The persistence of borderline personality disorder in adolescence

Symptoms characteristics of personality disorders associated with suicidal ideation and behaviors in a clinical sample of adolescents with a depressive disorder

Introduction

Pathological personality traits have repeatedly been identified as important risk factors for suicidal ideation and behaviors. Moreover, impulsive-aggressive traits, have shown a consistent association with suicidal behaviors across the lifespan. Adolescence represents a critical period for the emergence of different personality traits, mood disorders, and suicidal behaviors, but the relationship between these variables remain poorly understood.

Methods

These variables were examined in a cross-sectional case-control design involving three groups: 30 adolescents with a depressive disorder and past suicide attempt (Mean Age = 16.2, Females = 26), 38 adolescents with a depressive disorder but without past suicide attempt (Mean age = 16.0, Females = 29), and 34 healthy adolescent controls (Mean age = 15.2, Females = 22). Suicidal ideations were indexed using Suicidal Behavior Questionnaire (SBQ-R), psychiatric disorder assessed using a semi-structured questionnaire (K-SADS-PL), depressive symptoms with the Beck Depressive Inventory (BDI), symptoms characteristics of personality disorders with the Scheduled Clinical Interview for the DSM-IV (SCID-II) screening questionnaire, and impulsivity with the Barratt Impulsivesness Scale (BIS).

Results

Findings showed that impulsivity (F = 11.0, p < 0.0001) and antisocial symptoms characteristics of personality disorders (p < 0.001, d = 0.70) displayed the most robust association with adolescent suicide attempts. Borderline symptoms characteristics of personality disorders did not discriminate attempters from non-attempters but presented high correlations with suicidal ideation and depression severity. In an item-wise analysis, suicide attempt status was uniquely correlated with symptoms characteristics of an antisocial personality disorder. Suicide attempt status also correlated with non-suicidal self-injury and a chronic feeling of emptiness.

Discussion

The caveats of this cross-sectional study include the stability of symptoms characteristics of personality disorders in adolescence and the limited sample size. In sum, suicidal behaviors were characteristically correlated with increased impulsivity and antisocial symptoms characteristics of personality disorders, but other symptoms characteristics of personality disorders were relevant to adolescent depression and suicidal ideation. Understanding the emergence of symptoms characteristics of personality disorders and suicidal behaviors in a developmental context can ultimately inform not only the neurobiological origin of suicidal behaviors, but also provide new avenues for early detection and intervention.

Prediction of Treatment Outcome of Adolescents With Borderline Personality Disorder: A 2-Year Follow-Up Study

This study examined prediction of various clinical outcomes in adolescents with borderline personality disorder (BPD) features. Of the 112 adolescents who participated at baseline, 97 were seen at 2-year follow-up, of which 49 (50.5%) had clinically improved, defined as a decrease in BPD pathology of minimum 12 points on the Borderline Personality Features Scale for Children (BPFS-C). Eighty-one adolescents fulfilled the diagnostic criteria for BPD and scored above clinical cutoff on the BPFS-C at baseline, of which 26 (32%) had remitted at follow-up by self-report on the BPFS-C. Results showed that adolescents with comorbid oppositional defiant disorder at baseline were less likely to have clinically improved or remitted at follow-up. Participants with increased self-reported depression and less exposure to physical abuse at baseline had increased odds of remission. Our findings suggest that more internalizing and less externalizing symptoms increase the odds of positive treatment outcome in adolescents with BPD.

Identity Diffusion as the Organizing Principle of Borderline Personality Traits in Adolescents-A Non-clinical Study

Growing evidence shows that diagnosing and treating borderline personality disorder (BPD) is of high relevance for affected youths. Although identity crisis is part of the normative developmental process, identity diffusion is a potential candidate for being an appropriate concept in further developing screening tools and interventions for BPD treatment in adolescence. We hypothesized that severity of borderline traits (as indicated by the strength of their associations with identity diffusion) would be negatively associated with non-clinical adolescents' endorsement of borderline features' presence. We also hypothesized that identity diffusion had a central role in the network of borderline personality traits and could be conceived of as a latent organizing principle of borderline personality disorder. In our study, 169 non-clinical adolescents (81 girls and 88 boys; M _age = 15.38; SD_age = 1.52) filled out self-report measures of borderline personality features and identity diffusion. According to our results, having strong feelings and interpersonal sensitivity were the two most endorsed borderline personality features. Borderline personality features were positively correlated with identity diffusion. The more severe a borderline personality feature was, the less relevant it was for non-clinical adolescents. According to a network analysis, identity diffusion was the most central and least redundant element of the network of borderline personality traits. Results are discussed from a clinical point of view, further encouraging professionals to use identity diffusion screening tools to detect BPD in adolescence.

Psychometric Properties of the French Version of the Borderline Personality Features Scale for Children and Adolescents

Background:

The Borderline Personality Feature Scale for Children (BPFS-C) is currently the only dimensional measure of child and adolescent borderline features and the English version has been shown to have good psychometric properties. To extend the use of this measure with French speaking adolescents, it is essential to examine the reliability and validity of the French BPFS-C.

Objective:

The present study sought to assess the psychometric properties of the French BPFS-C.

Methods:

A community sample of 394 adolescents and young adults completed the Borderline Personality Features Scale for Children (BPFS-C), as well as the Million Adolescent Clinical Inventory (MACI) borderline tendency subscale, the Child Behavior Checklist- Youth Self-Report (CBCL-YSR) and the Beck Youth Inventories (BYI).

Results:

The findings show that both the long and short French BPFS-C have good internal consistency and convergent validity. Affect regulation, identity, relationship difficulties and self-harm were found to be closely inter-connected rather than distinct factors.

Conclusion:

The findings indicate that both long and short versions of French BPFS-C have good psychometric properties and provide preliminary evidence that the total scores are reliable and valid indicators of borderline personality features in adolescents and young adults.

Clinical Profiles Among Greek Adolescent Suicide Attempters

BACKGROUND

Suicide attempts are a significant public health problem among youth, resulting in a major social and economic burden for communities and a devastating impact on families.

AIMS

To determine whether we can identify distinct clinical profiles using latent class analysis in a clinical sample of Greek adolescents who were admitted to hospital following a suicide attempt.

METHOD

Data on 11 clinical parameters from 182 adolescents were analyzed, with a two-class solution selected as the best fitting among the one- through three-class solutions that were examined.

RESULTS

We observed two distinct classes, specifically in the probability of mood disorders, substance use disorders, abandonment/neglect, and displaying traits of personality disorders. While most of the adolescents who attempted suicide showed a low probability of these parameters (71.7%), about a third of the sample (28.3%) showed a much more severe clinical profile. Analyses of pertinent contextual and risk factors indicated that those with a more severe clinical profile tend to come from overall more dysfunctional family systems, have more problems in school, and have made a previous attempt.

CONCLUSION

We conclude that the adolescent suicide attempt population is a heterogeneous group in need of focused differentiated care specifically targeted to particular subgroups.

Validity, utility and acceptability of borderline personality disorder diagnosis in childhood and adolescence: survey of psychiatrists

Aims and method

To establish the views of child and adolescent psychiatrists (n = 52) regarding the conceptual and empirical validity, clinical utility and acceptability of the diagnosis of borderline personality disorder in child and adolescent populations. A questionnaire survey was carried out.

Results

The child and adolescent psychiatrists' perception of the validity of borderline personality disorder for adult populations was relatively high (82% felt it to be valid). Significantly fewer of those considered borderline personality disorder to be valid for adolescent populations (37%). Strikingly different results were obtained when the questions related to child (<12 years) populations (2%).

Clinical implications

Given the views expressed by these consultant child and adolescent psychiatrists, it would seem appropriate to approach with caution suggestions that the borderline personality disorder category should have extended use with adolescent and child populations.

Identifying a borderline personality disorder prodrome: Implications for community screening

Elucidating early signs and symptoms of borderline personality disorder (BPD) has important implications for screening and identifying youth appropriate for early intervention. The purpose of this study was to identify dimensions of child temperament and psychopathology symptom severity that predict conversion to a positive screen for BPD over a 14-year follow-up period in a large, urban community sample of girls (n = 2 450). Parent and teacher reports of child temperament and psychopathology symptom severity assessed when girls were ages 5-8 years were examined as predictors of new-onset BPD cases when girls were ages 14-22 years. In the final model, parent and teacher ratings of emotionality remained significant predictors of new-onset BPD. Additionally, parent ratings of hyperactivity/impulsivity and depression severity, as well as teacher ratings of inattention severity, were also predictive. Results also revealed that elevations in these dimensions pose a notable increase in risk for conversion to BPD over the follow-up period. Supplementary analyses revealed that with the exception of parent-reported depression severity, these same predictors were associated with increases in BPD symptom severity over the follow-up period. These findings suggest BPD onset in adolescence and early adulthood can be detected from parent and teacher reports of temperament and symptom severity dimensions assessed in childhood. The identification of this prodrome holds promise for advancing early detection of children at risk prior to the development of the full-blown disorder. Copyright © 2017 John Wiley & Sons, Ltd.

Genetic and environmental influences on the codevelopment among borderline personality disorder traits, major depression symptoms, and substance use disorder symptoms from adolescence to young adulthood

Although borderline personality disorder (BPD) traits decline from adolescence to adulthood, comorbid psychopathology such as symptoms of major depressive disorder (MDD), alcohol use disorder (AUD), and drug use disorders (DUDs) likely disrupt this normative decline. Using a longitudinal sample of female twins (N = 1,763), we examined if levels of BPD traits were correlated with changes in MDD, AUD, and DUD symptoms from ages 14 to 24. A parallel process biometric latent growth model examined the contributions of genetic and environmental factors to the relationships between developmental components of these phenotypes. Higher BPD trait levels predicted a greater rate of increase in AUD and DUD symptoms, and higher AUD and DUD symptoms predicted a slower rate of decline of BPD traits from ages 14 to 24. Common genetic influences accounted for the associations between BPD traits and each disorder, as well as the interrelationships of AUD and DUD symptoms. Both genetic and nonshared environmental influences accounted for the correlated levels between BPD traits and MDD symptoms, but solely environmental influences accounted for the correlated changes between the two over time. Results indicate that higher levels of BPD traits may contribute to an earlier onset and faster escalation of AUD and DUD symptoms, and substance use problems slow the normative decline in BPD traits. Overall, our data suggests that primarily genetic influences contribute to the comorbidity between BPD features and substance use disorder symptoms. We discuss our data in the context of two major theories of developmental psychopathology and comorbidity.

Outpatient Dialectical Behavior Therapy for Adolescents Engaged in Deliberate Self-Harm: Conceptual and Methodological Considerations

The current review examines conceptual and methodological issues related to the use of dialectical behavior therapy for adolescents (DBT-A) in treating youth who engage in deliberate self-harm. A comprehensive review of the literature identified six studies appropriate for the review. Results indicated several inconsistencies and limitations across studies including the mixing of various forms of self-harm; variations in diagnostic inclusion/exclusion criteria, insufficient use of standardized self-harm outcome measures, variable lengths and intensity of provided treatment, and inadequate attention paid to DBT adherence. Each of these areas is reviewed along with a discussion of ways to improve the quality of future research.

The aetiological and psychopathological validity of borderline personality disorder in youth: A systematic review and meta-analysis

Controversy surrounds the diagnosis of Borderline Personality Disorder (BPD) in youth. This meta-analysis summarised evidence regarding the aetiological and psychopathological validity of youth BPD (the extent to which youth and adult BPD share common risk factors and psychopathology). We identified 61 studies satisfying predetermined inclusion criteria. Statistically significant pooled associations with youth (19 years of age and under) BPD were observed for sexual abuse (all youth: odds ratio=4.88; 95% confidence interval=3.30, 7.21; children: OR=3.97; 95% CI=1.51, 10.41; adolescents: OR=5.41; 95% CI=3.43, 8.53); physical abuse (all youth: 2.79 [2.03, 3.84]; children: 2.86 [1.98, 4.13]; adolescents: 2.60 [1.38, 4.90]); maternal hostility/verbal abuse (all youth: 3.28 [2.67, 4.03]; children: 3.15 [2.55, 3.88]; adolescents: 4.71 [1.77, 12.53]); and neglect (all youth: 3.40 [2.27, 5.11]; children: 2.87 [1.73, 4.73]; adolescents: 4.87 [2.24, 10.59]). Several psychopathological features were also associated with youth BPD, including comorbid mood (3.21 [2.13, 4.83]), anxiety (2.30 [1.44, 3.70]) and substance use (2.92 [1.60, 5.31]) disorders; self-harm (2.81 [1.61, 4.90]); suicide ideation (all youth: 2.02 [1.23, 3.32]; children: 6.00 [1.81, 19.84]; adolescents: 1.75 [1.20; 2.54]) and suicide attempt (2.10 [1.21, 3.66]). Results demonstrate that adult and youth BPD share common aetiological and psychopathological correlates. This offers some support for the diagnostic validity of youth BPD and indicates the need for clinical recognition in this age group.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

Clinical and psychosocial outcomes of borderline personality disorder in childhood and adolescence: a systematic review

BACKGROUND

While there is a growing body of research on borderline personality disorder (BPD) in children and adolescents, controversy remains regarding the validity and diagnosis of the disorder prior to adulthood.

METHOD

MEDLINE, EMBASE, Psych INFO and PubMed databases were systematically searched for articles pertaining to the clinical and psychosocial outcomes (i.e. predictive validity) of BPD first diagnosed in childhood or adolescence (i.e. prior to 19 years of age). All primary empirical studies were included in the review. A narrative synthesis of the data was completed.

RESULTS

A total of 8200 abstracts were screened. Out of 214 full-text articles, 18 satisfied the predetermined inclusion criteria. Quality assessment indicated that most studies had high risk of bias in at least one study domain. Consistent with the adult literature, the diagnostic stability of BPD prior to the age of 19 years was low to moderate, and mean-level and rank-order stability, moderate to high. Individuals with BPD symptoms in childhood or adolescence had significant social, educational, work and financial impairment in later life.

CONCLUSIONS

Studies indicate that borderline pathology prior to the age of 19 years is predictive of long-term deficits in functioning, and that a considerable proportion of individuals continue to manifest borderline symptoms up to 20 years later. These findings provide some support for the clinical utility of the BPD phenotype in younger populations, and suggest that an early intervention approach may be warranted. Further prospective studies are needed to delineate risk (and protective) factors pertinent to the chronicity of BPD across the lifespan.

Correlates, stability and predictors of borderline personality disorder among previously suicidal youth

This article examines a large cohort of previously suicidal adolescents, identifying those that surpassed threshold criteria for borderline personality disorder (BPD), according to the Abbreviated Diagnostic Interview of Borderlines (Ab-DIB), and determining the stability, correlates and predictors of BPD from early-to-late adolescence. Two hundred and eighty-six youth (mean baseline age 14.6 years; SD 1.5), presenting consecutively to a metropolitan pediatric hospital emergency department for evaluation of suicidality, were assessed at initial consultation for Axis I and II disorders and demographic and clinical variables. Two hundred and twenty-nine (80%) were re-assessed for those variables 4 years later and 204 (70.3%) had complete data sets at recruitment and follow-up. Previously suicidal youths who met BPD threshold on the Ab-DIB at recruitment were distinguishable at baseline from those who did not in conduct disorder symptoms (p < 0.003), lower levels of functioning (p < 0.001), drug use (p < 0.001), stressful life events (p < 0.003) and family relations (p < 0.001). The BPD diagnosis was consistent, according to this measure, at baseline and follow-up for 76% of participants. Four groups with respect to borderline pathology (persisting, remitting, emerging and never) were identified (ICC = 0.603, 95% CI = 0.40-0.78). Persistent BPD status was predictable by older age at presentation (p < 0.01) and level of functioning (p < 0.05). Eight percent were also suicidal at the 4-year follow-up. Using a self-report measure of BPD, we suggest that suicidal youth can indeed be diagnosed with the disorder at 14 years old, supporting the shift from DSM-IV to DSM-5, given what appears to be its temporal stability, differentiation of those suffering with considerable symptomatology or not, and predictors of its status in late adolescence. The low suicidality rate at follow-up indicates a good short-term prognosis.

Neurological soft signs in adolescents with borderline personality traits

OBJECTIVE

This study investigated the prevalence and severity of neurological soft signs (NSS), and their relationships with borderline personality (BP) traits in adolescents.

METHODS

Eighty-nine adolescents with BP traits (BP-trait group), and 89 adolescents without traits of any personality disorder (control group), were recruited in China. BP traits were diagnosed by the BPD subscale of the Personality Diagnostic Questionnaire for the DSM-IV (PDQ-4+). The soft sign subscales of the Cambridge Neurological Inventory were administered to all participants. The group differences in prevalence of soft signs and in NSS scores were analyzed, as well as the associations between the NSS scale and borderline personality traits.

RESULTS

Five soft signs were significantly more frequent in adolescents with BP traits. A total of 59.6% of adolescents with BP traits exhibited at least 1 NSS, whereas only 34.8% of adolescents without BP traits did (p < 0.01). A total of 42.7% of adolescents in the BP-trait group exhibited at least 2 NSS, while only 16.9% of adolescents without BP traits did (p < 0.001). Moreover, adolescents with BP traits showed more sensory integration, disinhibition, total neurological soft signs, left-side soft signs, and right-side soft signs, than adolescents without BP traits. Sensory integration and disinhibition were positively associated with BP traits.

CONCLUSION

These findings suggest that adolescents with BP traits may have a nonfocal abnormality of the central nervous system.

Diagnosing Borderline Personality Disorder During Adolescence: A Review of the Published Literature

Borderline personality disorder (BPD) is a debilitating disorder that occurs in approximately 1% to 3% of the general population. BPD is not only relatively prevalent; it is also associated with significant public health and security concerns. The clinical and social burden of adult BPD diagnosis has resulted in the desire for early diagnosis and the implementation of early intervention programs. A qualitative review of the scientific literature suggested that adolescence is a critical point for the early identification and therapeutic treatment of BPD. Although findings are far from conclusive, the inter-rater reliability and internal consistency of the Diagnostic and Statistical Manual of Mental Disorders symptom criteria for BPD during adolescence seem adequate. Recent studies based on a rigorous methodology of BPD assessment and large community samples reported prevalence rates for BPD diagnosis during adolescence that were less suspect than previous findings. A number of research studies addressed the construct validity of BPD in adolescents (i.e., whether a BPD diagnosis during adolescence actually measures what is intending to measure) and reported consistent relationships between BPD and associated areas of dysfunction and distress as evidence of the validity of the BPD diagnosis. Research evidence indicates that there is no single symptom that is predictive of later BPD diagnosis during adolescence; rather, a pattern of two to three selected BPD symptoms that are evident during adolescence seemed to be highly predictive of later BPD diagnosis, particularly when measures that were specifically designed to assess for BPD during adolescence were used as part of the assessment process.

If It Looks Like a Duck and Quacks Like a Duck: Evaluating the Validity of Borderline Personality Disorder in Adolescents

Background:

The validity of borderline personality disorder (BPD) has been a topic of much controversy in psychiatry. Over the last two decades, a wealth of empirical work has challenged long-held concerns regarding the validity of adolescent BPD. However, this research has been conducted within a traditional approach to psychiatric nosology.

Objective:

In this article, we aim to evaluate the validity of adolescent BPD as guided by both the Robins and Guze criteria for the validity of psychiatric constructs and the new National Institute of Mental Health Research Domain Criteria (NIMH RDoC).

Method:

We used the five principles of the Robins and Guze approach to evaluate selected research from our own and other groups regarding the validity of adolescent BPD. These principles include clinical description studies, laboratory studies, studies that delimitate the disorder from other related syndromes, follow-up studies, and family studies.

Results:

Within the Robins and Guze criteria framework, evidence to date supports the validity of adolescent BPD to some extent. However, limitations of the research about the construct validity of adolescent BPD have also been identified, most notably regarding the delimitation of adolescent BPD from other disorders as well as a lack of longitudinal and family studies.

Conclusions:

Given these limitations and the limitations of the Robins and Guze approach to psychiatric nosology, we recommend exploring the potential of the National Institute of Mental Health Research Domain Criteria as a complement to previous work.

Six-month trajectory of suicidal ideation in adolescents with borderline personality disorder

Few studies have longitudinally examined suicidal ideation in those with adolescent-onset borderline personality disorder (BPD). The current study aimed to examine the trajectory of suicidal ideation in adolescents with BPD longitudinally over 6 months, with follow-ups at 2, 4, and 6 months posthospitalization for elevated suicide risk. Results indicated that the BPD group exhibited a greater decrease in suicidal ideation in the months following hospitalization than those without a BPD diagnosis. The findings of this study indicated that suicidal ideation in adolescents with BPD is not stable, and although ideation may decrease quickly after hospitalization, regular assessment of ideation is recommended.

Borderline personality disorder in suicidal adolescents

The diagnosis of borderline personality disorder (BPD) in adolescents has been controversial. Thus, few studies have examined BPD in suicidal adolescents, even though it is strongly associated with suicidal behaviours in adults. This study examines differences between suicidal adolescents with (n = 47) and without (n = 72) BPD on history and characteristics of suicidal behaviour, Axis I co-morbidity, affect regulation and aggression. Assessments were completed with both adolescents and parents, and consensus ratings based on best available data were analysed. BPD participants were more likely to have a history of suicide attempts and to have been admitted because of a suicide attempt (vs. suicidal ideation). There were no significant differences in self-injurious behaviours or degree of suicidal ideation. BPD participants also had more psychiatric co-morbidity and higher aggression scores but no significant differences in affective dysregulation compared with suicidal adolescents without BPD. Diagnostic stability over 6 months was modest. Our results demonstrate that, compared with other acutely suicidal adolescents, the clinical profile of BPD participants is unique and suggests an increased risk for suicidal behaviours. This extends upon other studies that support the construct validity of BPD during adolescence and suggests that BPD should be considered in suicide risk assessment for adolescents.

Borderline personality disorder in adolescence: the case for medium stay inpatient treatment

BACKGROUND

The diagnosis of personality disorders in adolescents has been a topic of debate in recent years.

METHOD

This manuscript reviews the case of an adolescent girl admitted for a medium length combined inpatient and partial hospitalization program. This program has developed protocols to assess for Axis I and II pathology as well as various psychological processes. Comprehensive outcome measures were administered to the patient at discharge and follow-up.

RESULTS/CONCLUSIONS

Diagnosis of a personality disorder in adolescence appears to be associated with psychological processes usually identified in adults. Against the background of an emerging debate about the need to reform a culture of ultra-short inpatient care, this case study provides some support for more thorough assessment, diagnosis, and treatment of adolescents who appear to have comorbid Axis I and II disorders.

Borderline personality disorder in adolescents: evidence in support of the Childhood Interview for DSM-IV Borderline Personality Disorder in a sample of adolescent inpatients

Empirical evidence is increasing in support of the validity of the construct of borderline personality disorder (BPD) in adolescence. There is growing consensus that the early identification and treatment of emerging borderline traits may be an important focus. However, few diagnostic (questionnaire- or interview-based) measures specifically developed or adapted for adolescents and children exist. The Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD) [Zanarini, 2003] is a promising interview-based measure of adolescent BPD. Currently, no studies have explicitly been designed to examine the psychometric properties of the CI-BPD. The aim of the current study was to examine various psychometric properties of the CI-BPD in an inpatient sample of adolescents (n = 245). A confirmatory factor analytic approach was used to examine the internal factor structure of the 9 CI-BPD items. In addition, internal consistency, interrater reliability, convergent validity (with clinician diagnosis and 2 questionnaire-based measures of BPD), and concurrent validity (with Axis I psychopathology and deliberate self-harm) were examined. Similar to several adult studies, the confirmatory factor analytic results supported a unidimensional factor structure for the CI-BPD, indicating that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria on which the CI-BPD is based constitute a coherent combination of traits and symptoms even in adolescents. In addition, other validity criteria were excellent. Taken together, the current study provides strong evidence for the validity of the CI-BPD for use in adolescents.

Development of borderline personality disorder in adolescence and young adulthood: introduction to the special section

Recognizable symptoms and features of borderline personality disorder (BPD) appear during adolescence. However, there has been resistance to diagnose or research this disorder prior to adulthood because of clinical lore that BPD is a long-standing illness and that personality traits are not stable until adulthood. This has resulted in little information regarding the development of and risk factors for BPD in youth. The goal of this special section is to examine the development of BPD in adolescence and young adulthood using a broad collection of approaches, including a theoretical review paper, two prospective studies, and a multi-method cross-sectional study. This body of work provides new insights into vulnerabilities that may transact with early attachment relationships and experiences to predict the emergence of BPD in adolescence and young adulthood. These papers also point to future research that is needed to better understand the etiology, development, and course of BPD.

Theory of mind and emotion regulation difficulties in adolescents with borderline traits

OBJECTIVE

Dysfunctions in both emotion regulation and social cognition (understanding behavior in mental state terms, theory of mind or mentalizing) have been proposed as explanations for disturbances of interpersonal behavior in borderline personality disorder (BPD). This study aimed to examine mentalizing in adolescents with emerging BPD from a dimensional and categorical point of view, controlling for gender, age, Axis I and Axis II symptoms, and to explore the mediating role of emotion regulation in the relation between theory of mind and borderline traits.

METHOD

The newly developed Movie for the Assessment of Social Cognition (MASC) was administered alongside self-report measures of emotion regulation and psychopathology to 111 adolescent inpatients between the ages of 12 to 17 (mean age = 15.5 years; SD = 1.44 years). For categorical analyses borderline diagnosis was determined through semi-structured clinical interview, which showed that 23% of the sample met criteria for BPD.

RESULTS

Findings suggest a relationship between borderline traits and "hypermentalizing" (excessive, inaccurate mentalizing) independent of age, gender, externalizing, internalizing and psychopathy symptoms. The relation between hypermentalizing and BPD traits was partially mediated by difficulties in emotion regulation, accounting for 43.5% of the hypermentalizing to BPD path.

CONCLUSIONS

Results suggest that in adolescents with borderline personality features the loss of mentalization is more apparent in the emergence of unusual alternative strategies (hypermentalizing) than in the loss of the capacity per se (no mentalizing or undermentalizing). Moreover, for the first time, empirical evidence is provided to support the notion that mentalizing exerts its influence on borderline traits through the mediating role of emotion dysregulation.

Identity disturbance in adolescence: associations with borderline personality disorder

Although establishing a coherent identity is often viewed as a normative developmental task of adolescence, an important question is whether forms of identity disturbance seen in adult personality disorders can also be distinguished in adolescents. If so, such disturbances would constitute an essential target for research and clinical interventions. The goal of this study is to investigate the nature of identity disturbance in an adolescent clinical sample and to explore its links with personality pathology, particularly borderline personality disorder. A national random sample of 139 psychiatrists and clinical psychologists completed a battery of instruments on a randomly selected adolescent patient in their care, including measures of Axis II symptoms and the Identity Disturbance Questionnaire-Adolescent Version, an instrument designed for clinically experienced observers that assesses a wide range of manifestations of potential identity disturbance among adolescents. Factor analysis of the Identity Disturbance Questionnaire--Adolescent Version yielded four clinically and conceptually coherent factors that resembled dimensions previously identified in adults: lack of normative commitment, role absorption, painful incoherence, and lack of consistency. As in adults, identity disturbance in adolescents is a clinically meaningful, multidimensional construct exhibiting significant relationships with different forms of severe personality pathology, most notably borderline personality disorder. As such, identity disturbance can be a manifestation of psychopathology above and beyond the typical Sturm und Drang (storm and stress) of adolescence.

Stability, change, and heritability of borderline personality disorder traits from adolescence to adulthood: a longitudinal twin study

Although personality disorders are best understood in the context of lifetime development, there is a paucity of work examining their longitudinal trajectory. An understanding of the expected course and the genetic and environmental contributions to these disorders is necessary for a detailed understanding of risk processes that lead to their manifestation. The current study examined the longitudinal course and heritability of borderline personality disorder (BPD) over a period of 10 years starting in adolescence (age 14) and ending in adulthood (age 24). In doing so, we built on existing research by using a large community sample of adolescent female twins, a sensitive dimensional measure of BPD traits, an extended follow-up period, and a longitudinal twin design that allowed us to investigate the heritability of BPD traits at four discrete ages spanning midadolescence to early adulthood. Results indicated that mean-level BPD traits significantly decline from adolescence to adulthood, but rank order stability remained high. BPD traits were moderately heritable at all ages, with a slight trend for increased heritability from age 14 to age 24. A genetically informed latent growth curve model indicated that both the stability and change of BPD traits are highly influenced by genetic factors and modestly by nonshared environmental factors. Our results indicate that as is the case for other personality dimensions, trait BPD declines as individuals mature from adolescence to adulthood, and that this process is influenced in part by the same genetic factors that influence BPD trait stability.

Persönlichkeitsstörungen im Kindes- und Jugendalter?

Durch die Fortschritte bei der Behandlung von Persönlichkeitsstörungen im Erwachsenenalter wird die Übertragung dieser Konzepte auf das Kindes- und Jugendalter heute intensiv diskutiert. Argumente für und gegen eine Vergabe von Persönlichkeitsstörungsdiagnosen im Kindes- und Jugendalter werden diskutiert. Es werden aktuelle Erkenntnisse zur Diagnostik und dem Verlauf von Persönlichkeitsstörungen berichtet. Das Pro und Contra einer Diagnosestellung wird vor diesem Hintergrund gegenübergestellt.

Fact or fiction: diagnosing borderline personality disorder in adolescents

Borderline Personality Disorder (BPD) has long been considered a mental health problem that results in considerable costs in terms of human suffering and psychiatric expenses among adult patients. Although the diagnosis of BPD for adolescents is frequently used in clinical settings, the field of mental health has questioned whether one should diagnose BPD among adolescents. This paper reviews the recent empirical literature (identified through PsycINFO 1980 to present) to evaluate prevalence, reliability, and validity of a BPD diagnosis in adolescents. It is concluded that the features BPD diagnoses in adolescents are comparable to those in adults. Furthermore, there appears to be a legitimate subgroup of adolescents for whom the diagnosis remains stable over time as well as a less severe subgroup that moves in and out of the diagnosis. While caution is warranted, formal assessment of BPD in adolescents may yield more accurate and effective treatment for adolescents experiencing BPD symptomatology. More longitudinal research is necessary to further explicate the issues of diagnosing BPD in adolescents.

Borderline personality disorder: A comparison between children and adults

Recently, more empirical studies have been devoted to the investigation of borderline personality disorder (BPD) in children and adolescents. Against this background, the purpose of the current review is to compare research findings on diagnostic-related phenomena in child and adolescent samples with those in adult samples to establish the utility of the BPD construct in childhood and adolescence. A search of relevant publications reported in Pubmed and PsycInfo from 1940 (the first clinical descriptions of BPD in childhood) to 2006 was carried out. A total of 58 studies were included. The review of the adult literature was not exhaustive but relied on excellent existing and comprehensive reviews of the adult literature carried out in the past 5 years. Although significant differences seem to exist between juveniles and adults in diagnostic-related phenomena associated with BPD, these can be explained by the principle of heterotypic continuity in development. Moreover, enough overlap between juvenile and adult BPD has been observed to warrant further empirical investigation into the construct of juvenile BPD. Specific areas for future research in juvenile BPD suggested by this review include studies of comorbidity, measure development, and the use of neurobiological measures such as functional neuroimaging.

Brain maturation in conduct disorder versus borderline personality disorder

Conduct disorder (CD) and borderline personality disorder (BPD) have been associated with abnormalities in brain function. The present study assessed whether adolescents with significant symptoms of CD and BPD display abnormal brain maturation. Participants recruited from the community were categorized as CD only, BPD only, CD plus BPD, or controls with neither CD nor BPD. Brain maturation was estimated by the amplitude difference in the P300 event-related brain potential between participants < versus > or = 17 years old. With increasing age, controls and BPD only participants exhibited a P300 amplitude decline. This pattern was not evident in the CD only and CD plus BPD groups. The different brain maturation patterns seen in adolescents with CD versus BPD symptoms may contribute to differences in age-of-onset, clinical course, and resistance to treatment.

The development of impulsivity and suicidality in borderline personality disorder

Borderline personality disorder (BPD) is characterized by a broad pattern of impulsivity and suicidality. BPD usually begins in adolescence; the full clinical picture of the disorder is associated with developmental increases in impulsivity. However, BPD also has childhood precursors. The developmental pathways are similar to those found in other impulsive spectrum disorders, but children who later develop BPD probably have both externalizing and internalizing symptoms. Research in this area has made use of retrospective data from adults, prospective data from community studies, follow-up studies from children at risk, as well as research on "borderline pathology of childhood" (a condition with symptoms similar to adult BPD). Existing evidence suggests that both temperamental and environmental risk factors play a role in the development of the behavioral patterns associated with the disorder. These pathways also help account for the life course and outcome of BPD in adulthood.

Predicting change in borderline personality: Using neurobehavioral systems indicators within an individual growth curve framework

The natural history and course of borderline personality disorder (BPD) has long been the focus of speculation, typically guided by impressions from clinical work with BPD-affected individuals. Not unlike the other personality disorders (PDs), it has long been assumed that BPD is relatively stable, traitlike, and enduring in nature. The extent to which BPD is or is not a plastic construct has implications not only for understanding its longitudinal course, but also for understanding its development and, ultimately, its treatment and/or prevention. This paper consists of two parts. The first part reviews the longitudinal research corpus that bears directly upon the issue of stability of BPD in both adolescents and adults. The consistent trend in very nearly all studies, whether using a categorical or dimensional approach to assessment, is one of considerable change over time. This literature presents complexities, however, because most of the extant studies examine BPD-affected individuals who have been exposed to treatment. However, at least two large-scale longitudinal studies, which include both treated and untreated persons, also provide support for viewing BPD as a malleable disorder that declines in severity over time. The second part presents original data from the Longitudinal Study of Personality Disorders that specifically examine the predictors of change in BPD using a neurobehavioral model of personality within an individual growth curve (IGC) analytical framework. This IGC analysis revealed important predictors of both overall level of BPD features as well as rate of change in BPD features, with particularly important roles played by the agentic positive emotion (i.e., incentive motivation) and anxiety (negative emotion) systems. The benefits of the IGC approach for understanding the developmental psychopathology of BPD is also stressed.

Difficulties in the assessment of personality traits and disorders in eating-disordered individuals

There are compelling reasons to examine personality variables in the eating disorder (ED) field but many impediments to the collection of useful data. In addition to the conceptual and methodological difficulties associated with personality assessment in the general case, the EDs present a number of special problems. These include patients' young age at onset and evaluation, the "state" effects of semi-starvation and chaotic eating, denial and distortion in self-report, the instability of ED subtypes, and the intrusion of eating and weight concerns into a wide range of apparently unrelated domains. Although there is substantial support for the clinical view that personality variables are linked to anorexia nervosa (AN) and bulimia nervosa (BN), the identification of stable traits and Axis II disorders in individual patients should be deferred until after the initial phase of treatment.

A "little five" lexically based perspective on personality disorder symptoms in adolescence

Recently, De Clercq and De Fruyt (2003) examined the relation between adaptive and maladaptive personality functioning in adolescence, using adult measures to describe adolescent personality and personality pathology, i.e., that is the NEOPI-R (Costa & McCrae, 1992) and the ADP-IV (Schotte & De Doncker, 1994) respectively. The present study extends this work, administering a lexically based and age-specific measure of adaptive personality, i.e., that is the Hierarchical Personality Inventory for Children (HiPIC; Mervielde & De Fruyt, 1999), to 454 nonclinical adolescents. Results largely replicated across adult FFM versus lexically derived and age-specific measures, although HiPIC domains explained a larger proportion of disorder variance, with Benevolence and Conscientiousness especially demonstrating less descriptive specificity. Lexically derived facets were further helpful to achieve greater disorder-descriptive specificity. Finally, adolescent personality pathology, when operationalized using Axis II criteria, showed more overlap in adolescence than in adults. It is concluded that future studies should focus on age-specific taxonomies and measures to assess personality pathology in adolescence.

Factor Structure of the Borderline Personality Inventory in Adolescents

Summary: Borderline personality disorder (BPD) is a frequent disorder in in- and outpatient settings. However, empirical studies suggest that BPD lacks construct validity in adolescents. Problems with validity may be linked to the fact that borderline symptoms can occur in the course of normal adolescence. This study examined the factor structure of borderline symptomatology in a community-based sample of 616 adolescents (mean age = 16.9±1.5). Borderline symptomatology was assessed by the Borderline Personality Inventory (BPI), a self-report instrument for which reliability and validity have been demonstrated. An exploratory factorial analysis, which was performed on the first half of the sample, extracted six factors. They were the dissociative/psychotic symptoms factor, the substance use factor, the interpersonal instability factor, the affectivity/identity disturbances factor, the narcissistic features factor, and the impulsivity factor. This six- factor model was tested using a confirmatory factorial analysis on the second half of the sample and on the whole sample. It provided an adequate fit with the data. This factor structure captured central components of borderline symptomatology. As it differs from the one obtained in the study of the BPI in adults, these components may be specific to adolescents and reflect developmental issues rather than psychopathology.

Personality disorder symptoms in adolescence: a five-factor model perspective

The five-factor model has been widely used to describe adaptive and maladaptive functioning in adulthood. However, less is known about the structure and developmental antecedents of personality pathology and personality disorders. In the present study, we examined the validity of the most recent DSM-IV predictions (Widiger, Trull, Clarkin, Sanderson, & Costa, 2002) in a sample of 419 non-clinical adolescents and explored the validity of the unique FFM facetvariances (using the NEO PI-R) to predict disorder symptoms (using the ADP-IV). Our results demonstrate a largely similar correlation and regression pattern between adult and adolescent data, indicating that adaptive and maladaptive trait-descriptive systems relate across a more extended developmental span than has been demonstrated before.

Factor analyses of the DIB-R in adolescents

The goal of this study was to examine the factor structure of the Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Franckenburg, & Chauncey, 1989) in a nonpatient sample of 118 adolescents. A principal components factor analysis with a Varimax rotation extracted three factors. A confirmatory factor analysis showed that this three-factor model provided an adequate fit. The first factor, which included depression, anxiety, helplessness/hopelessness, loneliness/emptiness, and also encompassed odd thinking/unusual perceptive experiences and quasi-psychotic experiences, appeared to be centered on painful feelings and dissociative defense. The second factor, labeled "impulsivity," consisted of impulse action patterns, counterdependency, and stormy relationships. This factor seemed to be centered on defensive acting-out. The third factor, called "aggressiveness," consisted of anger, hypomania, devaluation/manipulation/sadism, and demand/entitlement, and might express manic/narcissistic defenses. These analyses suggest that there may be homogeneous components of borderline symptomatology in adolescents that may reflect affective disturbances and defensive mechanisms.

The borderline diagnosis II: biology, genetics, and clinical course

In Part I of this three-part article, consideration of the core features of BPD psychopathology, of comorbidity with Axis I disorders, and of underlying personality trait structure suggested that the borderline diagnosis might be productively studied from the perspective of dimensions of trait expression, in addition to that of the category itself. In Part II, we review the biology, genetics, and clinical course of borderline personality disorder (BPD), continuing to attend to the utility of a focus on fundamental dimensions of psychopathology. Biological approaches to the study of personality can identify individual differences with both genetic and environmental influences. The aspects of personality disorder that are likely to have biologic correlates are those involving regulation of affects, impulse/action patterns, cognitive organization and anxiety/inhibition. For BPD, key psychobiological domains include impulsive aggression, associated with reduced serotonergic activity in the brain, and affective instability, associated with increased responsivity of cholinergic systems. There may be a strong genetic component for the development of BPD, but it seems clear, at least, that there are strong genetic influences on traits that underlie it, such as neuroticism, impulsivity, anxiousness, affective lability, and insecure attachment. The course of BPD suggests a heterogeneous disorder. Predictors of poor prognosis include history of childhood sexual abuse, early age at first psychiatric contact, chronicity of symptoms, affective instability, aggression, substance abuse, and increased comorbidity. For research purposes, at least, biological, genetic, and prognostic studies all continue to suggest the need to supplement categorical diagnoses of BPD with assessments of key underlying personality trait dimensions and with historical and clinical observations apart from those needed to make the borderline diagnosis itself.

Frequency of borderline personality disorder in a sample of French high school students

OBJECTIVE

To estimate the frequency of borderline personality disorder (BPD) in French high school students.

METHOD

A random sample of high school students (n = 1363) ranging in age from 13 to 20 years agreed to complete a questionnaire, the Screening Test for Comorbid Personality Disorders (STCPD); 107 of them volunteered to be interviewed. We assessed this group using the Revised Diagnostic Interview for Borderlines (DIB-R). We conducted a regression analysis to determine a cut-off for BPD diagnosis with the STCPD.

RESULTS

We estimated the overall frequency of BPD to be 10% for boys and 18% for girls. After a peak of frequency at age 14 years for both sexes, the frequency increased significantly again in late adolescence.

CONCLUSION

This study found a high frequency of BPD in French adolescents, which adds to questions regarding the validity of diagnosing this disorder in adolescents.

Stability and course of personality disorders: the need to consider comorbidities and continuities between axis I psychiatric disorders and axis II personality disorders

The literature pertaining to the stability and course of personality disorders is briefly reviewed. Available data suggest that PD diagnoses demonstrate only moderate stability and that--although generally associated with a plethora of negative outcomes--they can show improvement over time. This paper highlights the pervasiveness of diagnostic co-occurrence and its implications for continued investigation of the question of PD stability. In addition to examining the stability (and outcome) of PDs, longitudinal studies need to consider continuities between diagnoses. The Collaborative Longitudinal Personality Disorder Study (CLPS) is described briefly vis-a-vis some of these major issues.