Birthdays, Holidays and Celebrations. We hope these occasions are filled with joy, happiness, and the making of memories for years to come. Parents and families organise themed birthday parties, attend weddings, host sleepovers, and celebrate with Fireworks. However, despite their best efforts for some families, these events often seem to end with a Big Bang.
Families that include young people diagnosed with Borderline Personality Disorder can experience anxiety and fear during the lead up to celebrations of any kind.
From a simple family gathering to more elaborate affairs, navigating emotionally sensitive young adults’ unpredictable responses can be quite a challenge.
Young people with BPD
‘There will be tears before bedtime.‘
Many young people and teenagers can be sensitive at times. In some way, it is part of navigating the tricky years between childhood and independence.
For young people with BPD, increased sensitivity, highly activated, or emotional episodes are more frequent and more intense than other children of a similar age.
Celebrations and group activities can prove particularly challenging for young people with BPD. It is often difficult for this group of teenagers to experience ‘connectedness.’
The lack of meaningful relationships can leave adolescents with BPD feeling isolated and rejected, even in a room full of people. It can feel that way, even when it is clear to others that the exact opposite is happening. Researchers have described this cognitive perception as ‘negative evaluation bias.’
In social and family situations, the ‘blink of an eye’ switches in mood can be difficult to navigate. You may find that your daughter or son frequently changes their mind about attending events, celebrating birthdays, or taking part in family activities.
Parents often describe not being able to ‘get it right’ despite their very best efforts.
Black and white thinking
Black and White thinking can also be tricky to manage. When people, places, and situations are either ‘All Good or All Bad,’ it can be nerve-wracking to attempt to negotiate with a teenager who makes it particularly clear that they do not want to take part, be present or accept a situation.
This can be evident if the focus of the celebration is not on something related to them; it can be equally prominent if the affection, love, or celebration are centred on their needs or wishes. The unpredictability leads families to recoil for fear of a ‘scene’ or rageful outburst.
Young people who feel that things are not going in the way they expected may report illness, crisis or evoke conflict in social situations; sometimes resorting to fictitious reporting to provide some relief to the internal world of pain and conflict.
This group of young people can experience a continual need for acceptance from their desired connection, with continual validation and positive affirming words and actions.
This need for affirmation is similar to a vast and Empty Imaginary Container. The young person needs to fill the container to the very top. The container is filled with perceived devotion, intense relationships, individual attention, validation, and sometimes adoration. Should the other party not be able (or wish to) continually fill the container, the contents spill out, and the imaginary container leaks and eventually crumbles.
Body Image issues, which can be the domain of many teens, are also significantly more pronounced in young people with a BPD diagnosis. Research continues in this area. Self-reported levels of satisfaction with the appearance, in general, are particularly low in this group. It can also play a role in social situations where poor self-image can be a precursor to feeling less than others and reinforce the internal message of being rejected by others.
The rollercoaster of high emotions may lead to volatile situations in social settings or avoidance.
Walking a tight rope
‘I Hate You, Don’t Leave Me‘, is a great book for anyone who has experienced the ‘push-pull’ of a Borderline relationship. (Jerold J. Kreisman, MD and Hal Straus).
‘When Your Daughter has BPD‘ is also an invaluable resource for parents. (Daniel. S. Lovely. PhD)
Another useful read for parents is; The Essential Family Guide to Borderline Personality Disorder. Randi Kreger.
Informed parenting is one of the most important steps to recovery.
Parents can feel that the extreme and sudden changes between pleasant and unpleasant interactions are impossible to manage. This can leave parents’ feeling alone, isolated, ashamed, confused, and impotent in their decision making.
Professional help (and some good books) can go along way in supporting the whole family.
All-in all-out relationships.
Interpersonal Relationships are deeply desired and are central to much of the discord experienced in young people with BPD.
Intense relationships are a hallmark of BPD. There is often a magnetic ‘All-in and All-out’ pattern that is evident in the friendships and relationships that are formed by young people with BPD behaviours. This intensity is often difficult for parents to watch, particularly if the ‘new’ relationships are accompanied by rapid shifts in interests, preferences, and behaviours.
Parents may notice a dwindling network of older childhood friends. It can be uncomfortable for parents and families to witness young people moving through the teenage years without a long term group of friends. Instead, friendships appear disposable. While they are incredibly intense, they are often short-lived. Friendships that were inseparable and magnificent become hate-fuelled enemies seemingly overnight.
Friendship and relationship breakdowns can be incredibly unsettling for young people diagnosed with BPD. The breakup can proceed a breakdown. This is often seen to be a triggering event in incidents of self-harm (Welch & Linehan, 2002) or suicidal gestures or end of life attempts (Brodsky, Groves, Oquendo, Mann & Stanley, 2006) in young people.
The aftermath and, on occasion, desire for revenge can be fuelled with powerful emotions that feel difficult for young people to manage. The increased risk at this time can increase the anxiety and pressure experienced in family systems.
Relationships and feeling slighted, rejected, or abandoned are some of the most frequent triggers of highly volatile, emotional, or rage-filled responses in Teenagers and Young Adults challenged by BPD.
What is Rage?
Rage is anger which is inappropriate, intense, or uncontrolled (American Psychiatric Association, 2000).
While not all young people diagnosed with BPD will experience Rage, it is one of the criteria listed in DSM-V in the evaluation of Borderline Personality Disorder.
What is Rejection and Abandonment Sensitivity?
Highly sensitive to rejection appears to be one of the main descriptors that young people experiencing the signs and symptoms of BPD and their families report on assessment or upon admission to a specialist BPD treatment centre for adolescents.
Anxiously fearing rejection or believing that they will be left alone or abandoned is one of the most troubling factors in the world of an adolescent with BPD. Left untreated this can contribute to increasingly intense emotional instability and identity difficulties.
Teenagers may often experience situations or people as neglectful, withholding, uncaring, or abandoning. It is this experience that largely precedes and determines the Rage that follows.
Emptiness is often described and accompanies the fear of abandonment. Eating Disorders and Substance use Disorders can be frequently seen to coexist with Borderline Personality Disorder, with a feeling of numbness or emptiness a regularly describes the feature.
How is Borderline Personality Disorder diagnosed?
Borderline Personality Disorder is a serious mental illness.
Patterns of behaviour associated with BPD frequently begin in adolescence or during the transition into early adulthood. In some cases, behaviours are noted by families and physicians during the pre-teen years. If the signs and symptoms of BPD have been present for a period in excess of one year, it may be diagnosed before the age of 18.
DSM-V lists the following Criteria for The Diagnosis of Borderline Personality Disorder.
(American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th Edition. Washington DC. 2013)
1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of intense or unstable relationships with others
3. Marked and Persistent identity disturbance
4. Impulsivity in at least two areas that are potentially self-damaging, such as spending, sex, substance abuse, reckless driving, or binge eating
5. recurrent suicidal behaviour, gestures, or threats, self-mutilating behaviours
6. Affective instability with marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate or intense anger or difficulty controlling anger
9. Transient stress-related paranoid ideation or dissociative symptoms.
If you feel that three or more of the behaviours are present in your Teen or Young Adult, it is advisable to make an appointment with a Child and Adolescent Mental Health Professional or The BPD Admissions Team at The Wave.
Therapeutic Challenges in Borderline Personality Disorder
Young People with BPD are frequently seen in all clinical settings. Despite making up only 2-3% of the population, they make up somewhere in the region of 20٪ the visits to inpatient treatment centres and 10% of the visits to Primary Care medical practices.
Often visits come at times of crisis; both self-harm and suicidal thoughts are increased in this group of young adults.
Research by Zanarini et al, indicated that young people would typically begin treatment at around 18 years of age, despite the symptoms having been evident for several years. The same research demonstrated that over 30% of young people begin self-harming at around 12 years old, sometimes earlier.
Supportive connections that promote and sustain recovery can be found in good therapeutic settings. Clinicians experienced in the treatment of Borderline Personality Disorder will be well versed in crisis management, skills building, and psychoeducation for the family system and young person.
Good Psychiatric Management adapted for Adolescents
GPM-A (Good Psychiatric Management adapted for Adolescents), DBT and CBT-e (where indicated) are evidence-based, effective therapeutic tools for managing Borderline Personality Disorder in Young people.
Psychoeducation is essential for young people and families challenged by BPD in adolescence. BPD has long been considered an untreatable lifelong condition.
It is that belief, amongst other reasons, that has prevented many adolescents from receiving the help that they need early on in the course of the presenting conditions.
Specialised treatments for BPD
The reality is that many young people with BPD who receive assistance in specialised treatment settings (not in the crisis interventions settings on Primary Care or The Emergency Department) do reasonably well in the long term. In fact, many no longer meet the criteria for diagnosis later in life. Young People with BPD do get well!
Specialist treatments for BPD are essential in the treatment of these young adults. Successful treatment is usually between 1-3 years in duration, across a variety of treatment settings.
Treatment may begin in specialist residential centres for adolescents, in programs that include evidence-based treatments. The Wave Programs for BPD are long term treatment programs utilising well researched and Teen friendly protocols.
Whilst the initial phases of treatment may be undertaken in settings that meet the needs of young people who require a higher level of care, step down programs similar to those found in Transitions by The Wave allow for further independence and the development of social skills and education. This is a supported bridge to living.
Those who have 18 months or more in treatment have been found to have a significantly improved likelihood of having gainful employment or educational success in an 8 year follow up study. (Bateman A, Fonagy P. 2008)
Therapeutic support should be considered into adulthood, where many young people will be considered to be in long term recovery.
Relapses, if and when they happen, can usually be managed on an outpatient basis if an existing therapeutic relationship is in place.
Managing Social situations. The Top 10 Tips for Parents and Teens from The WaveBPD Team
Planning in advance for stressful or highly charged situations is a great strategy. Teens and young adults are not at their ‘thinking best’ when dealing with intense emotions or situations. Creating a plan when you and your teen are not feeling anxious or low in mood can really help in moments of high activation.
Take some time to prepare a support plan with your teen. It is a project young adults can do alone or with support and take to their next therapy appointment, perhaps leaving a copy with a therapist or trusted person.
Prepare yourself in advance for events, maybe offering to help with arrangements or decorations. Being involved and having a distraction can help. Finding things that can be enjoyable or soothing during the event can also be helpful.
1. Use an imaginary container. Building your own imaginary box (or even a real box) together with mindfulness practices can be great for temporarily ‘containing’ big feelings and emotions. Mindfulness, DBT, and EMDR use skills similar to this. Put all of the day’s tricky situations into your container for safekeeping and make an appointment with your therapist to unpack the box of feelings.
2. Play some great music and Dance. Music is wonderful for changing and uplifting our mood, allowing us to remember times when we felt less stressed or anxious. Have your playlist ready and downloaded. Make it easy to find when you think that a distraction will be useful. Drawing, writing, or other creative activities can help. Putting your big feelings onto paper can be a safe outlet.
3. Make a list of the people that can support you in times of heightened feelings or crisis with their contact details. On the reverse, make a list of people who are not so great or helpful for you in these times.
4. On your list, include the numbers of two 24 hour support lines. Whilst you may have a therapist, it is important to remember that there may be times when they are not available. Support lines can be invaluable in this situation.
5. Write down the high-risk behaviours that are usual for you to do at this time (cutting, burning, taking too many pills) and Plan what you will do instead (talk to a friend, go for a walk, take Pets for a walk, music playlist, write a journal, call therapist) Add the numbers of your local emergency room, A & E or Private Paramedic service and a safety plan.
Teens and Young Adults who experience overwhelming thoughts and feelings can feel alone in their struggles. Finding a therapeutic community able to provide long term care can help Teens to feel supported and included. Finding companionship, friendship, and community is essential in the healing process.
Fiona Yassin is an Accredited Clinical Supervisor (UNCG) and International Clinical Director at The Wave Clinic (Young Adults). Fiona has a specialist interest in Psychiatric Diagnosis across the Female Lifespan, Borderline Personality Disorder and Eating Disorders. Trained in GPM, EMDR (EMDRIA Registration number #100054651), DBT and CBTe (CREDO), and STEPPS (for BPD).
Fiona is a Fellow ACCPH, A member of The International Association of Eating Disorder Professionals and Federation of Drug and Alcohol Professionals. Fiona is currently enjoying further study in Child and Family (Custody Evaluations) and PAS (Accredited by The California Board of Behavioral Sciences)
Dr Abdul Rasyid Sulaiman, Consultant Psychiatrist and Medical Director of The Wave Young Adults. Dr Rasyid has extensive experience in the Psychiatric management of Teenagers and Young Adults in the residential setting. Dr Rasyid has a specialist interest in BPD, Eating Disorders, and Addiction in Teenagers and Young Adults.
Dr. Rasyid leads the Medical Team at The Wave Clinic, together with his Position as Senior Faculty Member at The International Medical University.
Fiona and Dr. Rasyid have extensive experience in working with Families. Advocates of HEAS Principles, Intuitive Eating, and the involvement of The Family in The Care of Children and Adolescents. The Wave Clinic is a Member of The Association of Child Protection Professionals.