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10 Feb

Helping Adolescent Girls with Borderline Personality Disorder

Pamela grew up in an affluent city in California. Her father died when she was a little girl. She was reared under the care of her mother who spent a lot of time away from home, even though her mother did not need to work due to a very large inheritance.

A “fussy” baby and an emotional toddler, Pamela started experiencing difficulties at age ten with severe episodes of depression. She began cutting for emotional relief. At age 12 she began restricting how much she ate and experimented with some purging. She soon tried drugs. Nothing worked as well as the cutting; she found herself cutting on a weekly basis.

Pamela most often cut on her arms but began cutting her stomach and upper thighs when she no longer wanted the cuts to be observable. Outpatient treatment was ineffective and seemed to increase her desire for self-harm.

Pamela began intense, explosive, short-lived romantic relationships with her male peers at a young age. This caused marked stress between Pamela and her mother.

By the age of 15 Pamela had a highly conflicted relationship with her mother, mostly centered around Pamela’s use of drugs, Pamela’s poor choice in boyfriends, and Mom never being home. When I met Pamela as her therapist in a treatment program, she showed great difficulty trusting staff, peers, and other professionals due to the trauma she’d experienced from the wreckage of past relationships.

Her cutting subsided after she experienced living in a structured residential treatment environment, but her depression, intense interpersonal relationships, addictive thinking patterns, and low self-esteem remained problems. She was unsure she would ever want to, or be able to, quit cutting when she turned eighteen and was no longer under her parents’ care.

While there was no serious abuse in her history, the neglect Pamela suffered was enough to stir within her intense feelings of worthlessness and pain. What she wanted more than anything was acceptance, attention, and love. Not receiving it from peers or family was more than she could bear. Pamela is one of a growing number of adolescent females diagnosed with borderline personality disorder, or BPD.

What is a Personality?

All of have patterns of behavior, patterns of thought, and patterns of feeling. When we say we like or dislike someone’s personality, it’s really these sets of patterns that we are referring to. People’s personalities are evident when they report how they perceive the world, when they act in the world, and when they express emotion about the world and other people.

The Disordered Personality

A personality is disordered when one’s behaviors, thoughts, and feeling patterns toward the world, toward oneself, and toward others are maladaptive, incongruent, or inflexible. A personality disorder impairs one’s ability to function in the world.

A disordered personality can manifest in a variety of ways, including:

  • Inability to be spontaneous in showing one’s true feelings
  • Lack of flexibility and authenticity
  • Underdeveloped sense of entitlement, assertiveness, power, and rights
  • A sense of guilt and depression after asserting onself
  • Inability to self-nurture
  • Inability to tolerate and maintain appropriate intimacy and closeness in relationships
  • Inability to separate from other people-dependency upon interaction with others for identity
  • Inability to make commitments

Borderline Personality Disorder

According to the DSM-IV, the American Psychological Association’s diagnostic manual, in order to diagnose a person with BPD, that person must manifest a pervasive pattern of instability in interpersonal relationships, self-image, and affect, accompanied by marked impulsivity. These symptoms begin by early adulthood and present in a variety of contexts, as indicated by at least five of the following:

  • frantic efforts to avoid real or imagined abandonment
  • a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  • identity disturbance: markedly and persistently unstable self-image or sense of self
  • impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
  • recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  • emotional instability due to a marked reactivity of mood (e.g., intense depression, irritability, or anxiety lasting only a few hours or days)
  • chronic feelings of emptiness
  • inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  • stress-related paranoid ideation or dissociative symptoms

BPD is one of the most highly publicized personality disorders. Research shows that about 11% of people who seek outpatient treatment and about 19% of those treated in inpatient settings have BPD. About 74% of those diagnosed with BPD are women.

More and more, I work with adolescent girls who have been misdiagnosed with BPD. Therapists should be use care when considering such a diagnosis for an adolescent, noting in particular the importance of detecting a pervasive pattern of five or more of these behaviors for more than one consecutive year. Still, teens with pervasive personality disorders such as BPD do exist and can benefit from the appropriate treatment.

What Causes Borderline Personality Disorder?

No one is sure what causes BPD, but most experts agree that a bio-psycho-social model is the best explanation. A person with BPD might have a history like this:

  • Early trauma, such as sexual abuse
  • Genetic predisposition to aggressive and depressive emotions
  • Genetically temperamental
  • Familial pathology (lack of boundaries, overly structured, enmeshed, abusive, parental pathology [see below], etc.)

Is BPD Treatable?

There are many popular treatments for BPD. Marsha Linehan’s Dialectical Behavioral Therapy (DBT) has been steadily gaining followers and press over the last two decades. Aaron Beck published Cognitive Therapy of Personality Disorders in 1990 to showcase how his Cognitive Behavioral Therapy (CBT)-the most widely researched therapeutic style-could help persons with BPD. To date, most research on the treatment of BPD has been done with adults.

In general, New Haven Residential Treatment Center proposes a systemic approach to healing families and individuals; our approach to treating Borderline Personality Disorder is no different. Interestingly, research shows that the best treatment for any client struggling with any issue is for her therapist to have an open, healthy therapeutic relationship with her. I assert that how a therapist interacts with a client with BPD is the key to successful treatment and is the best predictor of a positive outcome.

That said, we can infer that parents should be able to master the same relationship-building skills that therapists spend years in school mastering. This requires parents to think clearly about their feelings toward their daughter, their behaviors toward her, and their thoughts about her. In short, like therapists, parents must master their own personalities if they ever hope to be able to influence their daughters’ disordered personality!

Over the years, I’ve found that clear, consistent, lovingly-applied, somewhat strict boundaries create a climate of security and predictability for teens with BPD. Unlike some other clients, I have found that I can never give them an inch, even if they’ve been “good” for a long period of time. My expectations must remain fair and constant, or it sends the teen into a tail-spin. No matter the loop-hole they think they may have found, I must remain true to the literal meaning and the intended purpose of the established rules.

Look back at the case of Patricia. Like Patricia, most teens with BPD are great weather-testers. In other words, they are always standing with a wet finger lifted to the sky, assessing any changes in the wind’s strength or direction. They never feel secure just being themselves. They morph, chameleon-like, into whatever they believe we want them to be. They are also adept at applying social pressure to get us to act the way they want us to. They are never comfortable simply being who they really are. In fact, if I were to ask Patricia or most any teen with BPD who she is, she will tell me (when she is being honest) that she doesn’t know who she is, that she is confused, or that she feels too “empty” to even begin an answer to that question.

A teen with BPD feels so unsafe, feels so fearful of being rejected by those she loves, that she thinks she has to control every social interaction. And yet, by doing this, she feeds the very insecurity which keeps her from having meaningful relationships. This prohibits her from ever healing from the fear of abandonment and loneliness she struggles to manage.

Again, a healthy relationship and rigid, clear rules and expectations are the most important things parents and therapists can implement to help a teen with BPD begin healing.

Dustin Tibbitts, LMFT,is the Executive Director for New Haven Residential Treatment Center, part of the InnerChange family of adolescent treatment programs.