BPD IN ADOLESCENCE
The Diagnosis of BPD
BPD is a severe mental disorder that is characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image. BPD is defined by any 5 of the 9 criteria (see Table 1) in the Diagnostic and Statistical Manual for Mental Dis- orders, Fifth Edition (DSM-5).1 The term “pervasive” indicates that these criteria should not be met exclusively in certain contexts or during periods of mental state disorder, such as depression. BPD has gained increased attention from the scientific and clinical communities and the publicmainly because it is associated with a high risk of suicide, extensive use of mental health services, severe impair- ment in psychosocial functioning, and high social and economic costs.2
Diagnosing BPD in Adolescence
Despite long-standing general agreement that personality disorders have their roots in childhood and adolescence, di- agnosing BPD before age 18 years has been controversial.3 In many settings around the world, clinicians are still hesitant to diagnose BPD in youth,mainly because of 4 concerns: First, the diag- nosis of BPD is not valid in adolescence. Second, typical features of BPD, such as affective instability or disturbed self- image, are normative among adoles- cents. Third, personality development is
still in flux, and this precludes diagnosis. Fourth, and possibly most important, BPD is a pejorative term, and clinicians wish to protect their patients from stig- matizing and pessimistic attitudes. How- ever, research over the past decade has disproven the first 3 assumptions, and greater knowledge of this has potential to influence the fourth.
There is increasing evidence in support of both diagnosing and treating BPD in adolescence. BPD has been found to be just as reliable and valid in adolescence as it is in adulthood,4,5 it shows similar stability in adolescence compared with adulthood,6 and it has incremental validity over and above common mental disorder diagnoses.7,8 Most important, disorder-specific treatment is beneficial, including early intervention.9 Thus, national treatment guidelines, Section 3 of the new DSM-5, and the proposed International Classification of Diseases, 11th Revision, personality disorder classification have all recently confirmed the legitimacy of the BPD diagnosis in adolescents.1,10–12 This highlights the need to communicate this new knowl- edge about BPD in adolescence to health care professionals.
SIGNIFICANCE OF ADOLESCENT BPD
Prevalence and course
Epidemiologic data in adolescents are limited,with conservativepoint prevalence
estimates ∼0.9%.13,14 Cumulative preva- lence rates suggest that 1.4% of young people will meet diagnostic criteria for BPD by age 16 years, rising to 3.2% by age 22 years.13 These data are comparable to adult prevalence data of 0.7% to 2.7%.15,16
BPD is a commonand important disorder in adolescentmental health settings, with an estimated prevalence of 11% in psy- chiatric outpatients17 and up to 50% in inpatient settings.18
Although the female-to-male ratio in clinical settings is usually reported to beat least 3:1, population-basedstudies do not show substantial gender dif- ferences in the prevalence of BPD in adults19,20 or children.21 The reasons for the unequal gender distribution in clinical settings might be an artifact of sampling or diagnostic biases22 or might reflect true biological, psycho- logical, or social differences between males and females.
Longitudinal data show a normative in- crease in BPD traits after puberty (demarcating the onset of adoles- cence), reaching peak prevalence in early adulthood and subsequently de- clining in a linear fashion over subse- quent decades.23,24 The diagnostic stability of BPD has been found to be similar in adolescents and adults.6 Ten years after initial diagnosis, 85% of adults with BPD will “remit” in terms of no longermeeting $5 BPD criteria25; this number rises up to 99% after 16 years.26 These data con- firm that BPD usually becomes clinically apparent during adolescence, peaks in young adulthood, and attenuates across the remainder of the life course.27
Risk Taking and Self-Harm
Young people’s affinity to highly impul- sive and self-damaging behavior places them at risk for adverse health out- comes. Both repetitive nonsuicidal self- injury (NSSI) and suicidal behavior are core features of BPD,1 and most adults with BPD report a long-standing history of repetitive self-harm behaviors, dating