First my young adult daughter. Now one of my young adult sons. Both diagnosed with Borderline Personality Disorder (BPD) – which I totally accept and embrace.
But why did this diagnosis take over a decade?
With each possessing a history of early trauma and displaying a multitude of maladaptive behaviors, professionals went fishing for answers. Meanwhile, I walked on eggshells.
First came FASD – Fetal Alcohol Spectrum Disorder. Since their foster care case manager knew about birthmom’s drinking during pregnancy, she took them a geneticist. The diagnosis proved to be a starting point for secondary disabilities.
Next was ADHD in elementary school. Not entirely correct. With reduced sensory input, they became less anxious, paid better attention and executed fairly well. Plus the stimulant medication, typically used to treat ADHD, negatively affected their moods late in the afternoon. A sign many missed.
That led to Bipolar Disorder by middle school. Even with the traditional meds, they still struggled and exhibited explosive behavior – usually short in duration and often repeated daily. However, these rapidly changing mood swings didn’t fully resemble the static ones associated with bipolar.
Then RAD – Reactive Attachment Disorder. Yet the most recent DSM-5 criteria actually says otherwise. Although their attachment ebbed and flowed during times of stress, they had indeed connected to me and other adult caregivers. Click here for complete DSM-5 wording.
A More Definitive Diagnosis
The long trail of diagnoses – with some not entirely accurate – eventually led to Borderline Personality Disorder in adulthood.
Unlike RAD, BPD can be a result of genetics, environmental and social factors (neglect and abuse) or brain disorders (FASD, PTSD or developmental trauma).
Ironically, the name itself is misleading – originally meaning a “borderline” between psychosis and neurosis. The National Education Alliance for BPD offers an updated view.
Current ideas about the condition focus on ongoing patterns of difficulty with self-regulation (the ability to soothe oneself in times of stress) and trouble with emotions, thinking, behaviors, relationships and self-image. Some people refer to BPD as “Emotion Dysregulation.”
According to the National Institute of Mental Heath website, BPD is a serious, chronic mental disorder that affects functioning.
People with BPD may experience extreme mood swings and can display uncertainty about who they are. As a result, their interests and values can change rapidly. Other symptoms include.
– Frantic effort to avoid real or imagined abandonment
– A pattern of intense and unstable relationships with family, friends and loved ones, often swinging from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
– Distorted and unstable self-image or sense of self
– Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving and binge eating
– Recurring suicidal behavior/threats or self-harming behavior, such as cutting
– Intense and highly changeable moods, with each episode lasting from a few hours to a few days
– Chronic feelings of emptiness
– Inappropriate, intense anger or problems controlling anger
– Having stress-related paranoid thoughts
– Having severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body or losing touch with reality
Seemingly ordinary events may trigger symptoms. For example, people with BPD may feel angry and distressed over minor separations or sudden changes of plans. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.
What about Teens?
My daughter and son fit every symptom on the list as teenagers. The same goes for three of my other young adult children – who have similar personal histories. Only my son with a more pronounced intellectual disability shows none of the symptoms.
But not a single one in their teens received consideration of possible BPD. Psychology Today explains this past reluctance to diagnosing BPD prior to adulthood.
Until recent years many clinicians avoided offering the diagnosis of Borderline Personality Disorder (BPD) for adolescents. Since BPD is considered a more pervasive and persistent diagnosis, it seemed premature to label teenagers with a potentially stigmatizing personality disorder, since their personalities are still forming. Additionally, the characteristics of BPD are similar to those of typical adolescent struggles–unstable sense of identity , moodiness, impulsivity, strained interpersonal relationships, etc. Therefore, many therapists hesitated to distinguish borderline traits from normality.
But distinctions can be made.
An angry teen may yell and slam doors. A teen with BPD will throw a lamp through the window, cut on himself, and run away. After a romantic break-up, a typical adolescent will grieve the loss and turn to friends for consoling. The teenager with Borderline may isolate with feelings of hopelessness and act on suicidal feelings.
One study of young adults indicated that BPD symptoms were most severe and consistent from ages 14 to 17, then declining over the years into the mid-20’s.
Unfortunately, psychiatric symptoms in adolescents may be minimized or camouflaged by other, more blatant problems, such as depression, anxiety or substance abuse. When BPD complicates another illness, as is frequently the case, prognosis becomes more guarded. In all medical illnesses, and especially in psychiatric disorders, early intervention is important.
Several psychotherapeutic models have been adapted for utilization with teenagers, including, most prominently, Dialectical Behavioral Therapy and Mentalization Based Therapy.
Medications have not usually proven helpful, except for treatment of collateral illnesses, such as depression.
Research suggests that BPD symptoms in adolescence are less anchored and may respond more robustly to intervention. In later years, borderline features may be more ingrained. Thus, this is a critical period in which to initiate treatment.
The Next Step
The key to a proper BPD diagnosis – and appropriate treatment – is personal history. Too many psychiatrists or psychologists do not take time to collect it, much less to connect the dots. At the same time, blaming the parent continues to be far too common.
Labeling teens with everything from Oppositional Defiant Disorder to Conduct Disorder is easy – without giving the affected individuals the right therapy. I’m talking about intense, evidenced-based interventions that give individuals practical, realistic skills – which they would never develop on their own.
Personal tools to self-regulate – initially through coaching. Eventually with prompting. One day on their own. Habitually. Independently.
Not more smoke and mirrors. Not another list of meaningless coping skills.
BPD symptoms in adolescence are less anchored and may respond more robustly to intervention.
Both of my children with BPD and one other had expensive stays in residential treatment centers. Safe but at what cost? All three returned home with new bad habits on top of the ones that professionals never successfully addressed.
A one-size-fits-all philosophy prevailed.
What if Dialectical Behavior Therapy (DBT) became the gold standard within the trauma/FASD community like Applied Behavior Analysis (ABA) within the autism community? And what if it became readily available?
Diagnoses for DBT current participants range from BPD and PTSD to FASD and RAD. Nearly all have a history of past trauma oraddiction.
The framework, developed by Marsha M. Linehan in the late 80s at the University of Washington, is straight-forward in building skills. It’s also been clinically proven effective – with a lack of skills being the primary reason that people with BPD fail time and time again. No wonder they account for 19% of psychiatric admissions.
The highly trained DBT facilitator starts by setting clear boundaries for clients and enforcing them. NO to rehashing past events and maladaptive behaviors – over and over. NO to making excuses. YES to owning the problem. YES to accepting personal responsibility.
Then YES to committing to change.
The facilitator, seen as an ally rather than an adversary, uses the carefully structured DBT curriculum over a one-year period in a group setting to help clients develop the requisite skills in mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness. Individual therapy and phone coaching offer ongoing support to the client.
My daughter spent 12 months in DBT group therapy with amazing results – after more than a decade of failed attempts with individual therapy sessions that always went nowhere. Always heavy on feelings. Never balanced with skills that needed to be carefully taught and practiced.
For the first couple of DBT sessions, she was a guarded yet willing participant – which was essential. Soon she openly shared with me her newfound knowledge. Today she shares the following insight – which is a far cry from where her thoughts used to lie.
Relationships with people are the most important thing.
I learned to understand the difference between my past trauma and today’s emotional episode.
I must stay in the present moment at all times and step back if necessary. That way I look at the situation realistically and do not feel it personally.
The person without Borderline experiences something offensive, becomes upset for a quick second but realizes that the situation isn’t serious. On the other hand, the person with Borderline perceives the experience 100% emotionally and 0% rationally – and instantly reacts in an inappropriate way like she’s done in the past.
The fallout begins immediately and easily escalates to a point of no return.
My daughter is now teaching her younger brother some of the same skills, since a DBT program consistent with his cognitive level isn’t presently available.
And he’s slowly responding to her coaching. Hopefully he will soon respond to my prompting.
What if modified version of DBT began in elementary school via special education and continued at a more intense level in middle school – before maladaptive behaviors become engrained and are more difficult to change. Skills training could be a valuable component of any Behavior Intervention Plan.
No doubt, the right diagnosis matters.
The right skills matter too.
Both give me hope for the trauma/FASD community. DCP
Craig Peterson publishes EACH Child every Tuesday. To subscribe, open this link and “Like” the page. EACH Child is Special: Working Smarter Not Harder to Raise Every ONE
To learn more about Adopting Faith: A Father’s Unconditional Love, Craig’s soon-to-published memoir about raising six children with special needs, click here: Adopting Faith: A Father’s Unconditional Love
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