Should Personality Disorders be Diagnosed in Adolescence?
Looking at both sides of the debate
There is a growing debate among mental health professionals on whether BPD can be accurately diagnosed in adolescence, whether it is essential for treatment, or whether it could cause more harm than good. Borderline Personality Disorder (BPD) is a mental health condition characterized by emotional dysregulation, impulsive behaviour, interpersonal challenges, unstable sense of self, and difficulties in self-soothing. It has a reputation for being hard to treat.
Borderline individuals have a reputation for being treatment-resistant, attention-seeking, and manipulative. Can a diagnosis lead to a self-fulfilling prophecy? Let’s explore these arguments further.
This article looks at will look at both sides of this contentious issue. Whatever side you stand on to diagnose BPD or not; we can all agree that adolescence is a vulnerable time, and there are many factors to consider in treating their mental health concerns and whether a diagnosis of BPD is warranted, helpful or harmful.
DBT is the most empirically evidence-based practice for DBT. DBT is about finding balance. There is a kernel of truth in all perspectives. As a clinician, I take this balanced approach and find it is helpful to look at these issues dialectically. Diagnosis for some youths will be helpful, but for some clients, it will be detrimental.
Arguments in Favor of Diagnosing BPD
Advocates for diagnosing BPD in adolescence argue that early identification and intervention can lead to better outcomes for individuals with the disorder. Without a diagnosis, this makes it difficult to obtain treatment resources by diagnosing BPD in adolescence. Healthcare professionals can provide targeted treatments and programs to support and help individuals manage their symptoms and improve their overall well-being.
They argue in other countries such as Australia, Europe, and the US diagnosis of BDP is standardly made. In the Editorial: Should Child and Adolescent mental health professional be diagnosing personality disorders, the authors underscore the lack of scientific evidence in the arguments by those who are against adolescents receiving a diagnosis of BPD (2022)
They further argue that diagnosing BPD in adolescence can help reduce the stigma associated with the disorder. By acknowledging that BPD can occur in adolescents, we can promote understanding and empathy, ensuring that young people receive the appropriate treatment and support they need. Early diagnosis can also facilitate communication between healthcare professionals, educators, and families, fostering a collaborative approach to treatment.
Supporting Evidence for BPD Diagnosis
Several studies provide supporting evidence for diagnosing BPD in adolescence. Research has shown that the symptoms of BPD, such as emotional dysregulation, impulsivity, and unstable relationships, are often observed and experienced in adolescence. Longitudinal studies have also found that individuals diagnosed with BPD in adolescence often continue to exhibit symptoms and meet diagnostic criteria in adulthood. Chann 20220 argues,
From a scientific perspective, compelling evidence indicates that it is illogical to be willing to diagnose a personality disorder in a 23-year-old but not a 13-year-old.
Chann further argues delaying diagnosis will delay treatment. There is a family who lost twin girls and a child to suicide. The family argues if their daughters were diagnosed with BPD and received adequate treatment, it may have saved their child. On the other side of the debate, diagnosis offers us an understanding of more tools, and resources (Cannon and Gould)
The Controversy Surrounding BPD Diagnosis
Despite the arguments in favor of diagnosing BPD in adolescence, there is a significant controversy surrounding its diagnosis. Critics argue that the symptoms of BPD can overlap with typical adolescent behavior, making it challenging to differentiate between normal developmental processes and symptoms of personality disorders.
They assert that labeling teenagers with BPD may pathologize normal experiences, leading to unnecessary treatment or stigmatization. The chief reason identified is that the disorder is not just based on an individual factor it could have developed due to environmental factors such as trauma.
“Proponents argue that the PD wrongly positions the dysfunction within the individual therefore ignoring factors such as Childhood trauma and sexual violence that may have contributed to the individuals emotional pian” (Cavelti et al )2023.
Those who promote diagnosing youth with personality disorder argue, we cannot adequately treat a disorder if it is not diagnosed. Not diagnosing will limit the resources and treatment the most vulnerable youth receive.
Some experts have postulated that there are concerns about the reliability and validity of the diagnostic criteria for BPD in adolescence. Critics argue that these criteria were primarily developed based on research conducted with adult populations and may not accurately capture the unique presentation of the disorder in adolescents. They suggest that a more developmentally sensitive approach is needed to ensure accurate diagnosis and appropriate treatment.
They believe those diagnosed with BPD experience systemic discrimitioan, that will cause more harm,. BDP such as in the article.Chartonas, D., Kyratsous, M., Dracass, S., Lee, T., & Bhui, K. (2017). Personality disorder: Still the patients psychiatrist's dislike? The writers draw attention to the stigma those with BPD continue to face in mental health care systems. They conducted a study of physiatrist’s attitude toward BPD patients and concluded.
“This study supports the view that psychiatrists form pejorative, judgmental, and rejecting attitudes towards those who have been give the diagnosis of personality disorder, Patients previously labeled as personality disorder were seen as manipulative, difficult to manage, unlikely to rouse sympathy, annoying and not deserving of NHS resources (pg. 47)
Arguments Against Diagnosing BPD
Opponents of diagnosing BPD in adolescence argue for a more cautious approach, focusing on providing supportive interventions rather than applying a diagnostic label. They point out that many of the symptoms associated with BPD, such as mood swings and impulsivity, are common during adolescence and may resolve naturally over time.
Instead of diagnosing BPD, they propose using a dimensional approach that considers the severity and frequency of symptoms, providing targeted support without pathologizing normal adolescent experiences. In addition, some experts believe it is a result of trauma such as sexual violence.
Opponents question the potential negative consequences of diagnosing BPD in adolescence. They argue that a diagnosis of BPD may lead to self-fulfilling prophecies. Individuals may internalize the label and develop a fixed identity as someone with a personality disorder. This can hinder personal growth and limit future opportunities for individuals who may otherwise overcome their symptoms and flourish.
Criticisms of the BPD Diagnosis Criteria
Critics of diagnosing BPD in adolescence also question the validity and reliability of the diagnostic criteria and further argue it creates stigma. Those in the field who are against diagnosing BPD point out that it does more than good as Adolescence is a vulnerable time as youth are forming their identity, and symptoms of personality disorder overlap with normal adolescent development.
They question the validity of the BPD diagnosis as socially constructed a discriminatory to women. There have been many articles addressing the Stigma of Personality Disorder. e. diagnosing personality disorders in adolescents is not without its challenges such as fear of abandonment and unstable relationships, which are common among teenagers navigating the complexities of friendships and romantic relationships.
Critics suggest that refining the diagnostic criteria to account for developmental differences could improve the accuracy of BPD diagnosis in adolescence. Those who oppose diagnosing adolescents with personality disorder argue that it will worsen symptoms and that adolescents possess many of the traits of personality disorder as adolescence such as impulsivity and emotional dysregulation.
Alternative Perspectives on BPD
In addition to the arguments against diagnosing BPD in adolescence, alternative perspectives offer different ways of conceptualizing the disorder. Some researchers propose the concept of “emerging borderline personality disorder is a more accurate diagnosis, that captures the unique presentation of the disorder in adolescence. This approach acknowledges that BPD symptoms may fluctuate during this developmental period and emphasizes the importance of providing tailored interventions that address the specific needs of adolescents.
Others argue for a dimensional approach, focusing on assessing and treating specific symptoms rather than applying a categorical diagnosis. By evaluating the severity and impact of individual symptoms, healthcare professionals can provide targeted interventions that address the unique challenges faced by adolescents with BPD-like symptoms.
The Importance of Accurate Diagnosis and Treatment
Regardless of the ongoing debate, it is crucial to recognize the importance of accurate diagnosis and treatment for individuals experiencing BPD symptoms in adolescence. Whether diagnosed with BPD or not, these individuals often struggle with intense emotions and challenging behaviors that can significantly impact their well-being and daily functioning. Early intervention, regardless of the diagnostic label, can provide much-needed support and resources to help them navigate these difficulties.
Accurate diagnosis also ensures that appropriate treatment modalities, such as dialectical behavior therapy (DBT) and Mentalization are available to those who may benefit from them. DBT has been shown to be effective in helping individuals with BPD develop skills to manage their emotions, improve interpersonal relationships, and reduce self-destructive behaviors. By diagnosing BPD in adolescence, we can ensure that these evidence-based treatments are offered to those who need them most.
Conclusion: The Ongoing Debate Surrounding BPD Diagnosis
The controversy surrounding the diagnosis of BPD in adolescence highlights the complexities of understanding and addressing mental health conditions in young people. While some argue for early identification and intervention, others caution against pathologizing normal adolescent experiences. Regardless of the diagnostic label, it is essential to provide appropriate support and resources to individuals experiencing BPD-like symptoms in adolescence.
As our understanding of BPD continues evolving, we must consider alternative perspectives and refine diagnostic criteria. As a professional, I think it is essential to think dialectically and outside the box. Madison Crease (2022), in her article Debate” One Young Person’s Story OF CAMHS and BPD quotes a youth in the system in her interview.
Looking back across my journey. I feel extremely protective of my younger self. i can’t go back and change the way i experienced my teenage years but I hope through awareness, i can help professionals and those with lived experience find a common ground. I hope for a more collaborative future where both parties and young people’s wider network, can all meet to explore and learn about the more about the individual’s mental health needs' ( pg 208)
By fostering a collaborative approach between healthcare professionals, educators, and families, we can ensure that individuals with BPD symptoms in adolescence receive the care they need to thrive. This is a lot of factors to consider prior to putting a label on a youth. I believe in honesty and transparency. It is a conversation that professionals need to have with youth and their parents and discuss the pros and cons of diagnosing DBT.
We send our adolescents to DBT, therefore as professionals, we need to think dialectically as well. Dialectical thinking recognizes the truth in all sides and balances wants and needs pros and cons. In addition, we as health care need to address the stigma of professionals’ attitudes toward borderline personality disorder, providing more education and empathy training.
References
Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry, 14(5), 249–256. https://doi.org/10.1080/10673220600975121
Chanen, A. M. (2022). Debate: It is time to stop turning a blind eye to personality disorder in young people. Child and Adolescent Mental Health, 27(2), 194–195. https://doi.org/10.1111/camh.12554
Chartonas, D., Kyratsous, M., Dracass, S., Lee, T., & Bhui, K. (2017). Personality disorder: Still the patients psychiatrists dislike? BJPsych Bulletin, 41(1), 12–17. https://doi.org/10.1192/pb.bp.115.052456
Crease, Madison. (2022). Debate: One Young Person’s Story of CAMHS and BPD
Hartley, S., Baker, C., Birtwhistle, M., Burgess, J. L., Chatburn, E., Cobbaert, L., Howley, M., Huggett, C., MacKenzie‐Nash, C., Newton, A., Parry, S., Smith, J., Taylor, C. D., Taylor, P. J., & Timoclea, R. (2022). Commentary: Bringing together lived experience, clinical and research expertise — A commentary on the May 2022 debate (should <scp>camh</scp> professionals be diagnosing personality disorder in adolescence?). Child and Adolescent Mental Health, 27(3), 246–249. https://doi.org/10.1111/camh.12586
Lewis, G., & Appleby, L. (1988). Personality disorder: The patients psychiatrists dislike. British Journal of Psychiatry, 153(1), 44–49. https://doi.org/10.1192/bjp.153.1.44
Sheehan, L., Gaurean, B., & Corrigan, P. W. (2022). Debate: Stigma implications for diagnosing personality disorders in adolescents. Child and Adolescent Mental Health, 27(2), 203–205. https://doi.org/10.1111/camh.12556
