Borderline Character Disorder in Adolescents

Question

In teenagers (13-17 years of age), what is the recommended treatment for borderline character disorder?

Action from Mary E. Muscari, PhD, CPNP, APRN-BC, CFNS

Borderline personality disorder (BPD) is a complicated psychiatric disorder characterized by unstable individual relationships, intense anger, feelings of vacuum, and worries of desertion. The most recent edition of the Diagnostic and Statistical Handbook of Mental Illness, 4th Edition, Text Modification (DSM-IV-TR) allows BPD to be diagnosed in adolescents when maladaptive traits have actually existed for a minimum of 1 year, are relentless and comprehensive, and are not likely to be limited to a developmental stage or an episode of an Axis I disorder. [1,2] However, the character of adolescents is still developing; for that reason, the medical diagnosis of BPD should be made with fantastic care in this population. [3]

Borderline pathology in kids refers to a syndrome characterized by a combination of disruptive behavioral problems, mood and stress and anxiety symptoms, and cognitive symptoms. Follow-up studies of these kids show that they have a tendency to establish a wide range of character disorders, not just BPD. Although borderline pathology in youth is not necessarily a precursor to BPD in their adult years, evidence suggests that both have strikingly comparable risk factors, which might show a typical etiology. These danger elements consist of family environments defined by trauma, neglect, and/or separation; direct exposure to sexual and physical abuse; and major parental psychopathology, such as antisocial personality disorder and substance abuse. [4]

Qualities of BPD

Teenagers with BPD have disrupted thinking patterns and always appear to be in crisis. They can be rational and calm one minute, and then explode into inappropriate anger in response to some perceived rejection or criticism the next. The disorder takes place in all races, prevails in women (female-to-male ratios as high as 4:1), and typically provides by late adolescence. [4] Signs and symptoms of BPD may consist of considerable worry of real or imagined desertion; intense and unstable relationships that vacillate in between severe idealization and decline; considerably and persistently unsteady self-image; significant and possibly self-damaging impulsivity (spending, sex, binge consuming, betting, drug abuse, and careless driving); repeated self-destructive habits, gestures, or risks; self-mutilation (carving, burning, cutting, branding, picking and plucking skin and hair, biting, and excessive tattooing and body piercing); affective instability and substantial reactivity of mood (intense dysphoria, irritation, or anxiety that lasts for a few hours or days); relentless feelings of vacuum; improper anger or difficulty managing anger; and short-lived, stress-related extreme dissociative signs or paranoid ideation. [1]

Comorbidities prevail with BPD. These conditions, that include state of mind conditions, substance-related conditions, eating conditions (significantly, bulimia), posttraumatic tension disorder, other anxiety conditions, dissociative identity condition, and attention-deficit/hyperactivity condition, can complicate both diagnosis and treatment. Anxiety is especially typical in clients with BPD. [3] Other character conditions have likewise been recorded as comorbid with BPD. A study of 138 teenagers and 117 adults with BPD revealed a substantial incident of schizotypal and passive-aggressive character disorders in the teen group and antisocial personality disorder in the adult group. The scientists recommended that BPD may represent a more scattered range of psychopathology in adolescents than adults, because adults had comorbidity just with another Cluster B condition, whereas teen comorbidity encompassed aspects of Clusters A and C. [5] (A brief description of the clustering system in personality conditions is offered at the National Mental Health Association Web site.

Treatment Concerns

Due to the complex nature of this condition, psychiatric nurse practitioners (NPPs) must think about the following when establishing a treatment plan [6]:

• Persistent depression: Anxiety arises from continuous sensations of abandonment. Although the depression of BPD is intense and pervasive, the NPP must eliminate significant anxiety or consider it as a comorbid condition.
  Inability to be

• alone: Chronic fear of abandonment likewise causes these adolescents having little tolerance for being alone. This leads to a continuous look for friendship, no matter how unsatisfying. Clinging and distancing: Relationships

• tend to be disruptive due to the adolescents ‘alternating clinging and distancing habits. When clinging, they might exhibit dependent, helpless, childish habits. They overidealize the person they wish to invest all their time with, constantly seeking that individual out for peace of mind. When they can not be with their picked person, they display acting-out behaviors, such as tantrum and self-mutilation. Distancing is characterized by anger, hostility, and decline, typically arising from discomfort with nearness. Splitting: Dividing occurs from the adolescents’failure to

• accomplish things constancy and is the main defense mechanism in BPD. They see all individuals, including themselves, as either all good or all bad. If the NPP is helpful, the NPP will be idealized. If the nurse-patient relationship is threatened( eg, the NPP goes on vacation ), the caretaker’s image modifications from beneficent caretaker to cruel persecutor. Manipulation: Separation fears are so intense that these adolescents become masters of manipulation

• . They will do almost anything to accomplish remedy for their separation anxiety, but their most typical ploy is to play one private versus another, including pitting their medical care nurse professional( NP)against their NPP. Self-destructive habits: Self-mutilation is particular of BPD. The behaviors are normally manipulative gestures, however some acts can prove deadly. Suicide efforts are not unusual and typically happen in fairly safe places, such as swallowing tablets in the house while reporting the deed to another individual on the telephone. Other self-destructive habits consist of cutting and burning (eraser burns, a burnlike sore resulting from rubbing the skin with a pencil eraser, are common in adolescents). Impulsivity: Poor impulse control can result in drug abuse, binge eating, careless driving, sexual promiscuity, excessive costs, or gaming. These behaviors can occur in reaction to real or perceived desertion.
  Treatment Treatment

  studies on adolescents with BPD are virtually nonexistent. Although treatments reliable in grownups would be expected to be efficacious, research that demonstrates this effectiveness is needed. [3]

In general, treatment preparation need to resolve BPD, in addition to any existing comorbid conditions, and should be versatile to respond to the altering attributes of the teen over time. The NPP, teen, and household require to recognize that treatment will take a prolonged quantity of time. Psychiatric therapy is the main treatment of BPD. Extensive therapy is needed to achieve and maintain lasting improvement in their personality, interpersonal problems, and total functioning. Long-term dialectical behavior modification(DBT )appears to be the

most effective. DBT is a type of cognitive behavioral therapy that concentrates on coping skills, so clients learn to better manage their emotions and behaviors. This might be complemented with symptomatic psychopharmacology to attend to affective instability, impulsivity, psychotic-like signs, and self-destructive behavior. Psychoanalytic/psychodynamic therapies have likewise shown reliable. [7] NPPs can utilize guidelines on the treatment of BPD from the American Academy of Psychiatry, although they need to understand that these suggestions are not adolescent-specific [7]: Consider the treatment setting to guarantee that outpatient treatment is warranted over hospitalization: Partial

hospitalization– hazardous spontaneous habits, degrading scientific image, complex comorbidities, symptoms unresponsive to outpatient treatment; Short inpatient hospitalization– major self-destructive ideation

• or effort, impending risk to others, signs unresponsive to partial hospitalization;
  and Extended inpatient hospitalization– relentless self-destructive ideation, nonadherence to other treatments, dangerous comorbid Axis I disorder, continued danger of assaultive habits,

• severe signs that disrupt living. Develop a strong healing alliance that includes compassionate recognition of the client’s suffering and experience. Coordinate and work together

• with the treatment team. Know and handle splitting issues, and assist the teen in integrating both favorable and unfavorable elements of self and others. Supply education to the teen and the family on BPD. Handle extreme sensations produced

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Consider cultural aspects. Prevent cultural predisposition related to sexual habits, psychological expression, and