Borderline personality disorder used to only be diagnosed in young people after the age of 18. But there is now a consensus in the medical community that BPD can be reliably and accurately diagnosed during adolescence, with a similar prevalence and stability of symptoms to the disorder among adults.
What’s more, research suggests that borderline personality disorder symptoms and traits are often identifiable even earlier, before children reach their teenage years. These traits may be identified before someone meets the full criteria for a diagnosis. In these cases, it can be helpful to talk about naming rather than diagnosing BPD.
It’s important to intervene as soon as we are able to name stable BPD traits – those that continue for at least 6 months. Providing early interventions that support young people’s social and emotional development is vital in preventing much of the harm that may be caused by BPD. These interventions often focus on the family system and the way it impacts young people’s behaviours, as well as working with the young person themselves.
How Early Can We Name BPD Traits and Symptoms?
Borderline personality disorder is usually diagnosed in young adulthood, around the age of thirty. But research suggests that, on average, BPD symptoms emerge in the pre-teens or early teens. In a retrospective study among people with BPD, almost everyone (95%) said that their symptoms began during adolescence, with an average age of 12.1 years.
Other research has found that prodromal BPD traits may be observed in children as young as eight. These traits might include impulsivity, difficulties soothing intense emotions, intense emotional reactions to social situations, inattention, and low mood. Research suggests that around 50% of girls with high levels of hyperactivity/impulsivity, emotionality, depression, and inattention between the ages of five and eight might develop BPD by the age of 22.
While it may not always be possible to make a categorical diagnosis in younger children, it’s important to name BPD traits – that may later develop into the full disorder – as soon as possible. Naming borderline personality disorder allows clinicians to build a reliable and accurate picture of what’s going on, enabling direct access to effective treatment.
BPD and Vulnerabilities in the Family System
It’s often also possible to identify features that are associated with borderline personality disorder within a young person’s family. For example, children with BPD often grow up in a family system where parents have left or been pulled away from their parenting role. This might be because of maltreatment and abuse, but it can also happen as a result of family trauma or other conditions (including parent mental health disorders) that prevent parents from meeting a child’s emotional needs.
BPD may be especially linked to early relationships where care is inconsistent, when caregivers sometimes offer safety and support, and at other times emotionally withdraw or harm a child. This is known as disorganised attachment.
Why Is Early Intervention Important?
Early diagnosis allows us to intervene before a young person’s symptoms and traits start to impact other aspects of their life and well-being, leading to a more complex presentation. Without specialist support, children and teenagers with BPD symptoms often develop co-occurring mental health disorders that can make treatment more difficult. They may face challenges in family relationships, friendships, and school that can intensify symptoms.
BPD traits often disrupt a child’s development, preventing young people from developing the secure attachment relationships and stable sense of self that are crucial for social and emotional learning and integrating experiences. Treating BPD symptoms early opens the door to skill learning, growth, and development.
A recent study found that, on average, there was an eighteen-year gap between the time when BPD symptoms first emerged and the age of diagnosis. Many young people are misdiagnosed for years with anxiety, depression, or obsessive-compulsive disorder. This can prevent young people from accessing the specialised BPD treatments that promote meaningful recovery.
Around 85% of people later diagnosed with BPD said they would have benefited from a diagnosis in adolescence.
Can BPD Be Reliably Diagnosed During Adolescence?
Experts used to disagree about whether BPD could be reliably diagnosed among adolescents. Some clinicians used to say that because adolescents’ personalities were still developing, it didn’t make sense to give a diagnosis of a personality disorder. They also speculated that BPD traits might not be so far outside of the usual ‘storm’ of adolescence.
However, there is now clear evidence that shows that BPD can, and should, be diagnosed during adolescence. Studies have found that BPD traits are as reliable and prevalent among adolescents as adults, and that many adolescents with BPD continue to experience symptoms when they’re older. Research shows that a personality disorder diagnosis in childhood or adolescence is the most powerful predictor of a personality disorder diagnosis in adulthood.
BPD traits and symptoms are also well outside of the “normal” developmental trajectory of adolescence. The intensity of emotions, self-harming behaviours, identity instability, and other features of BPD are very different from the increased impulsivity and identity formation that teenagers often experience.
Stigma and Missed Diagnoses
While the majority of clinicians now recognise the validity of personality disorders in adolescence, very few give diagnoses to the young people they work with. One reason for this is the stigma associated with BPD. This stigma exists in different parts of society, including among healthcare workers.
Many people feel like they are invalidated, overlooked, or discriminated against in treatment because they have a BPD diagnosis. They may also face discrimination from employers. With this in mind, some clinicians may be reluctant to give a BPD diagnosis, aware of the potential stigma they might face in the future.
However, evidence and experience suggest that the stigma surrounding BPD is slowly decreasing as we gain a better understanding of the disorder. Many misconceptions about BPD have been challenged among healthcare workers and employers alike, leading to a more accurate conception of BPD development, symptoms, and recovery.
While BPD may still be more stigmatised than other mental health disorders, naming BPD traits is fundamental for effective treatment and recovery. Instead of avoiding naming BPD, we should continue to challenge mental health stigma while providing a reliable and accurate diagnosis.
Is Borderline Personality Disorder a Lifelong Diagnosis?
Borderline personality disorder used to be considered a lifelong diagnosis, with little prospect of recovery. This misconception contributed to stigma around the disorder and a reluctance to diagnose: clinicians saw a BPD diagnosis as a kind of label that would be carried for the rest of someone’s life.
However, research now clearly shows that, when they have access to treatment, most people do recover from borderline personality disorder. A six-year study from the Harvard McLean hospital found that over the entire follow-up period, 73.5% had reached remission, meaning that they no longer met the diagnostic criteria for borderline personality disorder.
Of those in remission, only about 5% were diagnosed with BPD again sometime in the future.
This means that BPD actually has a high recovery rate compared to other mental health disorders, with a low rate of “relapse” or recurrence. A BPD diagnosis isn’t a life-long label or identity, but as a way of naming symptoms that paves the way for effective and specialised treatment.
Treating Borderline Personality Disorder in Children and Adolescents
There are several different treatment approaches available for BPD in young people. Timely treatment of BPD or early BPD traits can help prevent social and emotional harm and disruption to young people’s development. Specialised BPD treatment can have a huge impact on young people’s mental health and wellbeing, even before they may meet the criteria for a categorical BPD diagnosis.
Treatment for children and adolescents with BPD should also focus on the family. Sometimes, BPD traits can be maintained or intensified by dynamics within the family system. On the other hand, mutually supportive family relationships with well-defined boundaries can play a huge role in recovery. This means that supporting families to restructure their relationships, increase their knowledge about BPD, and develop parenting skills is vital. For younger children, family interventions may be the primary focus of treatment.
There are several evidence-based modalities for adolescents with BPD. These include:
- Dialectical-behavioural therapy for adolescents
- Mentalisation-based treatment for adolescents
- Emotional regulation training
- Integrative BPD-oriented adolescent family therapy
Borderline Personality Disorder in the UAE
In the United Arab Emirates, around 80% of the population are expatriates. This means that the society is hugely diverse, with people from many different cultures sharing spaces and institutions, including healthcare.
Most of the clinical practice surrounding mental health disorders is based on Western cultural frameworks. The majority of the research into the causes, course, and treatment of mental health conditions has been conducted in the West, especially for personality disorders such as BPD. But only around 5% of the UAE’s population have Western backgrounds, with most expatriates coming from different parts of Asia.
Experts have long questioned whether Western cultural frameworks of clinical practice can be applied to other cultures. Many have pointed out that the symptoms of mental health conditions may manifest differently in different social settings. For example, in Middle Eastern cultures, family structures often look very different to Western ones. These systems can have a profound effect on each individual’s thoughts, feelings, and behaviours. And when certain personality traits are more or less acceptable in another culture, they may be more visible or less pronounced.
Equally, treatment for personality disorders and other mental health conditions may also vary.
However, in the past years, there has been an increased focus on understanding BPD in Middle Eastern regions and other cultures. A 2024 study found that the Arabic translation of the most established BPD-screening test was reliable, valid, and culturally relevant.
A research paper authored by medics in a psychiatric centre in the UAE discusses the way stigma affects people with BPD in Middle Eastern countries. They speak about the role of cultural stigma in discouraging people from seeking help. They also describe the interplay between cultural norms surrounding family responsibilities and BPD symptoms. BPD symptoms often make it hard for individuals to fulfil the roles expected of them, leading to additional feelings of distress and shame.
The Wave Clinic: Specialist Recovery Programs for Young People
The Wave Clinic offers specialist recovery programs for young people living with borderline personality disorder, complex trauma, and other mental health conditions. From our residential and outpatient treatment spaces in Kuala Lumpur and Dubai, we provide exceptional clinical care through a diverse selection of treatment modalities, delivered by a team of experts.
We believe in the early naming of BPD and specialised early interventions, including for younger children. We focus on addressing family structures and dynamics that may be maintaining BPD traits, while developing parenting skills that promote emotional and social learning in young people and reduce symptoms of BPD.
Alongside clinical care, we offer personal curriculum learning, vocational education, enriching experiences, and community projects, supporting young people to develop a meaningful sense of self, belonging, and direction. By building self-confidence and forming connections, young people grow in resilience and strength.
If you’re interested in finding out more about our programs, get in touch today.
