Borderline personality disorder in adolescents
By Liz Lockhart
Carla Sharp is an associate professor and director of the Developmental Psychopathology Lab in clinical 
psychology at the University of Houston (UH). She became interested in the way people think, how they organise thoughts, execute a decision, then determine whether a decision is good or bad.
It was this interest that led her to explore further. Sharps new study is entitled ‘Theory of mind and emotion regulation difficulties in adolescents with borderline traits’. The study featured in the Journal of the American Academy of Child & Adolescent Psychiatry.
Sharp says ‘BPD is a condition in which people have long-term patterns of unstable or turbulent emotions about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships. The criteria for BPD includes excessive anger, affective instability, a clear pattern of self-harm over two years – burning, cutting, suicide attempts, abandonment fears, relationship problems, significant impulsivity – drinking alcohol, drug abuse, eating, anorexia, overeating and illegal activities.’
She adds ‘Clinicians have been reluctant to diagnose BPD in adolescence because there is the notion that personality is not fully developed in childhood and adolescence. We know that the brain is only fully developed by age 25, so how can we diagnose a personality disorder in someone if they don’t have a fully developed brain yet?’
‘On the one hand, we are finding in our research that kids do have a stable pattern of interaction with others. Parents will describe their kids to you in terms that remain stable over time. Therefore, personality researchers have highlighter the point that teens do not wake up at 19 and have a personality disorder on the first day of their 19th year, so there must be some precursors to the disorders. There’s been a group of people, including myself, advocating that we not necessarily diagnose borderline personality disorder in adolescence, but that we assess for it to make sure that we don’t miss these children.’
The research study covers a two-year period and included 111 adolescent inpatients between the ages of 12 to 17. This is the first time a research study provides evidence to support the relationship between BPD traits and ‘hypermentalising’ in adolescents according to Sharp. Mentalising is the social intelligence that refers to the ability to infer and attribute thoughts and feelings to understand and predict another person’s behaviour. The results of the data can be used for early intervention, treatment and identification of BPD in adolescents. The data supports further research in this area.
The research team used an innovative approach to assess the social cognitive process with children through a newly developed tool called the Movie for the Assessment of Cognition (MASC), along with self-report measures of emotional regulation and psychopathology.
The participants were shown actual film scenes. They were introduced to the characters in the film, Sandra, Michael, Betty and Cliff, by showing a photograph of each of them. They were told to watch the 15-minte film carefully to understand what the characters are feeling and thinking. They were then asked what the character in the film might be feeling or thinking. They had four options to choose from forcing a single response prompt from one of four categories – no mentalising, less mentalising, hypermentalising or accurate mentalisation.
The findings from the study showed that 23% of the adolescents met the criteria for BPD. The young adults who met this criteria had a higher frequency of the ‘overmentalising’ responses.
The second part of the findings was the ‘hypermentalising’ interacted with emotional regulation. The individuals with BPD misread people’s thoughts, upsetting the adolescent and creating a challenge with emotion regulation that leads to an increase in BPD symptoms.
‘This research is groundbreaking in that it’s the first to provide empirical evidence of the link between BPD and mentalising in adolescents. By identifying precursors and treating BPD early in adolescence, we can use validated treatments to help these children,’ Sharp said. ‘The danger of not recognising precursors of BPD in adolescents is that it can lead to years of confusion and pain for family members and the individual with misdiagnosis and lack of appropriate treatment.’
‘The next step is to try to do this while neuro-imaging the teen’s brain, so that we can look at the biological correlates of this. Such research could potentially lead to pharmacological intervention in addition to the talk therapy,’ Sharp concluded.
