Identifying Trajectories of Borderline Personality Features in Adolescence: Antecedent and Interactive Risk Factors

The role of youths' cardiac autonomic balance and parental responses to youth emotion in vulnerability to borderline personality disorder development

Developmental models of borderline personality disorder (BPD) emphasize the effects of youths' biological vulnerabilities and their experiences of parental responses to emotion, as well as the interaction between these two elements. The current study evaluated the independent and interactive effects of two indices of autonomic nervous system response and parental responses to youth negative emotions on severity and exacerbation of youths' BPD features during the transition to adolescence. The sample consisted of 162 psychiatric youth (10-14 years; 47.2% female) and their parents. At baseline, youth and their parents completed a lab-based conflict discussion during which parasympathetic and sympathetic nervous system response were measured and indices of sympathetic-parasympathetic balance and coactivation/coinhibition were calculated. Youth also reported on supportive and non-supportive parental responses. At baseline and after 9 months, youth self-reported on their BPD features. Results demonstrated that shifting toward sympathetic dominance independently predicted exacerbation of BPD across 9 months. Additionally, fewer experiences of supportive parental responses and more non-supportive parental responses were associated with greater severity of BPD features in youth. This study highlights the role of autonomic response to parent-child conflict as well as the significance of parental responses to youth emotion for the development of BPD during this developmental window.

Assessing Measurement Consistency: A Study of the BPFSC Invariance Across Age and Sex in Romanian Adolescents

The Borderline Personality Feature Scale for Children (BPFSC) is a widely used instrument and currently the only dimensional measure to investigate Borderline Personality features in children and adolescents. The present study aimed to investigate the factor structure and measurement invariance across age and sex in a community sample of 634 adolescents (mean age = 16.72, standard deviation = 1.31). To test for measurement invariance, we conducted multi-group confirmatory factor analysis (MG-CFA). Analysis showed residual invariance across age and sex. Based on the results, we conclude that BPFSC is a valid and reliable instrument to assess Borderline Personality features in adolescents. Implications for evidence-based assessment of Borderline Personality features in adolescence are discussed.

The Role of Cognitive Deficits in Borderline Personality Disorder with Early Traumas: A Mediation Analysis

(1) Background: although studies of cognitive functions are still limited in borderline personality disorder (BPD), the initial evidence suggested that BPD patients have deficits of executive functions and social cognition. In addition, patients who report physical and psychic traumatic experiences in childhood and adolescence show considerable neurocognitive impairment and severe BPD symptoms. The present study has a twofold aim: (1) to evaluate the differences in neurocognitive performances between BPD patients and healthy controls and (2) to verify in the BPD patients group whether neurocognitive deficits have the role of mediating the effect of early traumas on BPD psychopathology. (2) Methods: 69 subjects were enrolled: 38 outpatients with a diagnosis of BPD (DSM-5) and 31 healthy controls. BPD patients were tested with the Borderline Personality Disorder Severity Index (BPDSI), and the Childhood Trauma Questionnaire-Short Form (CTQ-SF). All subjects were evaluated with the Iowa Gambling task (IGT), the Berg card sorting test (BCST), the Tower of London task (ToL), and the Reading-the-mind-in-the-eyes-test (RMET). Statistical analysis was performed with the analysis of variance to compare the cognitive performances between BPD patients and controls. A mediation analysis was conducted with the Sobel Test in the BPD patients group. The significance level was p ≤ 0.05. (3) Results: significant differences between the two groups were found for several parameters of all the cognitive tests examined: BCST, IGT, ToL, and RMET. Mediation analysis with the Sobel test demonstrated that the percentage of correct answers in the BCST (BCSTc) and the RMET score significantly mediated the relation between the CTQ total score and BPDSI total score. (4) Conclusions: BPD patients showed an impairment of the following executive functions: set shifting, decision making, planning and problem solving, and social cognition abilities, in comparison with controls. Our results suggested that the effect of early trauma on BPD psychopathology was mediated by a deficit in two cognitive domains: cognitive flexibility and social cognition.

ADHD Symptoms, Peer Problems, and Emotion Dysregulation as Longitudinal and Concurrent Predictors of Adolescent Borderline Personality Features

OBJECTIVE

ADHD and borderline personality (BP) disorder are highly comorbid and characterized by emotion dysregulation and peer problems. However, limited research has examined social and emotional predictors of BP features in samples that include youth with ADHD.

METHOD

Using a sample of 124 youth with and without ADHD (52% female), ADHD symptoms, peer problems, and emotion dysregulation were assessed in childhood (8-13 years) and in adolescence, along with BP features (13-18 years).

RESULTS

In addition to the significant effect of ADHD symptoms, teacher-rated child peer victimization and adolescent-reported peer victimization, poorer close friendships, and emotion dysregulation domains significantly predicted adolescent BP features. Greater parent-rated child and adolescent emotion dysregulation domains also significantly predicted adolescent BP features, with ADHD symptoms no longer significant.

CONCLUSION

Even for youth with ADHD, peer and emotional vulnerabilities in childhood and adolescence may serve as important markers of risk for adolescent BP features.

Personality pathology in adolescence: relationship quality with parents and peers as predictors of the level of personality functioning

BACKGROUND

The dimensional approach to personality pathology opens up the possibility to investigate adolescence as a significant period for the development of personality pathology. Recent evidence suggests that symptoms of personality pathology may change during adolescence, but the negative consequences such as impaired social functioning persist later on in life. Thus, we think that problems in social functioning may further predict personality impairments. The current study aimed at investigating the role of relationship quality with parents and peers for the prediction of the level of personality functioning across adolescence. We hypothesized that 1) relationship quality with both parents and peers will significantly account for the level of personality functioning in adolescence and 2) the importance of relationship quality with peers for the relation to impairments in personality functioning will increase with age.

METHODS

A community sample consisting of 855 adolescents aged 11-18 (M = 14.44, SD = 1.60; 62.5% female) from different regions in Lithuania participated in this study. Self-report questionnaires included the Levels of Personality Functioning Questionnaire to investigate personality impairments and the Network of Relationships Questionnaire to assess the quality of dyadic relationships.

RESULTS

Discord in the parent, but not peer relationships, was related to a more severe level of personality functioning across adolescence. Lower levels of closeness with parents accounted for higher impairments in personality functioning. The importance of closeness with peers for the explanation of the level of personality functioning increased with age.

CONCLUSIONS

During the sensitive period for the development of a personality disorder, relationship quality with the closest adults and peers both remain important for the explanation of impairments in personality functioning.

Relationships of Homophobic Bullying Victimization during Childhood with Borderline Personality Disorder Symptoms in Early Adulthood among Gay and Bisexual Men: Mediating Effect of Depressive Symptoms and Moderating Effect of Family Support

This study investigated (1) the associations of homophobic bullying victimization in childhood with borderline personality disorder (BPD) symptoms in early adulthood among gay and bisexual men; (2) the mediating effect of depressive symptoms on the association between homophobic bullying victimization and BPD symptoms, and (3) the moderating effects of perceived family support on the association between homophobic bullying victimization and BPD symptoms. A total of 500 gay or bisexual men aged between 20 and 25 years were recruited into this study. The experiences of physical, verbal and social relationship bullying victimization during childhood were evaluated using the Mandarin Chinese version of the School Bullying Experience Questionnaire. The experiences of cyberbullying victimization during childhood were evaluated using the Cyberbullying Experiences Questionnaire. BPD symptoms were assessed using the Borderline Symptom List. Depressive symptoms were examined using the Center for Epidemiologic Studies Depression Scale. Perceived family support was evaluated using the Family Adaptation, Partnership, Growth, Affection, and Resolve index. The results of mediation analyses demonstrated that all the types of homophobic bullying victimization in childhood were directly associated with BDP symptoms in young adulthood as well as indirectly associated with BPD symptoms through the mediation of depressive symptoms. The results of moderation analyses demonstrated that the association between homophobic bullying victimization and BPD symptoms decreased when the individuals had more family support. Intervention programs to reduce homophobic bullying victimization and enhance family support for gay and bisexual men and their families are necessary. Interventions to improve depressive and BPD symptoms among gay and bisexual men are also necessary, especially for those who experienced homophobic bullying victimization during childhood.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Prevalence and comorbidity of borderline personality traits in the Quebec general population aged 12-14 years

PURPOSE

The early identification of borderline personality traits (BPT) in adolescents helps to prevent their progression. Data are available for the clinical population, but little has been published on the general population, especially regarding age and sex distribution in adolescence. Even less is known about the comorbidity of BPT with other mental disorders.

METHODS

We estimated the prevalence of BPT, by sex, age, and comorbidity, in a sample of adolescents aged 12-14 years (n = 799) from the Quebec Mental Health Survey. A complex sampling design was used to ensure representativeness. BPT was assessed with the abbreviated-diagnostic interview for borderlines-revised, with the adolescent as an informant. Reliability coefficients were above 0.80. Several levels of severity were explored using an independent criterion, defined by impairment according to the Columbia impairment scale.

RESULTS

The overall prevalence of BPT was 6.3%. Prevalence estimates for the most impaired were 3.2% for the entire sample and 1.3% for 12-year-olds. Prevalence increased significantly with age for most impairment levels but did not differ significantly between the sexes. In adolescents, BPT displayed moderate-to-strong comorbidity with anxiety (AD) and insomnia disorders, and very strong comorbidity with depressive (DD), attention deficit hyperactivity (ADHD), and oppositional defiant/conduct disorders (ODD/CD).

CONCLUSION

We, therefore, make two clinical recommendations for child psychiatry practice: (1) with respect to the lower rate of male adolescents attending BPT Health Programs, increase BPT screening in male adolescents; (2) evaluate BPT when children with ADHD or ODD/CD develop AD or DD during adolescence.

["Somatic symptom disorders" in adolescence. A systematic review of the recent literature]

OBJECTIVES

Body expression of mental disorders is common in adolescence. Only two literature reviews over the last five years have been identified about somatoform disorders in children., The present article provides a systematic review of articles in English, which concern "Somatic Symptom and Related Disorders" according to the DSM-5 (Diagnostic and Statistical Manual - 5th Edition) among adolescents.

METHODS

The article search was made on Medline, Psychinfo, Google Scholar, BiomedCentral, Central and tripdatabase (for grey literature) according to PRISMA criteria and with the items "somatoform disorders" or "somatic symptom disorders". An age filter was applied for "adolescents", and a selection was done from the last five years. All articles concerning adolescents (often associated with children) were initially included, except for articles concerning eating disorders, dysmorphic disorders or adult population. Comments, editorials, opinion or descriptive articles were also excluded. The authors then carried out an analysis of the main topics, themes and questions covered in the selected publications and presented a descriptive synthesis.

RESULTS

A total of seventy-seven publications were included in the analysis, from three hundred and seventy-two publications. First, the terms used to refer to these "somatic symptom disorders" were varied, such as "somatization", "somatic complaints/symptoms", "functional disorder", "unexplained symptoms" and "somatoform disorders". Then, studies related just to adolescents were limited: most of studies included children and adolescents in their methodologies; and some of them questioned somatic symptoms from a developmental perspective. Case reports were the most represented articles among all medical specialties, with clinical descriptions about "functional neurological symptom disorder", "factitious disorder" and "somatic symptom disorder" with a medical disease, among children and adolescents. We sometimes observed a controversial borderline between psychological and somatic disorders. Various explanatory models appeared, especially the trauma path; familial and social environment was also pointed out, with a possible peer group effect; neurocognitive theories were finally described. The literature highlights the effectiveness of psychosocial therapies (especially the cognitive-behavioral therapy) and the importance of multidisciplinary management. Finally, a few studies with a qualitative methodology are represented.

CONCLUSIONS

Only nine articles included "somatic symptom disorder" in their titles, despite a terminology valued by many authors (compared to "somatoform disorders" from the DSM-IV). The heterogeneity of terminologies, case reports and explanatory models witness a lack of connexions between medical specialties. This could explain in part the wandering of adolescents and their families in the health care system. It could also contribute to the delay before diagnosis, especially when neurological symptoms exist, and a late referral for psychiatric consultation. Further studies are needed to understand difficulties to use a clinical pathway among medical specialties, when the benefit of amultidisciplinary approach seems to be unanimous.

A systematic review of the factors associated with the course of borderline personality disorder symptoms in adolescence

BACKGROUND

Research on personality pathology in adolescence has accelerated during the last decade. Among all of the personality disorders, there is strong support for the validity of borderline personality disorder (BPD) diagnosis in adolescence with comparable stability as seen in adulthood. Researchers have put much effort in the analysis of the developmental pathways and etiology of the disorder and currently are relocating their attention to the identification of the possible risk factors associated with the course of BPD symptoms during adolescence. The risk profile provided in previous systematic reviews did not address the possible development and course of BPD features across time. Having this in mind, the purpose of this systematic review is to identify the factors that are associated with the course of BPD symptoms during adolescence.

METHODS

Electronic databases were systematically searched for prospective longitudinal studies with at least two assessments of BPD as an outcome of the examined risk factors. A total number of 14 articles from the period of almost 40 years were identified as fitting the eligibility criteria.

CONCLUSIONS

Factors associated with the course of BPD symptoms include childhood temperament, comorbid psychopathology, and current interpersonal experiences. The current review adds up to the knowledge base about factors that are associated with the persistence or worsening of BPD symptoms in adolescence, describing the factors congruent to different developmental periods.

Exploring mentalizing in adolescents with anorexia nervosa and borderline personality disorder: A comparative study of psychiatric inpatients and healthy controls

Background:

Impaired mentalizing, i.e., difficulties in understanding oneself and others in terms of mental states, has been associated with the development of Anorexia Nervosa (AN), mainly among adults. However, few studies have addressed this question in clinical samples of adolescents with AN. Moreover, no study has explored mentalizing abilities among inpatient adolescents presenting with AN and Borderline Personality Disorder (BPD), despite their high comorbidity in a highly relevant age group.

Objective:

This study attempted, for the first time, to further examine differences in mentalizing abilities and to identify specific mentalizing impairments in different psychiatric inpatient groups and healthy adolescents.

Methods:

Using samples of female adolescents aged 12–17, comparison analyses were performed between psychiatric inpatient adolescents with AN (n = 44), BPD (n = 101), AN+BPD (n = 48), other psychopathology (n = 163) and healthy adolescents (n = 129). Structured and semi-structured clinical interviews, and two experimental tasks were administered to assess AN, BPD and mentalizing, respectively.

Results:

Comparison analyses showed that patients with BPD and other psychiatric disorders evidenced higher levels of hypermentalizing compared to healthy adolescents. Hypermentalizing was also reported among inpatients with AN+BPD, although to a lesser extent. BPD and AN scores were positively correlated with hypermentalizing responses.

Conclusions:

Our results suggest that hypermentalizing is a specific mentalization impairment in inpatient adolescents, particularly with BPD and both AN+BPD. Further investigation into the efficacy of mentalization based treatments for adolescents with BPD and AN+BPD is recommended. Prospective studies are needed to assess mentalizing using experimental tasks among adolescents with AN, taking into account the potential influence of temporality and severity of the disorders’ symptoms.

Interactive Effects of Parent Emotion Socialization and Child Physiological Reactivity in Predicting Adolescent Borderline Personality Disorder Features

Theories suggest that a transaction between child biological vulnerability and parent emotion socialization underlies the development of borderline personality disorder (BPD) features. Yet, few studies have examined the interaction between these factors prospectively in at-risk samples. Consequently, this study tested whether parental reactions to children's negative emotions moderated the effect of the child's physiological reactivity to stress in predicting adolescent BPD features in a sample of youth with and without clinical elevations in attention deficit/hyperactivity disorder (ADHD). Participants were 61 children (52% female) and parents (90% mothers). When children were 9-13 years old, their physiological reactivity to a social stressor was assessed based on respiratory sinus arrhythmia (RSA) and skin conductance level (SCL) reactivity; parents also reported on their supportive and non-supportive reactions to their child's negative emotions. Children were followed-up four to five years later at ages 14-18 years old and their BPD features were assessed based on parent and adolescent report. Significant interactions between children's SCL reactivity and parental reactions to children's negative emotions were found in predicting adolescent BPD features. Children with low SCL reactivity to social stress and parents high in supportive/low in non-supportive reactions were lowest in adolescent BPD features. However, greater SCL reactivity predicted greater adolescent BPD features specifically when the parent was high in support or low in non-support. Childhood ADHD symptoms also significantly predicted greater adolescent BPD features. Findings suggest that children with different patterns of SCL reactivity may respond differently to parental reactions to their emotions.

Bullying Victimization and Trauma

Bullying victimization and trauma research traditions operate quite separately. Hence, it is unclear from the literature whether bullying victimization should be considered as a form of interpersonal trauma. We review studies that connect bullying victimization with symptoms of PTSD, and in doing so, demonstrate that a conceptual understanding of the consequences of childhood bullying needs to be framed within a developmental perspective. We discuss two potential diagnoses that ought to be considered in the context of bullying victimization: (1) developmental trauma disorder, which was suggested but not accepted as a new diagnosis in the DSM-5 and (2) complex post-traumatic stress disorder, which has been included in the ICD-11. Our conclusion is that these frameworks capture the complexity of the symptoms associated with bullying victimization better than PTSD. We encourage practitioners to understand how exposure to bullying interacts with development at different ages when addressing the consequences for targets and when designing interventions that account for the duration, intensity, and sequelae of this type of interpersonal trauma.

Differential Susceptibility to the Environment and Borderline Personality Disorder

Evolutionary models of psychopathology can shed light on gene-environment interactions. Differential susceptibility to the environment means that heritable traits can have positive or negative effects, depending on environmental context. Thus, traits that increase risk for mental disorders when the environment is negative can be adaptive when the environment is positive. This model can be applied to borderline personality disorder, with predictors such as emotional dysregulation and impulsivity seen as temperamental variations leading to negative effects in an unfavorable environment but to positive effects in a favorable environment. This model may also be useful in conceptualizing the mechanisms of effective therapy for borderline personality disorder.

Early Detection and Outcome in Borderline Personality Disorder

Borderline personality disorder (BPD) is a severe and heterogeneous mental disorder that is known to have the onset in young age, often in adolescence. For this reason, it is of fundamental importance to identify clinical conditions of childhood and adolescence that present a high risk to evolve in BPD. Investigations indicate that early borderline pathology (before 19 years) predict long-term deficits in functioning, and a higher percentage of these patients continue to present some BPD symptoms up to 20 years. There is a general accordance among investigators that good competence in both childhood and early adulthood is the main predictive factor of excellent recovery in BPD patients. Some authors suggest that specific childhood personality traits can to be considered precursors of adult BPD, as well as some clinical conditions: disruptive behaviours, disturbance in attention and emotional regulation, conduct disorders, substance use disorders, and attention-deficit-hyperactivity disorder. Unfortunately, diagnosis and treatment of BPD is usually delayed, also because some clinicians are reluctant to diagnose BPD in younger individuals. Instead, the early identification of BPD symptoms have important clinical implications in terms of precocious intervention programs, and guarantees that young people with personality disorders obtain appropriate treatments. This review is aimed to collect the current evidences on early risk and protective factors in young people that may predict BPD onset, course, and outcome.

Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

Using the same Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-V) criteria as in adults, borderline personality disorder (BPD) in adolescents is defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation. BPD can be reliably diagnosed in adolescents as young as 11 years. The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3%. The clinical prevalence of BPD ranges from 11% in adolescents consulting at an outpatient clinic to 78% in suicidal adolescents attending an emergency department. The diagnostic procedure is based on a clinical assessment with respect to developmental milestones and the interpersonal context. The key diagnostic criterion is the 1-year duration of symptoms. Standardized, clinician-rated instruments are available for guiding this assessment (eg, the Diagnostic Interview for Borderlines-Revised and the Childhood Interview for DSM-IV-TR BPD). The assessment should include an evaluation of the suicidal risk. Differential diagnosis is a particular challenge, given the high frequency of mixed presentations and comorbidities. With respect to clinical and epidemiological studies, externalizing disorders in childhood constitute a risk factor for developing BPD in early adolescence, whereas adolescent depressive disorders are predictive of BPD in adulthood. The treatment of adolescents with BPD requires commitment from the parents, a cohesive medical team, and a coherent treatment schedule. With regard to evidence-based medicine, psychopharmacological treatment is not recommended and, if ultimately required, should be limited to second-generation antipsychotics. Supportive psychotherapy is the most commonly available first-line treatment. Randomized controlled trials have provided evidence in favor of the use of specific, manualized psychotherapies (dialectic-behavioral therapy, cognitive analytic therapy, and mentalization-based therapy).

A whole of school intervention for personality disorder and self-harm in youth: a pilot study of changes in teachers' attitudes, knowledge and skills

BACKGROUND

The school environment offers an ideal opportunity for early identification and intervention for youth with self-harm and complex mental health issues, such as borderline personality disorder (BPD). Yet, class teachers often report minimal knowledge, feeling ill-equipped to respond, and experience high levels of stress when exposed to such challenges. Research is required to understand how training and development activities led by school counsellors may enhance teacher attitudes, confidence and knowledge of self-harm and complex mental health issues, such as BPD. We aimed to explore the extent that a whole of school initiative might enhance capacity for early identification and intervention.

METHOD

18 secondary schools implemented a manualised program, Project Air Strategy for Schools. N = 400 class teachers (71.3% female, mean age 42 years) across city and rural locations were evaluated before and after program implementation on attitudes, knowledge and skills.

RESULTS

Providing class teachers with additional training on complex mental health issues and associated behaviours such as self-harm was well received. Participants reported post-program improvements in their optimism (d = .35), confidence (d = .63), knowledge (d = .73) and skills (d = 0.67) in working with young people with complex mental health issues, such as BPD.

CONCLUSIONS

Providing school counsellor led structured approaches, to help class teachers identify and respond to youth in distress, closed identified gaps. Results indicated improvements in class teachers' knowledge and attitudes towards self-harm and BPD. The intervention also improved the capacity of schools to plan and implement strategies to reduce the impact of mental health problems on the young person and their peers. A stay-at-school psychological care approach was fostered by enhancing partnerships between class teachers and school counsellors.