Assessment of “personality disorder” in adolescence is a controversial topic. On the one hand, data suggests that the diagnosis of borderline personality disorder (BPD) in adolescents is as valid and reliable as in adults, and that recognition of this set of difficulties can allow appropriate interventions to be provided (Chanen et al. 2007, Miller et al. 2008). On the other hand, it has been argued that the diagnosis in adults is invalid and unreliable as it is, and hence its extension to adolescents simply compounds the problems with this stigmatising and meaningless label (Watts 2019).
Regardless, diagnosis of personality disorder in adolescents is now sanctioned in both DSM-V and ICD-11 (APA 2013, WHO 2018). The starting point for Skabeikyte and Barkauskiene’s systematic review is that we need to understand more about why, for some adolescents, the types of difficulties with emotion regulation, anger, self-harm, identity, relationships etc that might be termed “borderline personality disorder” are temporary, whilst for others these difficulties persist into later adolescence or adulthood. I certainly agree that this is an important question.
To answer this question, the authors undertook a systematic review of relevant literature. They included 14 studies in which traits of BPD were assessed across at least two different time-points in adolescents aged 10 to 18, and in which the association with other aspects of the adolescents’ lives were evaluated (e.g. mental health and personality characteristics, parental characteristics, relationships and life events). The studies had to be “prospective” i.e. they assessed the adolescents at one point in time, and then looked forward to see what happened to them later on. The authors undertook a “narrative synthesis” to summarise what different studies had found.
The authors grouped their findings into four categories: Child characteristics, Interpersonal factors, Parental psychopathology, Parenting factors.
This mainly included the adolescents’ mental health and personality characteristics. The studies reviewed by the authors found that the following factors were associated with either increases in or maintenance of BPD traits over time: high levels of emotionality, negative affect, inattention, oppositional behaviour, hyperactivity/ impulsivity, alcohol misuse, substance misuse, depression, anxiety, ADHD, somatisation; low levels of sociability and self-control. In short, unsurprisingly, if a teenager is struggling with other related aspects of their mental health, they are more likely to continue to struggle with the experiences and behaviour characteristic of “BPD”. A brief mention is made of one study in which stressful life events (examples of which are listed as suspension from school, death of a parent, changes in peer acceptance) were not linked to any change in BPD traits.
The following factors were found to be associated with increases in or maintenance of BPD traits over time: aggression in friendships, psychological and sexual violence, poor quality of relationship with father.
High levels of maternal BPD traits were associated with maintenance of adolescents’ BPD traits over time; maternal or paternal depression was not linked to any change in adolescent BPD traits.
Among parenting factors, exposure to intimate partner violence among parents was the only factor associated with BPD trait changes, and predicted slower declines in BPD traits throughout adolescence. Parental low warmth, maternal support/validation, maternal problem solving, and parental harsh punishment were not significant predictors of changes in BPD traits.
The authors conclude that comorbidity and current interpersonal experiences may play an important role in the course of borderline personality disorder development.
Strengths and limitations
The authors used tried and tested methods to ensure no relevant studies were missed, including searching seven different databases and looking through 618 potentially useful studies to find relevant papers. The authors acknowledge their findings are limited by the fact that six of the analysed studies were drawn from the same sample of urban girls. Further limitations I note are that only studies post-1980 were included and only those published in English.
I think that the authors were also limited in the scope of their conclusions by the studies that were available to review. Firstly, too few studies evaluated the same factors for meta-analysis to be undertaken, which could have provided a clearer synthesis of the findings. Secondly, it was notable that only two of the included studies evaluated the effect of traumatic life events on BPD traits (Greenfield et al. 2015, Sharp et al. 2020). This limits the ability of this review to reach any conclusion on the prognostic influence of a factor of known aetiological significance in adult BPD, and of importance to the debate about the reconceptualisation of ‘personality disorder’ as trauma survivorship.
Implications for practice
The authors suggest that their findings could be used clinically to identify high-risk groups of adolescents who have difficult temperaments, comorbid mental health problems, and are currently experiencing victimisation from peers or exposure to violence at home. I would hope that comorbid mental health problems and the role of psychological and physical violence amongst family and peers are already assessed by clinicians and incorporated into care planning. Certainly, the findings reinforce the importance of holistic assessment of all areas of adolescents’ mental health and lives, including experiences of relational trauma.
Statement of interests
None to declare.
Skabeikyte, G., & Barkauskiene, R. (2021). A systematic review of the factors associated with the course of borderline personality disorder symptoms in adolescence. Borderline Personality Disorder and Emotion Dysregulation, 8(1), 1-11.
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