Clinical features of BPD in children and adolescents
After reviewing the clinical literature, Bemporad and Cicchetti (1982) and Vela, Gottlieb, and Gottlieb (1983) described substantial consensus in diagnostic criteria for borderline children. Bemporad, Smith, Hanson, and Cicchetti (1982) outlined diagnostic criteria consisting of the following features: (1) a paradigmatic fluctuation of functioning, with rapid shifts between psychotic-like and neurotic levels of reality testing; (2) a lack of "signal anxiety" (Freud, 1926/1959) and a proneness to states of panic dominated by overwhelming concerns of body dissolution, annihilation, or abandonment; (3) a disruption in thought processes and content that shifts rapidly into loose, idiosyncratic thinking; (4) an impairment in relationships, with much difficulty, when under stress, in distinguishing self from others, in appreciating other people's needs, or in integrating disparate emotional experiences into a coherent relationship; and (5) a lack of impulse control, with an inability to contain intense affects, delay gratification, control rage, or modulate destructive and self-destructive tendencies. Vela et al. (1983) described six features: (l) disturbances in interpersonal relationships; (2) disturbances in the sense of reality; (3) excessive anxiety; (4) severe impulse problems; (5) "neurotic-like" symptoms; and (6) uneven or distorted development.
More recently, Petri and Vela (1990) further refined the diagnostic criteria by identifying two broad categories among children described as borderline in the literature: the borderline personality disorder (BPD)/borderline spectrum proper, and the schizotypal personality disorder (SPD)/schizotypal spectrum. Both groups present transient psychotic episodes, magical thinking, idiosyncratic fantasies, suspiciousness, and a disturbed sense of reality. Yet only schizotypal children have a family history of schizophrenia-spectrum disorder or present constricted or inappropriate affect, oddness of speech, and extreme discomfort in social situations, which contrasts with the intense, dramatic affect and hunger for social response of borderline youngsters. Petti and Vela's study parallels the findings of genetic, epidemiological, and follow-up studies of adult BPD, all of which separate the borderline spectrum from the schizophrenic-schizotypal spectrum. Such a distinction is likely to result in much greater diagnostic specificity with borderline children.
Children in the process of developing narcissistic or histrionic personality disorders present significant clinical overlap with children with BPl). Narcissistic and/or histrionic children are self-centered and self-absorbed, need constant attention, respond with rage to rejection or indifference, alternate between idealization and devaluation, are seductive or manipulative, and express affect with undue intensity and drama. This overlap supports the contention in DSM-III-R that these personality disorders should be clustered together. Borderline children, however, display much greater impulsivity, self-destructiveness, affective instability, disturbances in the sense of reality, and transient psychotic episodes, suggesting some significant differences in developmental and pathogenic factors. Goldman et al. (1992) proposed a slight modification of the DSM-III-R adult criteria for borderline children (see Table 1).
Early manifestations of developmental difficulties are apparent in children who subsequently develop BPI). History often reveals temperamentally "difficult" children, that is, infants with high activity levels, poor adaptability, negative mood, and problems settling into rhythmic patterns of sleep-wakefulness and feeding. Cranky and hard to soothe, these infants frequently challenge and burden their caretakers.
Hyperactivity and temper tantrums are common in the preschool years of many borderline children, while others are more notable for their clinginess and vulnerability to separations. By school age, borderline children almost invariably meet diagnostic criteria for an Axis I diagnosis, more commonly attention-deficit hyperactivity disorder, conduct disorder, separation anxiety disorder, or mood disorder. Many of these youngsters appear anxious, moody, irritable, and explosive. Minor upsets or frustrations trigger intense affective storms--episodes of uncontrolled emotion wholly out of proportion to the apparent precipitant. This lability of affect mirrors the kaleidoscopic quality of these children's sense of self and others. One moment they feel elated and expansive, blissfully connected in perfect love and harmony to an idealized partner. But at the next moment, they plunge into bitter disappointment and rage, coupled with self-loathing and despair.
On clinical examination, borderline school-age children may appear helpless and vulnerable, provocative and suspicious, or eager to comply and ingratiate themselves with the examiner. Leichtman and Nathan (1983) described how these youngsters quickly attempt to establish highly coercive, controlling relationships with their examiners. Some show surprisingly little anxiety about meeting alone with the clinician and proceed to take over the office as if they owned it. Even those who seem vulnerable and anxious try vigorously to set the agenda for the meeting. They become anxious and even more desperate and arbitrary when the examiner does not comply with their demands or when they feel that their control is threatened.
Borderline youngsters require a constant stream of emotional "supplies"--someone's love and attention, sex, drugs, or food--to protect them against overwhelming feelings of dyscontrol, hyperarousal, and aloneness. These supplies can transiently stave off such dreaded emotional whirlwinds. But when they are not forthcoming, these children panic, become enraged or temporarily psychotic, or experience an unbearable sense of basic disconnection from human nurturance and protection.
Thus these children direct much of their energy at coercing others to provide them with the "right" supplies and responses. Such efforts often take the form of elaborate maneuvers to induce others to assume particular roles that "fit" elaborate fantasies. As Chethik and Fast (1970) pointed out, these children become absorbed in a vivid fantasy world and demand that others become players in this world they have created. Although these children can generally recognize the arbitrariness with which they treat people and reality itself, they behave as if they must believe their own falsification of reality. It is in the enactment of their fantasies--whether in play or in their relationships--that they come to life, while they adamantly forbid reality to intrude and to question the arbitrariness they impose on reality. This rigid and desperate insistence on inducing interpersonal responses that support an illusory perspective is one of the most draining challenges facing clinicians working with such youngsters.
Cory, a Taiwanese-born 8-year-old girl, was adopted as a baby by a Caucasian family from the Midwest. Threats of separation from her adoptive mother--for example, the prospect of the mother visiting her sister for a weekend in a nearby city--triggered a dramatic disruption in Cory's contact with reality, as well as rage outbursts, fits, and tantrums both at home and in school. Cory also created a fantasy in response to her mother's absence: She "knew" that her biological mother was an Asian princess.
This fantasy was extraordinarily vivid for Cory, causing her to lash out at the world when it failed to appreciate her entitlement to royal prerogatives. Yet, even without reality's challenge, a dream or a bad thought typically sufficed to disrupt the idyllic fantasy. In Cory's dreams and play, the "princess" would be replaced by a witch, a vicious vixen whose facial appearance combined Asian and Caucasian features. This woman taunted Cory and tried to drag her into a bottomless pit, leaving the child with no choice but to strangle the witch. As Cory's fantasy unraveled, Cory also changed. When unable to invoke the princess--and to demand that others such as her mother or therapist "become" the princess--Cory would turn into a "Chinese bitch," filled with rage and destructiveness.
Cory's attempt to produce a perfect, magical union, while keeping safely apart the dangerous, rageful, and frustrating aspects of herself and others, often fell apart in the face of separation or the threat of loss of control. The collapse of such fantasied scenarios is one of the triggers of self-mutilation and suicidal gestures, which are also brought about by: (1) attempts to restore the capacity to experience feelings in children haunted by emotional numbness; (2) efforts to escape unbearable anxiety and depression; (3) desires to punish previously idealized partners; or (4) maneuvers to evoke guilt and involvement.
The psychological landscape of these youngsters can sometimes be glimpsed only through the lens of psychological testing. According to Leichtman and Nathan (1983), psychological testing reveals rigid and tenuous repressive defenses, coexisting with primitive defenses; a highly egocentric, arbitrary interpretation of reality; transitory disturbances in reality testing and impairments in formal thought processes in unstructured tests; constant or recurrent disturbances in ego functions such as frustration tolerance, attention, and goal-directedness; primitive, unmodulated experience of affects and drives; and marked disturbances in interpersonal relationships and in the experiences of self and others.
The developmental and psychosocial pressures of adolescence typically trigger the onset of the full range of borderline psychopathology and allow for greater diagnostic certainty. Unstable relationships with peers become prominent as transient idealization and clingy overdependence alternate with rage, devaluation, and feelings of abandonment and betrayal. Regardless of whether idealization or anger predominates, all of these youngsters' interpersonal exchanges have an intense, dramatic quality. Promiscuity is more common in borderline girls, particularly sexually abused girls for whom aggressive seductiveness affords the opportunity to turn around and gain control of the helplessness associated with being abused. Borderline boys are often burdened with intense shyness and fear of rejection. Manipulative efforts to secure attention and prevent abandonment become prominent interpersonal strategies for both boys and girls. Bulimic binges or drugs are relied on for soothing and comfort, and become essential regulators of well-being. Yet the transient nurturance derived from food binges, drug abuse, or promiscuous sex leads only to shame, guilt, and a dreaded feeling of inner deadness or emptiness.
- Bleiberg, Efrain; Borderline Disorders in Children and Adolescents; Bulletin of the Menninger Clinic, Spring 1994, Vol. 58, Issue 2.
Reflection Exercise #9
The preceding section contained information
about rage and impulsivity in children and adolescents with BPD. Write
three case study examples regarding how you might use the content of this section
in your practice.
According to Bleiberg, what are the four triggers of self-mutilation and suicidal gestures in a BPD client? Record the letter of the correct answer