Symptoms and features of borderline personality disorder are relatively common among adolescents. They’re often similar to borderline symptoms among adults, both in their character and intensity.
For example, young people may have traits or behaviours of impulsivity, substance abuse, sexual behaviours, identity disturbance, and social difficulties that are beyond normal adolescent behaviour.
However, despite this evidence, many clinicians are still reluctant to diagnose BPD in adolescents before they are 18. Stigma and misconceptions surrounding personality disorders cause clinicians to avoid the diagnosis, despite strong evidence that many young people show stable and persistent BPD symptoms. Instead, young people may be diagnosed with anxiety disorders, mood disorders, or psychotic disorders.
Sadly, these diagnoses often overlook the complexity of BPD symptoms and misrepresent a young person’s experience. Misdiagnoses can cause young people to miss out on effective treatment that’s proven to help reduce symptoms and drastically improve their mental health and quality of life in the future.
This blog explores the diagnosis of BPD in under-18s and what other diagnoses young people may receive. It also questions why some clinicians may be reluctant to diagnose BPD in young people and the potential consequences.
How Common Is BPD in Under-18s?
It’s still not clear exactly how common BPD is in under-18s. Studies use different criteria for what they consider a BPD diagnosis, which can lead to different results. Moreover, research has taken place in different parts of the world and among different compositions of young people.
However, studies agree that a significant proportion of young people could meet a BPD diagnosis. Taken together, the results of population studies suggest that the prevalence of diagnosable BPD in adolescents is at least 3%.
Some studies found that even children as young as 11 or 12 could describe behaviours accurately enough for medics to consider a diagnosis of BPD. Many young adolescents with BPD continue to experience BPD traits and features into adulthood, especially if they don’t receive treatment and support.
What BPD Symptoms Do Young People Experience?
Young people with BPD experience symptoms that cause significant distress in their daily lives. They also affect their emotional and social development, disrupting normal processes of learning and personal growth.
BPD symptoms in young people include:
- self-harm and suicidal ideation
- auditory and visual hallucinations
- identity disturbance
- unstable and quickly changing emotions
- intense anger
- feelings of emptiness
- persistent efforts to avoid abandonment
Why Are Some Clinicians Reluctant to Name BPD Symptoms in Under-18s?
Research shows that BPD can be reliably diagnosed before the age of 18. BPD in young people isn’t a different disorder from BPD among adults; instead, it’s the same disorder that persists from adolescence into adulthood, with symptoms typically rising around puberty and decreasing again. This means that terms like ‘adolescent BPD’ or ‘emerging BPD’ can be misleading.
Despite this evidence, many clinicians are still reluctant to diagnose BPD in those under 18. Some psychologists and psychiatrists hold the false belief that BPD features during adolescence are within adolescents’ normal developmental pathways and processes. For example, one study found that 40% of a group of Dutch psychologists thought that BPD features were simply the usual ‘storm and stress’ of adolescence.
However, research shows that BPD features in adolescents are well outside of what is normal.
When medics use age 18 as a cut-off for a BPD diagnosis, they also assume that young people’s development somehow ends or changes significantly at age 18. However, research shows that developmental processes of identity formation, cognitive functions, and personal development usually continue from the start of puberty until around the age of 25 – and certain processes continue for even longer.
It’s also important to recognise the stigma surrounding borderline personality disorder (and personality disorders in general). This stigma exists not only within the general public but also among clinicians and other professionals. Clinicians may be reluctant to diagnose BPD because they are afraid of the stigma and discrimination an individual will experience from the rest of society and how it may affect their work and other opportunities.
However, a delay in the diagnosis and treatment of BPD can cause serious harm to a young person’s future. It can affect their ability to work, form meaningful and supportive relationships, and live independently. This means that it’s important to find other ways to challenge BPD stigma while giving young people accurate and reliable diagnoses.
What Diagnoses Do Young People Receive Instead of BPD?
Instead of diagnosing young people with BPD, clinicians may give diagnoses of axis 1 disorders, as defined by the DSM-V (the go-to manual for diagnoses of mental health disorders). Axis 1 disorders include mood disorders like depression, anxiety disorders, psychotic disorders, and other mental health conditions. Importantly, axis 1 disorders don’t include any personality disorders, which fall into axis 2.
However, these diagnoses often misrepresent the experience of a young person with BPD features and symptoms. They may overlook the complexity of symptoms or misunderstand the underlying causes of their thoughts and behaviours. This can cause young people to receive treatment that is ineffective or unsuitable, affecting their health and well-being.
Understanding Axis 1 and Axis 2 Disorders
The division between axis 1 and axis 2 disorders is based on certain ideas about the difference between personality disorders (and intellectual developmental disorders) and other mental health conditions.
For example, personality disorders are often considered to be more stable and permanent than mood disorders like depression. Some experts have suggested that personality disorders have more to do with unstable identity, are less responsive to treatment than other mental health conditions, and are only reliable after the age of 18.
However, research now contradicts or calls into question many of these ideas. Evidence suggests that personality disorders are no more stable than other mental health conditions and often co-occur with them. Moreover, both personality disorders and other mental health conditions may share similar causes and developmental pathways. As we have seen, personality disorders can also be reliably diagnosed before the age of 18.
This means that many experts now question the division between Axis 1 and Axis 2 disorders and the precedent of only diagnosing under-18s with Axis 1 conditions.
Is BPD Different from Complex-PTSD?
One of the mental health disorders that has the biggest overlap of symptoms with BPD is post-traumatic stress disorder (PTSD), particularly complex PTSD.
Complex PTSD is a type of PTSD that usually develops from trauma experienced at an early age and/or over a period of time. Young people with complex PTSD experience symptoms of PTSD alongside other additional symptoms, such as difficulties controlling emotions or distrust of the world. Many of these symptoms are also symptoms of BPD.
Moreover, complex PTSD and BPD can share very similar developmental pathways. Complex PTSD usually develops after childhood trauma, especially during early childhood. Childhood trauma is also very common among young people with BPD – some research suggests that up to 90% of people with BPD have experienced some form of abuse or neglect during childhood.
However, some experts emphasise that BPD doesn’t just develop as a result of trauma but is caused by a combination of adverse experiences and other factors, such as personality traits (largely based on genetic and biological features). This means that categorising BPD as a form of complex PTSD is too simplistic.
Research also suggests that some core BPD features are different to the core features of PTSD, suggesting it is a separate diagnosis. These include desperate attempts to avoid abandonment, an unstable sense of self, unstable and intense interpersonal relationships, and impulsiveness.
The Wave Clinic: Specialist Mental Health Support for Young People
The Wave Clinic offers dedicated mental health support for young people, specialising in eating disorders, borderline personality disorder, and trauma treatment. Our programs aim to make a difference in their lives by providing exceptional clinical care with the most up-to-date, evidence-based treatments.
From our outpatient and residential centres in Kuala Lumpur, we offer a diverse range of modalities from our internationally registered, qualified and accredited team. At our residential space, we combine psychological and medical support with education, social responsibility, and a gap year experience, supporting young people to develop life skills and grow in self-confidence.
We cater to neurodiverse young people in everything we do, following our values of fairness, inclusivity, and exemplary treatment for all.
If you’re interested in finding out more about our programs, contact us today. We’re here to help.
