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Borderline Personality Impulse Control with Schema Therapy
Borderline & Schema Therapy continuing education MFT CEUs

Manual of Articles Sections 8 - 18
Introduction
DSM Diagnosis of Borderline Personality Disorders
Borderline Personality in Adolescence

CEU Answer Booklet | Table of Contents
| Borderline
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Borderline personality disorder in adolescence is a pervasive disorder with clear diagnostic signs, which can continue into adulthood. Many theorists have established the borderline core, signs of the disorder, which include intense emotions, poor self-control, illusory social adaptation, strained interpersonal relationships, vulnerability to brief psychotic episodes, and the persistence of the disorder. Development of the disorder is thought to be through environmental sources and object relations theory posits a developmental arrest in the separation-individuation phase of development. Gender and race considerations, issues related to the counseling relationship, general treatment strategies such as confrontation and coping skills training, and a specific modality Dialectical Behavior Therapy are discussed.
The personality dynamics of the borderline disorders in adults have been debated and discussed for decades. Although borderline personality disorder (BPD) is seen to have its roots in adolescence, research into BPD and adolescence has only surfaced within the last 10 years. As practitioners and researchers begin to realize the importance and necessity of early diagnosis and treatment of BPD in the adolescent years, counselors need to know the dynamics and treatment strategies for adolescents with symptoms of BPD. This article considers borderline personality disorder in adolescence through focusing on the important aspects of diagnosis, the possible developmental etiology, and some recognized treatment approaches.

Diagnostic Aspects
When diagnosing a client, it is important to recognize that the diagnostic criteria for BPD is identical for adolescents and adults (American Psychiatric Association, 1994). BPD is the most prevalent of the personality disorders and accounts for up to 60% of personality disorders among clinical populations (American Psychiatric Association, 1994). The symptoms are not transient and must persist for at least 1 year (American Psychiatric Association, 1994). Due to the pervasiveness of the disorder, it is important for counselors to be aware of the signs of the disorder in their adolescent clients. Ludolph et al. (1990) demonstrate that borderline adolescents can effectively be discriminated from nonborderline adolescents in an inpatient setting through differences in symptomology and quantity and quality of developmental trauma. Distinguishing variables of adolescents with BPD included history of "disrupted attachments, maternal neglect, maternal rejection, grossly inappropriate parental behavior, large number of maternal or paternal surrogates, physical abuse, and sexual abuse" (Ludolph et al., 1990, p. 470). In addition, adolescents with BPD have higher incidences of diagnoses of posttraumatic stress disorder (PTSD), mood disorders, and substance abuse and dependence problems.
Although diagnosis of BPD can be difficult, the literature outlines commonalities that make up a core of borderline characteristics (Dahl, 1990; Meissner, 1984; Spitzer & Endicott, 1979). Within the core diagnostic elements, the literature also points to unique cognitive and affective disturbances among clients diagnosed with BPD (Gunderson, 1984; Gunderson & Zanarini, 1987). For practitioners, knowledge of the borderline core and the contributing cognitive and affective problems are key to comprehending the client's treatment needs.

Intense Emotions
Weiner (1992) outlined six elements of the borderline core. The first element of the core, intense emotions, are episodes that make others feel uncomfortable due to the emotional intensity and unpredictability. The adolescent with BPD experiences emotional instability and lability ranging from extreme rage to extreme happiness. Accordingly, emotional moderation is rare. In fact, flat affect is so uncharacteristic that its presence usually is an indication to rule out BPD. According to Gunderson and Zanarini (1987), direct anger is a hallmark feature of BPD. In adolescent clients, the anger will feel qualitatively different than normal adolescent anger that may come from resistance to counseling. Anger emanating from a client exhibiting BPD will be unprovoked and inappropriate to the context of the session; normal anger has an identifiable trigger and is amenable to processing between counselor and client. Beck and Freeman (1990) assert that the cognitive disturbance of dichotomous thinking leads to extreme emotional reactions by the BPD client. The client cannot form an intermediate emotional response because the client's thinking is either-or in nature.

Impulsive Acts
Poor self -control, the second aspect of the core, demonstrates itself through impulsive acts. In adolescence, a client with signs of BPD may present with extreme sexual impulsivity, legal problems, or other delinquent behavior. Millon (1996) stated that adolescents exhibiting this core element of BPD will "seek to reaffirm status though promiscuous sexual activity, usually with minimal satisfaction or with the use of ." (p. 667). Other indicators such as self-mutilation and suicidal threats have a manipulative presentation. Reid, Balis, and Sutton (1997) state that the impulsivity is often an attempt to influence others, gain attention, or moderate internal anxiety. In one case experienced by the author, a 14-year-old female would scratch crosses into her arms with her eraser and proudly show her wounds to everyone on the inpatient unit as a sign of her self-destructive capabilities. Although manipulative in nature, counselors are encouraged to treat the impulsive behaviors as serious and regard the signs as a descriptive feature of BPD.

Illusory Social Adaptation
The third core component, illusory social adaptation, is characterized by a facade of social functioning, which is maintained by underachievement and the fear of being challenged. This element of the core is most visible in school interactions. On the surface, the teen will appear to be connected with school and extracurricular activities, but a closer examination will reveal participation in classes and clubs that guarantee success with moderate effort. Adolescents exhibiting signs of BPD will often display adequate functioning as long as their coping capacities are not challenged by uncertainty or a change in structure. When confronted with a change in routine or a challenging assignment, the adolescent will become agitated and demanding until the comfort of the old structure is returned. Overt aggression is not always the route pursued when challenged. Weiner (1992) noted that when faced with changing demands, adolescents with BPD often adopt a passive, helpless stance and perform poorly in a wide variety of activities (fail a class, show up late for a club meeting, and isolate from friends) until the demands revert to a predictable and comfortable pattern. Differentiation between BPD and other problems can be determined by the means used to change the environment. Whereas an adolescent with BPD will display generalized aggression or passivity toward a wide array of targets (friends, teachers, parents) in order to decrease a perceived challenge or ambiguity, normal adolescent apathy will be targeted at a specific goal and the apathy will appear consistent (i.e. generally sad or generally angry). Also, adolescents without BPD will often adapt to new situations, while adolescents with BPD will continue to be increasingly symptomatic until the perceived pressure decreases.

Strained Social Relationships
Due to the first three core elements, the adolescent with BPD has a very difficult time with relationships. The specific characteristics of these problems are illustrated in the fourth part of the core, strained social relationships. As with all situations, adolescents with BPD will confront relationships with an all-good or all-bad philosophy. If the adolescent sees relationships as all bad, then social isolation will be observed. Classmates, teachers and other people in the adolescent's life will be viewed as "users" and will be avoided. As one adolescent client diagnosed with BPD stated when asked about friends at school, "Why would I want friends? If you let them in you just open yourself up to getting ripped to shreds. I'll never have another friend for as long as I live." This fear of being used, hurt, or abandoned by others is coupled with a desperate need to be involved with others.
Adolescents can also present with extreme over-involvement in their past and current relationships. Relationships are intense, clinging and unstable, with the client being an interpersonal vacuum, sucking all the time and energy out of their partners. Cognitively, Pinto, Grapentine, Francis, and Picariello (1996) attribute these problems to impairments in self-concept and identity. Diagnostically, the counselor should see a pattern of intense, unsuccessful relationships, in which the client describes the situations as never fully satisfying. For adolescent clients, these relationships are frequent, short but very intense and the disintegration is almost always blamed on some outside force such as the boy/girlfriend, a scheming friend, or an authority figure.

Vulnerable to Brief Psychotic Episodes
The fifth core condition, vulnerability to brief psychotic episodes--which could involve dissociation, hallucinations, paranoid ideation, or a lack of reality sense--can occur when the client is presented with a lack of structure. Gunderson (1984) noted that any activity which stresses the BPD client could produce psychotic-like features. Diagnostically, the borderline adolescent may perform very well on structured tests such as the Wechsler inventories, but may become extremely agitated with unstructured tests such as the Rorschach (Edell, 1987; Gartner, Hurt, & Gartner, 1989; Singer & Larson, 1981). In fact, Singer (1977) claims that a combination of an adequate Wechsler test and a Rorschach characterized by loose and strange associations is an excellent indication of a BPD diagnosis.

Persistence of the Disorder
The last core condition, persistence of the disorder, speaks to the pervasiveness of all of the other conditions. Borderlines are predictable in their unpredictability. Grinker (1977) describes borderlines as having "stable instability," which shows that the disorder is more chronic and characterological than symptomatic in nature. A contributing factor to the persistence is that the conditions are viewed as egosyntonic by the client and, therefore, the client will often have little insight into how their personality is contributing to their problems. Due to the persistence of the disorder, the symptoms of BPD are not a phase of adolescence, but instead point to the first visible signs of a serious psychological disturbance that will become more severe if not treated. Accurate diagnosis and treatment at the earlier stage in adolescence can improve the prognosis of BPD. Due to the persistence of the disorder, Weiner (1992) urges practitioners to treat adolescents with BPD accordingly because it is, "more treatable than it will be later on, when personality style has become more firmly entrenched" (p. 168).

Having examined the core elements of BPD, it is important to understand the fundamental differences between normal adolescent behavior and the symptoms of a personality disorder such as BPD. Normal adolescent behavior, despite popular myths to the contrary, is not characterized by wild mood swings, rebellion, parent-child discord, or damaging anxiety and depression. In fact, research has demonstrated that mental problems exist in roughly the same proportion as the adult population and when they do exist, are short lived and amenable to treatment (Esser, Schmidt & Woerner, 1990; Tuma, 1989). Research has reported that overall, adolescence is a relatively smooth process of maturation with average problems and concerns (Manning, 1983; Powers, Hauser, & Kilner, 1989; Steinberg, 1987).
With this definition of adolescence in mind, counselors will note that the adolescent with signs of BPD will be exhibiting symptoms that are more frequent, intense, consistent, unpredictable, and persistent than those of a normal teenager. For example, although some emotionality is normative in adolescence, the anger often passes or is resolved. Anger, as a sign of BPD, is intense and is characterized by a heightened sensitivity to negative stimuli. A normal teen may dismiss a rude remark, but the same teen with BPD will react to every rude insinuation and will often erupt in an emotional outburst or frenzy. What may seem to be an innocuous statement ("Hey, nice outfit") can produce a wide array of intense, unpredictable, emotional responses in an adolescent with BPD. Parents, friends, and teachers of teens without BPD may report problems, but the reactions to the problem are often predictable for that adolescent. For example, Mary has problems with being teased and she cries and becomes depressed when she is teased by others. Parents, friends, and teachers of an adolescent with BPD will report more frequent problems. One common concern is that they never know what will trigger an episode, and they do not know how the adolescent will respond. When asked how a counselor can tell the difference between an adolescent with or without symptoms of BPD, the best answer was supplied by an adolescent with BPD: "I feel like a bonfire in a world of matchsticks. I just feel 'more,' but I'm different. I'm all alone."

Gender And Race Differences
In addition to the elements of the borderline core, other characteristics may be helpful with diagnosis. The DSM-IV (American Psychiatric Association, 1994) includes a section on gender and race considerations for every diagnostic category. Research on the demographics of BPD shows no significant race difference in the prevalence of a BPD diagnosis (Akhtar, Byrne, & Doghramji, 1986; Snyder, 1985). Far from conclusive, both studies encourage more rigorous research in this area.
Despite the lack of research addressing the impact of race on the diagnosis of BPD, there has been considerable attention given to the role of gender. Many studies point out that females are up to nine times more likely to receive a diagnosis of BPD, when compared to males with similar symptoms (Akhtar et al., 1986; Becker & Lamb; 1994; Henry & Cohen, 1983; Sheehy, Goldsmith, & Charles, 1980). Grilo et al. (1996) studied inpatient adolescents and reported a significant difference between males (39%) and females (61 %) diagnosed with BPD. Sex bias in mental health diagnosis is a problem on its own, but the diagnosis of BPD carries a greater stigma of insanity and resistance than other diagnoses (Reiser & Levenson, 1984). Understanding the impact and role of sex bias in diagnosis and the reasons more females are diagnosed with BPD can help the counselor make an accurate diagnosis.
Several articles in the literature attempt to explain the higher incidence of the BPD diagnosis in females. Grilo et al. (1996) postulate that the gender difference may be due to "extreme manifestations gender-linked values" (p. 1091). Specifically, adolescent females place a high value on relationships with others and cultivate a greater sense of self from the connections and feedback from other people in their environment, while males tend to be more inner or self-focused. Extreme manifestations of the value placed on others' views may resemble the intense emotionality, poor self-control and strained social relationships evident in the borderline core.
Other sources point out that the ambiguity of the symptoms leads many practitioners to view general, normative female socialization characteristics as fulfilling the BPD criteria. For example, in our society women are socialized to be comfortable with emotionality, while men are expected to be stoic and controlled. With adolescent girls, society fosters the need to please others, especially boys, and to vent emotionally. With the emphasis on "fitting in" to a peer group, many adolescent girls betray their sense of selves for what is popular. It is not too great a conceptual jump to translate each of these normal socialization processes into elements of the borderline core-intense emotions, strained interpersonal relationships, and illusory social adaptation, respectively (Becker, 1997). Extreme gender-based values and socialization are two explanations of the reported gender disparity of the BPD diagnosis. Research must continue to explore this area, and there are studies that argue against a sex bias for BPD.
Although there are studies that show a higher incidence of BPD diagnosis in females, some literature exists which refutes this claim and reports no significant gender difference (Corbitt & Widiger, 1995; Golomb, Fava, Abraham, & Rosenbaum, 1995). Garb (1995) pooled three studies on gender bias and BPD and found that although there was a gender difference in BPD diagnosis (86 of 155 females compared to 64 of 136 males diagnosed BPD), the difference was not statistically significant. Despite contradictory research findings, counselors are encouraged to be aware of possible gender and race bias when working with adolescents with BPD. The next section will outline etiological elements of BPD which can be used along with elements of the borderline core and gender and race information to make a more accurate diagnosis and treatment plan.

Etiology
Like many other psychological disorders, borderline personality seems to run in families. The DSM-IV (American Psychiatric Association, 1994) notes that borderline personality disorder is five times more common in first degree relatives than in the general population. However, there seems to be stronger evidence for an environmental causal factor. For example, although many studies have linked other personality disorders (such as schizotypal) with schizophrenia, studies have shown no genetic linkage between schizophrenia and borderline personality (Schulz et al., 1989). Twin studies (nonidentical and identical) also point to a minimal genetic influence in the manifestation of BPD (Torgersen, 1984).
Millon (1996) notes childhood abuse as an important environmental component in the emergence of BPD. Childhood abuse is so prevalent in the etiology of BPD that it has become a diagnostic component as mentioned earlier. Perry and Herman (1993) outline the vast research basis that correlates BPD with a history of child abuse. Although the nature of abuse is not specified or identical in each client, ranging across physical, emotional, and sexual forms of abuse, the perception of being an abuse victim in BPD clients is high (Paris, 1994; Paris & Zweig-Frank, 1992; Weaver & Glum, 1993). In comparison with other diagnoses, two studies reported that a history of physical abuse could be used to significantly discriminate between subjects with a diagnosis of BPD and those with other Axis II disorders (Links, Steiner, Offord, & Eppel, 1988; Paris, ZweigFrank, & Guzder, 1994). A child who grows in an abusive atmosphere experiences first hand the relationship where you are loved one day and beaten the next. Wilson (1997) expressed that children who are abused form a twisted sense of reality filled with feelings of terror, anticipation, and unpredictability. The polarity of mood intensity, the skewed sense of reality, and the confusing nature of relationships all are characteristic of adolescents with BPD.
The role of sexual abuse in the etiology of BPD has been given considerable attention in the literature. Despite the fact that sexual abuse is correlated with many Axis I and Axis II disorders, the linkage between borderline personality and sexual abuse has been extensively researched and is thought to be a major contributing factor in the etiology of the disorder (Katz & Levendusky, 1990, WaIler, 1994). Weaver and Glum (1993) reported that sexual abuse was the single significant predictor of BPD symptomology when other variables such as family environment, depression, and physical abuse were controlled. Zanarini et al. (1997) in a blind diagnosis study of 467 inpatients specified sexual abuse by a male noncaretaker as a significant risk factor for the emergence of BPD. Although sexual abuse appears to be associated with the etiology of BPD, Zanarini et al. (1997) stresses that sexual abuse alone is "neither necessary nor sufficient for the development of borderline personality disorder" (p. 1105). Counselors are encouraged to view any type of abuse as a "red flag" issue; one that alerts the counselor to cautiously consider the possible diagnosis of BPD or a related diagnosis such as posttraumatic stress disorder (PTSD).
When considering abuse as a component of BPD in adolescence, it is also wise to consider the diagnosis of PTSD. Both diagnoses have considerable overlap in the criteria, but PTSD emphasizes the trauma as the primary cause of symptoms, while BPD focuses on the personality of the individual. Many researchers feel that when abuse is reported in an adolescent, the diagnosis of PTSD should be considered before BPD, because treatment can address the trauma rather than personal dysfunction (Carmen, Rieker, & Mills, 1984; Courtois, 1988). PTSD can manifest at any time after the trauma, although symptoms usually appear 3 months after the initial abuse (American Psychiatric Association, 1994). Additionally, recovery or improvement can be seen in as little as 3 months, while BPD seems more persistent and pervasive. Counselors should consider the diagnosis of PTSD with a note to rule out BPD or with a provisional diagnosis of BPD if the abuse has been recent and if the symptoms have recently appeared. Persistent symptoms, longer than 1 year, with evidence of the borderline core components could indicate BPD. As treatment progresses and more information is gathered, the counselor can modify the diagnosis as needed.
Theoretical writings on the impact of the adolescent's environment on the manifestation of BPD are numerous (Millon, 1996). One accepted explanation of the emergence of borderline personality centers on early life experiences, primarily the mother-child relationship. Object-relations theory focuses on the intrapsychic development and the interruptions in that development. Masterson's views are used as the developmental model for emergence of the disorder in this overview. According to object-relations theory, intrapsychic structure develops slowly and progressively through differentiation of self from object with interrelated maturation of ego defenses (Masterson, 1978). Mahler postulated four stages of development:
autistic, symbiotic, separation-individuation, and object constancy. Masterson worked within this stage framework to conceptualize borderline personality.
According to Masterson (1978), if developmental arrest occurs in the separation-individuation phase, between the 18th and 36th month, the self and object representations would be split into all good or all bad representations. This arrest may occur because the mother encourages and rewards attachment, but sabotages autonomy. Beresin (1994) stated that the mother, not being able to tolerate separation or abandonment, transmits to the child the message that the child must stay attached to the mother or die. Masterson also postulated other problematic situations such as a psychotic mother, an absent mother, or a depressed mother. Beresin (1994) concluded that the mother does not need to be a borderline personality, but does need to be extremely intolerant of separation and fearful of abandonment.
An adolescent who develops the arrest will continue to form relationships to escape abandonment, seeking a pure symbiotic relationship. Without individuation, there is no sense of real or false self, and the adolescent will continue to use the splitting defense, seeing others as all good or all bad, due to the lack of object constancy.
In addition to the object-relations' view, studies have supported the role of disrupted or maladaptive attachments in the development of the borderline personality. Bezirganian, Cohen, and Brook (1993) studied 776 adolescents and found that maternal inconsistency in child upbringing predicted an emergence of adolescent BPD, but was not related to any other personality disorder. All of these factors can be integrated with Masterson's theory of developmental arrest and fear of abandonment, especially if the factors occurred during the separation-individuation stage. Overall, the etiology of BPD seems to be complex interplay of chaotic forces working within the adolescent's environment. Although the research associates factors such as abuse, maternal inconsistency, and neglect with BPD, no single factor is predictive of the emergence of the disorder. Counselors are encouraged to globally assess the client's social and family history while examining the presenting symptoms when considering a possible BPD diagnosis.
- Fall PhD, Kevin and Stephen Craig, "Borderline Personality in Adolescence: An Overview for Counselors", Journal of Mental Health Counseling, Oct 98, Vol 20 Issue 4, p315, 17p
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The article above contains foundational information. Articles below contain optional updates.
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