating early intervention for borderline personality disorder and mood disorders. Harv Rev Psychiatry. 2016;24(5):330–41.
Hutsebaut J, Videler AC, Verheul R, Van Alphen SPJ. Managing borderline personality disorder from a life course perspective: clinical staging and health management. Personal Disord. 2019;10(4):309–16.
Hutsebaut J, Hessels CJ. Clinical staging and early intervention for borderline personality disorder. Tijdschr Psychiatr. 2017;59(3):166–74.
Krueger RF, Kotov R, Watson D, Forbes MK, Eaton NR, Ruggero CJ, et al. Progress in achieving quantitative classification of psychopathology. World Psychiatry. 2018;17(3):282–93.
Stern A. Psychoanalytic investigation of and therapy in the border line group of neuroses. Psychoanal Q. 1938;7(4):467–89.
Gunderson JG, Singer MT. Defining borderline patients: an overview. Am J Psychiatry. 1975;132(1):1–10.
Waters F, Allen P, Aleman A, Fernyhough C, Woodward TS, Badcock JC, et al. Auditory hallucinations in schizophrenia and nonschizophrenia populations: a review and integrated model of cognitive mechanisms. Schizophr Bull. 2012;38(4):683–93.
Correll CU, Galling B, Pawar A, Krivko A, Bonetto C, Ruggeri M, et al. Comparison of early intervention services vs treatment as usual for early-phase psychosis: a systematic review, meta-analysis, and meta-regression. JAMA Psychiatry. 2018;75(6):555–65.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association; 1994.
Niemantsverdriet MBA, Slotema CW, Blom JD, Franken IH, Hoek HW, Sommer IEC, et al. Hallucinations in borderline personality disorder: prevalence, characteristics and associations with comorbid symptoms and disorders. Sci Rep. 2017;7(1):13920.
Tschoeke S, Steinert T, Flammer E, Uhlmann C. Similarities and differences in borderline personality disorder and schizophrenia with voice hearing. J Nerv Ment Dis. 2014;202(7):544–9.
Kingdon DG, Ashcroft K, Bhandari B, Gleeson S, Warikoo N, Symons M, et al. Schizophrenia and borderline personality disorder: similarities and differences in the experience of auditory hallucinations, paranoia, and childhood trauma. J Nerv Ment Dis. 2010;198(6):399–403.
Slotema CW, Daalman K, Blom JD, Diederen KM, Hoek HW, Sommer IEC. Auditory verbal hallucinations in patients with borderline personality disorder are similar to those in schizophrenia. Psychol Med. 2012;42(9):1873–8.
Kelleher I, DeVylder JE. Hallucinations in borderline personality disorder and common mental disorders. Br J Psychiatry. 2017;210(3):230–1.
Merrett Z, Rossell SL, Castle DJ. Comparing the experience of voices in borderline personality disorder with the experience of voices in a psychotic disorder: a systematic review. Aust N Z J Psychiatry. 2016;50(7):640–8.
Pearse LJ, Dibben C, Ziauddeen H, Denman C, McKenna PJ. A study of psychotic symptoms in borderline personality disorder. J Nerv Ment Dis. 2014;202(5):368–71.
Hepworth CR, Ashcroft K, Kingdon D. Auditory hallucinations: a comparison of beliefs about voices in individuals with schizophrenia and borderline personality disorder. Clin Psychol Psychother. 2013;20(3):239–45.
Slotema CW, Niemantsverdriet MBA, Blom JD, van der Gaag M, Hoek HW, Sommer IEC. Suicidality and hospitalisation in patients with borderline personality disorder who experience auditory verbal hallucinations. Eur Psychiatry. 2017;41:47–52.
De Loore E, Gunther N, Drukker M, Feron F, Sabbe B, Deboutte D, et al. Persistence and outcome of auditory hallucinations in adolescence: a longitudinal general population study of 1800 individuals. Schizophr Res. 2011;127(1–3):252–6.
Kelleher I. Auditory hallucinations in the population: what do they mean and what should we do about them? Acta Psychiatr Scand. 2016;134(1):3–5.
Cavelti M, Thompson KN, Hulbert C, Betts J, Jackson H, Francey S, et al. Exploratory comparison of auditory verbal hallucinations and other psychotic symptoms among youth with borderline personality disorder or schizophrenia spectrum disorder. Early Interv Psychiatry. 2019;13(5):1252–62 This study illustrates that auditory verbal hallucinations are comparable in youth with BPD and youth with schizophrenia spectrum disorder, and suggests that presence of auditory verbal hallucinations in BPD may be indicative of a more severe form of the disorder.
Birchwood M, Chadwick P. The omnipotence of voices: testing the validity of a cognitive model. Psychol Med. 1997;27(6):1345–53.
Cavelti M, Thompson K, Hulbert C, Betts J, Jackson H, Francey S, et al. Preliminary evidence for the cognitive model of auditory verbal hallucinations in youth with borderline personality disorder. Front Psychiatry. 2019;10:292.
Slotema CW, Bayrak H, Linszen MMJ, Deen M, Sommer IEC. Hallucinations in patients with borderline personality disorder: characteristics, severity, and relationship with schizotypy and loneliness. Acta Psychiatr Scand. 2019;139(5):434–42.
Sharp C, Ha C, Michonski J, Venta A, Carbone C. Borderline personality disorder in adolescents: evidence in support of the childhood interview for DSM-IV borderline personality disorder in a sample of adolescent inpatients. Compr Psychiatry. 2012;53(6):765–74.
Michonski JD, Sharp C, Steinberg L, Zanarini MC. An item response theory analysis of the DSM-IV borderline personality disorder criteria in a population-based sample of 11- to 12-year-old children. Personal Disord. 2013;4(1):15–22.
Zanarini MC, Temes CM, Magni LR, Fitzmaurice GM, Aguirre BA, Goodman M. Prevalence rates of borderline symptoms reported by adolescent inpatients with BPD, psychiatrically healthy adolescents and adult inpatients with BPD. Personal Ment Health. 2017;11(3):150–6.
Schuppert HM, Bloo J, Minderaa RB, Emmelkamp PMG, Nauta MH. Psychometric evaluation of the borderline personality disorder severity index-IV--adolescent version and parent version. J Personal Disord. 2012;26(4):628–40.
DeFife JA, Malone JC, DiLallo J, Westen D. Assessing adolescent personality disorders with the Shedler-Westen assessment procedure for adolescents. Clin Psychol Sci Pract. 2013;20(4):393–407.
Crick NR, Murray-Close D, Woods K. Borderline personality features in childhood: a short-term longitudinal study. Dev Psychopathol. 2005 Fall;17(4):1051–70.
Sharp C, Steinberg L, Temple J, Newlin E. An 11-item measure to assess borderline traits in adolescents: refinement of the BPFSC using IRT. Personal Disord. 2014;5(1):70–8.
Sharp C, Mosko O, Chang B, Ha C. The cross-informant concordance and concurrent validity of the Borderline Personality Features Scale for Children in a community sample of boys. Clin Child Psychol Psychiatry. 2011;6(3):335–49.
Haltigan JD, Vaillancourt T. The borderline personality features scale for children (BPFS-C): factor structure and measurement invariance across time and sex in a community-based sample. J Psychopathol Behav Assess. 2016;38(4):600–14.
Vanwoerden S, Garey L, Ferguson T, Temple JR, Sharp C. Borderline personality features scale for Children-11: measurement invariance over time and across gender in a community sample of adolescents. Psychol Assess. 2019;31(1):114–9.
Chang B, Sharp C, Ha C. The criterion validity of the borderline personality features scale for children in an adolescent inpatient setting. J Personal Disord. 2011;25(4):492–503.
Fossati A, Sharp C, Borroni S, Somma A. Psychometric properties of the borderline personality features scale for Children-11 (BPFSC-11) in a sample of community dwelling Italian adolescents. Eur J Psychol Assess. 2019;35(1):70–7.
Chanen AM, Jovev M, Djaja D, McDougall E, Yuen HP, Rawlings D, et al. Screening for borderline personality disorder in outpatient youth. J Personal Disord. 2008;22(4):353–64.
Noblin JL, Venta A, Sharp C. The validity of the MSI-BPD among inpatient adolescents. Assessment. 2014;21(2):210–7.
van Alebeek A, van der Heijden PT, Hessels C, Thong MSY, van Aken M. Comparison of three questionnaires to screen for borderline personality disorder in adolescents and young adults. Eur J Psychol Assess. 2017;33(2):123–8.
Venta A, Magyar M, Hossein S, Sharp C. The psychometric properties of the personality assessment inventory–adolescent’s borderline features scale across two high-risk samples. Psychol Assess. 2018;30(6):827–33.
Goth K, Birkhölzer M, Schmeck K. Assessment of personality functioning in adolescents with the LoPF–Q 12–18 self-report questionnaire [Internet]. J Pers Assess. 2018;100:680–90. Available from. https://doi.org/10.1080/00223891.2018.1489258.
De Clercq B, De Fruyt F, De Bolle M, Van Hiel A, Markon KE, Krueger RF. The hierarchical structure and construct validity of the PID-5 trait measure in adolescence. J Pers. 2014;82(2):158–69.
Zanarini MC, Temes CM, Frankenburg FR, Reich DB, Fitzmaurice GM. Description and prediction of time-to-attainment of excellent recovery for borderline patients followed prospectively for 20 years. Psychiatry Res. 2018;262:40–5.
Alvarez-Tomás I, Soler J, Bados A, Martín-Blanco A, Elices M, Carmona C, et al. Long-term course of borderline personality disorder: a prospective 10-year follow-up study. J Personal Disord. 2017;31(5):590–605.
Soloff PH, Chiappetta L. 10-year outcome of suicidal behavior in borderline personality disorder. J Personal Disord. 2018;22:1–19.
Ng FYY, Bourke ME, Grenyer BFS. Recovery from borderline personality disorder: a systematic review of the perspectives of consumers, clinicians, family and carers. PLoS One. 2016;11(8):e0160515.
Juurlink TT, Ten Have M, Lamers F, van Marle HJF, Anema JR, de Graaf R, et al. Borderline personality symptoms and work performance: a population-based survey. BMC Psychiatry. 2018;18(1):202.
Ostby KA, Czajkowski N, Knudsen GP, Ystrom E, Gjerde LC, Kendler KS, et al. Personality disorders are important risk factors for disability pensioning. Soc Psychiatry Psychiatr Epidemiol. 2014;49(12):2003–11.
•• Moran P, Romaniuk H, Coffey C, Chanen A, Degenhardt L, Borschmann R, et al. The influence of personality disorder on the future mental health and social adjustment of young adults: a population-based, longitudinal cohort study. Lancet Psychiatry. 2016;3(7):636–45 This population cohort study describes the poor long-term social and health outcomes associated with the presence of PD in young adulthood, even at a subthreshold level.
Caruana E, Cotton SM, Farhall J, Parrish EM, Chanen A, Davey CG, et al. A comparison of vocational engagement among Young people with psychosis, depression and borderline personality pathology. Community Ment Health J. 2018;54(6):831–41.
• Hastrup LH, Kongerslev MT, Simonsen E. Low vocational outcome among people diagnosed with borderline personality disorder during first admission to mental health services in Denmark: a nationwide 9-year register-based study. J Personal Disord. 2019;33(3):326–40 This study highlights the severe, negative impacts that BPD has on vocational functioning in comparison to other personality and psychiatric disorders.
Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304–13 e3.
Pistorello J, Fruzzetti AE, Maclane C, Gallop R, Iverson KM. Dialectical behavior therapy (DBT) applied to college students: a randomized clinical trial. J Consult Clin Psychol. 2012;80(6):982–94.
Mehlum L, Tørmoen AJ, Ramberg M, Haga E, Diep LM, Laberg S, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53(10):1082–91.
Santisteban DA, Mena MP, Muir J, McCabe BE, Abalo C, Cummings AM. The efficacy of two adolescent substance abuse treatments and the impact of comorbid depression: results of a small randomized controlled trial. Psychiatr Rehabil J. 2015;38(1):55–64.
McCauley E, Berk MS, Asarnow JR, Adrian M, Cohen J, Korslund K, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. JAMA Psychiatry. 2018;75(8):777–85.
Beck E, Bo S, Jørgensen MS, Gondan M, Poulsen S, Storebø OJ, et al. Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial. J Child Psychol Psychiatry. 2019. https://doi.org/10.1111/jcpp.13152.
Chanen AM, Jackson HJ, McCutcheon LK, Jovev M, Dudgeon P, Yuen HP, et al. Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial. Br J Psychiatry. 2008;193(6):477–84.
Schuppert HM, Timmerman ME, Bloo J, van Gemert TG, Wiersema HM, Minderaa RB, et al. Emotion regulation training for adolescents with borderline personality disorder traits: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1314–23 e2.
Mehlum L, Ramleth R-K, Tørmoen AJ, Haga E, Diep LM, Stanley BH, et al. Long term effectiveness of dialectical behavior therapy versus enhanced usual care for adolescents with self-harming and suicidal behavior. J Child Psychol Psychiatry. 2019;60(10):1112–22.
Chanen A, Jackson H, Cotton SM, Gleeson J, Davey CG, Betts J, et al. Comparing three forms of early intervention for youth with borderline personality disorder (the MOBY study): study protocol for a randomised controlled trial. Trials. 2015;16(1):1–10.
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Andrew M. Chanen, Katie Nicol, Jennifer K. Betts, and Katherine N. Thompson each declare no potential conflicts of interest.
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Chanen, A.M., Nicol, K., Betts, J.K. et al. Diagnosis and Treatment of Borderline Personality Disorder in Young People. Curr Psychiatry Rep 22, 25 (2020). https://doi.org/10.1007/s11920-020-01144-5
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DOI: https://doi.org/10.1007/s11920-020-01144-5