Kevin Reynolds The Adolescent Development of BPD
Abstract
A lot can be said about the formation of Borderline Personality Disorder (BPD) traits in an adolescent individual. While many sources will argue that personality disorders cannot be diagnosed until an individual is of a certain, adult age (APA, 2012), it is certainly true that adolescents can experience borderline personality traits and behaviors (Videler et al., 2019). It is not a difficult leap to presume that BPD symptoms will worsen if left unrecognized and untreated. Additionally, it could easily be postulated that BPD symptoms which are treated in adolescence could lead to intervention in terms of developing the BPD condition itself. Regardless, it is clear that there is gap in knowledge and applicable research which could help therapists and mental health professionals identify BPD features in an adolescent. It is also reasonable to state that closing this gap could lead to more successful BPD symptom treatment approaches when it comes to adolescent individuals who exhibit the symptoms. Better comprehending the BPD symptoms, etiological factors, and parenting styles surrounding adolescents experiencing BPD symptoms could give mental health professionals an edge in appropriating the correct defensive mechanisms when it comes to developing treatment plans for these types of behaviors and symptoms. This study is more than a proposition for BPD symptom data collection during adolescence, but a moral decree for the better understanding of when and how BPD develops in an individual, regardless of prior DSM constructs.
Introduction
Borderline Personality Disorder (BPD) has been diagnosed in 1.6 percent of Americans (Chapman et al., 2022), and it is arguable that it afflicts many more who never receive a proper diagnosis. Understanding the full etiology of BPD is an important facet in understanding the condition as a whole, as well as how to treat the condition. That said, BPD typically onsets during adolescence (Videler et al., 2019). There are some very common etiological risk factors shared by many BPD individuals, a lot of which are present or forming during childhood and early adulthood. Some of these etiological factors include genetics, hereditary, trauma, separation from parents, and lack of significant parental role (Paris, 2016).
Breaking down the etiology of BPD could be called imperative in comprehending how BPD afflicts an individual and develops throughout adolescence. For some individuals, it is genetic, literally being passed down by a parent (Distel et al., 2009). For others, it could be a learned trait, as parents, siblings, or other close relatives display traits and symptoms of BPD themselves (Gunderson, 2007). There is also the possibility of developing BPD from having suffered a childhood trauma of some kind, especially sexual in nature (Bandelow et al., 2005). It is also possible for a child to develop BPD after having been separated from their parents (Zanarini, 2000). And finally, the lack of a significant parental influence in one’s life, especially a father figure, is a heavy contributing factor in the development of BPD (2000).
How Borderline Personality Disorder forms in each individual varies greatly. There are many symptoms which may or may not be present from case to case (Paris, 2005). It is also true that some individuals may only experience a few symptoms, while other individuals experience all of the symptoms (Bozzatello et al., 2019). It is reasonable to suggest that therapists and mental health professionals may benefit from understanding the full symptom list which may be present during the early development of BPD during adolescence. It is suggestable that some of the BPD symptoms are likely present in adolescents before they receive an officially BPD diagnosis. It is also possible to diagnose BPD in adolescents when symptoms are present, and a mental health professional understands those symptoms as a part of the condition (Larrivee, 2013). This proposed study will help these mental health professionals identify the potential prevalence of BPD in adolescence based upon the perceived risk factors and observable symptoms.
It is imperative to better enumerate the BPD symptoms which are present for adolescents, as the condition is often rooted in childhood trauma (Cattane et al., 2017). Without connecting the dots, despite the DSM’s preference for diagnosing personality disorders in adults only, it is arguably impossible to fully understand the appropriate route for treatment of the condition. It is also reasonable to suggest that treatment should start when symptoms emerge, rather than after a firm diagnosis. This is because it could be said that treating symptoms earlier could lead to better control of the symptoms and a possible intervention of the condition entirely. This study postulates that therapists, mental health professionals, and researchers need to be better equipped in terms of knowledge of emerging BPD symptoms and behavior in adolescents, in order to offer better support early on.
It should also be noted that many resources indicate that proper treatment of BPD symptoms earlier in life can lead to prevention of the condition manifesting into BPD altogether (Bozzatello et al., 2019). It is also noteworthy that the many symptoms of BPD can have life-altering effects in an adolescent individual, modifying one’s life trajectory and decision-making capability for the next couple of decades (Winsper et al., 2021). Whether the DSM supports diagnosing adolescents with BPD or not, it is arguable to suggest that the symptoms still deserve treatment, and that the adolescent’s support system (parents, caregivers, teachers, physicians, etc.) should be well-versed on the condition and the way it manifests in an adolescent, however, subtly.
Without a firm understanding of the BPD condition in its infancy, it could be said that treatment specialists are at a significant disadvantage. To ignore the fact that BPD symptoms often materialize far earlier than the diagnosis, and that many BPD individuals have experienced childhood trauma, is inviting maladaptive treatment plans, ignorance to the patient’s etiological factors, and inefficient communication in terms of understanding a patient’s full experience. Due to the fact childhood trauma plays such a large part in the development of BPD (Cattane et al., 2017), it could be argued essential that this part of a BPD symptom-suffering individual be afforded the courtesy of treatment earlier in life.
Literature Review
Although there is not as much research on identifying Borderline Personality Disorder in the adolescent, some studies do exist to help mental health professionals determine BPD symptoms in youth. These existing studies and research indicate a rise in the detection of BPD cases amongst adolescents (Sharp & Fonagy, 2015). Many of these studies reference the prevalence of behavioral phenotypes which clearly outline the formation of BPD in an adolescent. Still, these journals typically reference the existence of barriers and obstacles in terms of clinically diagnosing BPD in an individual under the age of 18. This does not make the identification of BPD symptoms in a youth any less important, as it is easily arguable that the transpiring of the symptoms is what ultimately creates a BPD diagnosis later in life (2015).
It has been well known for decades that BPD in adolescents can be a wavering condition, which is why the most up to date DSM suggests personality disorders can only be formally diagnosed in individuals over 18 (APA, 2012); however, this does not mean that BPD cannot manifest in youths, or that they cannot display BPD symptoms. One study outlined 14 cases of adolescent BPD, of which only 3 cases were persistent enough for a diagnosis after 3 years (Meijer et al., 1998). This is despite many of the participants still maintaining BPD symptoms (1998). Another journal has suggested diagnosing BPD in adolescents to be a topic of high controversy (Miller et al., 2008). This could arguably be due to the fact the personality and brain of an adolescent is still underdeveloped. It is also argued that personality traits are not stable until adulthood (Stepp, 2012). This type of research suggests a need to better understand the BPD condition as it forms in the developing youth.
Regardless of the controversy surrounding BPD diagnoses in adolescents, there are still some attempts to learn the most effective treatment protocols for the condition in the afflicted youth. One author indicated that BPD diagnosis and treatment should be an imperative part of routine clinical practice in affected adolescents as a way of improving their overall, future well-being and long-term prognosis (Kaess et al., 2014). For these reasons, many pediatric psychiatry classification systems and national treatment guidelines include sections on BPD treatment (2014). One study enumerated the many specialized treatment methods which have been approached thus far (Biskin, 2013). This study suggested that structured therapy could be one of the most viable therapeutic models in treating BPD amongst adolescents (2013).
One recent study has proposed that the symptoms and etiological factors behind BPD in adolescents and adults are similar (Stead et al., 2019). This study may suggest that it is just as important, if not more important, to understand BPD during adolescence to get the upper hand on treating BPD before it more solidly develops. The study even indicated that adolescents may be more prone to exhibiting some of the more acute, extreme symptoms of BPD, such as non-suicidal self-injury (NSSI) and suicidal behavior. Unfortunately, the same investigation determined there is a lack of consistent, effective treatment of BPD in adolescence (2019).
Authors of modern research on diagnosing BPD in adolescents have suggested that BPD can be reliably diagnosed in adolescents as young as 11 years old (Guilé et al., 2018). The authors also indicate that BPD may be as prevalent as 3 percent amongst adolescents and 78 percent amongst hospitalized, suicidal adolescents. This study suggests that diagnostic procedure during youth should still be based upon clinical assessment with particular respect to “developmental milestones and interpersonal context.” In general, the key diagnostic criterion includes the persistence of symptoms for a duration of at least one year (2018).
An analysis of the adolescent pathology of BPD includes such elements as childhood temperament, comorbid psychopathology, and interpersonal experiences (Skabeikyte & Barkauskiene, 2021). It has been suggested that some of the most important childhood-related risk factors include roles of stressful life such as frequent suspension from school, death of a parent, changes in peer acceptance, or general abandonment. Additionally, the comorbid existence of other disorders such as alcohol use disorder or substance use disorders (SUDs), major depressive disorder, anxiety, attention deficit hyperactivity disorder, and somatization significantly contributed to the development of BPD, persistence of BPD symptoms, and the slower decline of BPD symptoms in an adolescent (2021). Negative emotionality, poor emotion control, low self-control, impulsivity, affective instability, aggressive behaviors, and inappropriate anger have all been investigated as potential pathological traits contributing to the onset of BPD in an adolescent (Bozzatello et al., 2019).
It should be noted that while there is an array of treatment methodology suggested for treating BPD in adolescence, the actual role of treatment components in successful cases is largely foggy and left unclear (Chanen et al., 2020). While there is evidence that indicates a diagnosis can occur in a young person, it has been suggested that more evidence is necessary to define the appropriate age for detection. The same is true for intervention and treatment of proposed adolescent BPD. It has also been proposed that a stronger emphasis needs to be placed on functional outcomes of treatment plans (2020).
While less studies exist on how the etiological factors of BPD during childhood contribute to the childhood diagnosis of BPD, there is plenty of evidence which supports the concept that these same etiological factors in childhood contribute to adult diagnoses of the condition (Distel et al., 2009). This is especially true in terms of evidence which indicates an experience of separation or loss from a parent. It is also true in terms of childhood trauma or having experienced growing up in a household with a BPD-confirmed parent (2009). Additionally, a child who experiences a mother imposing overbearing attachment needs leaves the child more vulnerable to developing borderline personality disorder symptoms, and the condition as a whole (Kerr et al., 2022).
In contrast to the recent data which suggests BPD can be identified and diagnosed in adolescents, it has been determined in one study that there still is not enough validity in the diagnosis of an adolescent individual to firmly support the diagnosis from adolescence into adulthood (Bondurant et al., 2004). This same study did concur that the symptoms could be measured in adolescence, only that the construction of said symptoms was far less reliable. This study pays credence to the concept that more information is necessary about how the symptoms manifest throughout adolescence. It also poses the question of whether or not the symptoms could be better measured and quantified, in order to give mental health professionals a better understanding of how the condition begins to bloom in earlier life (2004). Studies like this help lay the foundational groundwork for future studies on the investigation of early-life BPD symptoms and the eventual development of the actual condition itself, and ultimately, a firm borderline personality disorder diagnosis.
One recent study exists which attempts to delineate the likelihood of borderline pathology prior to age 19, helping pave the way for diagnoses earlier in life (Winsper et al., 2021). The authors of this study indicate that regardless of the diagnosis itself, the prevalence of BPD symptoms in an adolescent can still have long-term effects in terms of deficits of functioning throughout a child’s life, even so far as 20 years into the future. The study outlined the difficulties these adolescent individuals would face throughout their early to mid-adulthood to include impairments in their social life, educational potential, work life, and finances. The authors make it clear that this data proves the BPD phenotype in a younger population is a real scenario which needs to be addressed (2021).
Another study focuses on the neuropsychological dysfunctions which may be present in younger people exhibiting BPD symptoms and behavior. This study highlights the neurological deficits these individuals face on a daily basis, explaining that the adolescents experiencing these symptoms may be dealing with a disadvantage in terms of decision-making (Coolidge et al., 2000). The study itself focused on children exhibiting borderline personality features using a model called the Coolidge Personality and Neuropsychological Inventory for Children, and compared the participants to a control group. Interestingly enough, these behavioral disturbances were directly linked to neuropsychological dysfunction, paying more credence to the concept that BPD is able to spawn in children. It is important to note that none of the children in this study were subjected to traumatic brain injury (TBI), and thus, the BPD condition may be more commonly rooted in more naturally formed neuropsychological anomalies (2000).
Although Borderline Personality Disorder was first described about 80 years ago, it took decades to be accepted as a sanctioned classification of mental disorders (Paris, 2014). Much existing research is still unsure of its true nature, which is especially true due to the extremely diverse scale of existing, known contributing factors. In short, it has been determined that there is no single explanation for the development of BPD. Still, much recent research has concluded that the BPD condition generally forms during adolescent years, remitting by middle age. Regardless, there is a lack of evidence supporting any consistent childhood precursors. That said, there is still much research which suggests the BPD symptoms begin manifesting throughout childhood and adolescence, even in individuals which develop the condition (or receive an official diagnosis) later in life. Furthermore, it has been determined that adolescent BPD is extremely similar to the clinical picture of BPD during adulthood (2014).
The authors of one study analyzed the display of behavioral symptoms in female adolescent participants aged 14 to 19 years old to determine any generalization of symptoms during adolescence (Stepp et al., 2014). This study determined trait differences between the participants, however, also noted that there were at least some categories of traits which were almost always present in an adolescent female developing BPD. In other words, not all females displayed the same traits, however, all females displaying BPD symptoms were able to be categorized in some extent in terms of “type of traits” displayed. Some of the measured dimensions which became categories included childhood temperaments such as emotionality, behavioral activity, lower sociability, and shyness. These traits were considered predictors of adolecent BPD symptom development. The data was collected from parents and teacher informants (2014).
Recent research has outlined how prevalent maltreatment during childhood is when it comes to an adolescent developing Borderline Personality Disorder (Ibrahim et al., 2018). While the authors of this study admit that the research is limited, it does outline childhood maltreatment as a risk factor for borderline features in childhood. This study was considered a systematic review, analyzing 10 other studies to find a link between maltreatment during childhood and the actual development of BPD. The study did develop links between the development of BPD in adolescents and other risk factors as well, including cognitive and executive functioning deficits, parental dysfunction, and genetic vulnerabilities (2018). These types of meta-analyses provide greater insight when it comes to connecting risk factors with the development of BPD symptoms and behavior in childhood.
Another study on maltreatment in children has discovered a similar link to the development of Borderline Personality Disorder (Hecht et al., 2014). This study also focused on additional, predicted precursors including subtype, developmental timing, and chronicity of child maltreatment. The study included 314 maltreated and 285 nonmaltreated children who came from similar demographic backgrounds. The participants were asked to self-report their experiences and their symptoms. Maltreated children were found to have significantly higher “borderline feature scores,” and were considered to be of higher risk for developing BPD. Chronicity of maltreatment was found to contribute to higher borderline feature scores, as well as onset patterns for developing the actual BPD condition (2014).
One text outlines the difficulties in assessing children with BPD, explaining it as a “gap in existing knowledge” (Crick et al., 2005). The authors describe this gap further calling it a lack of significant, systematic, and prospective empirical attention to precursor developments of borderline personality features in children. Specifically, they focus on four exploratory attempts to eliminate these existing limitations. The first involves developing a psychometrically sound self-reporting instrument which can assess BPD symptoms and features in children. The second would be to examine the stability of these same symptoms and features in childhood. The third is to evaluate gender differences of borderline personality features in children. And the fourth focuses on evaluating the evaluating process of the features in general. The study itself was conducted over the course of 9 months and included a sample size of 400 participants in grades four through six. Roughly 54 percent of participants were female. The study determined that borderline personality features were more prevalent amongst females, although regardless of gender, the features which were exhibited were largely persistent in each participant throughout the study (2005).
Some research has attempted to quantify the similarities between adolescent and adult diagnoses of BPD. For example, one study compared results and findings on diagnostic-related phenomena which was found in both adolescents and adults (Sharp & Romero, 2007). The purpose of this study was to determine any construct of similar risk factors or precursors between the two age groups. While some of these risk factors and facets of BPD development overlapped, there were some significant differences found between the diagnostic-related phenomena of the two diagnosis age groups. Some of the ways these two groups overlapped included general diagnostic criteria, interview data, comorbidity with antisocial behavior and other disorders, stability of diagnosis, and environmental precursor factors. Some of the ways these groups differed included the prevalence of the manifestation of BPD was much higher in adolescents. Despite previous research which disagrees, this study also found that there was no real elevation in female diagnosis of BPD over males in adolescents (2007).
Several studies have indicated that the onset of Borderline Personality Disorder relies upon a combination of genetic and environmental factors, labeled GxE (Cattane et al., 2017). These factors are particularly sensitive to biological vulnerabilities and having experienced trauma as a child or adolescent. In terms of traumatic experience, it has been determined that there can be alterations in several biological processes, as well as in brain morphological features, which can contribute to BPD. It has been proven that alterations within the Hypothalamic-Pituitary-Adrenal axis, especially as it relates to neurotransmission within the endogenous opioid system after experiencing childhood trauma leaves an adolescent more vulnerable to developing BPD. There has been confirmation that morphological changes in several areas of the brain known to be associated with the BPD condition exist for childhood trauma victims, especially those associated with stress response. Additionally, epigenetic mechanisms have been suggested to be mediators when it comes to effects of trauma experienced in childhood or adolescence and BPD vulnerability.
Adolescents and children of mothers with Borderline Personality Disorder have been proven to be more susceptible to developing the condition themselves (Stepp et al., 2012). These children are at such a higher risk for BPD due to the diverse array of negative psychosocial outcomes that are associated with their environmental factors. BPD mothers display abnormal and detrimental parenting styles which may explain the increase in risk of transmission of the condition from mothers to their offspring. It is interesting that this transmission vulnerability is actually present from infancy throughout adolescence. The two most common contributing parenting styles for increasing a child’s risk of developing BPD were found to be extreme hostile control and passive aloofness in interactions with the children. Usually, these two patterns are exhibited in alternating fashion by a BPD mother. Fortunately, there is research suggesting that intervention is possible when the BPD mother receives the appropriate psychoeducational coaching in order to acquire skills and practices for providing more consistent, trustworthy parenting styles (2012).
Another study analyzed the relationship between various types of childhood maltreatment and the child’s perceived parenting style in children afflicted with Borderline Personality Disorder symptoms (Hernandez et al., 2012). A test coined as the “Kendall’s Tau partial correlation” was conducted to control the effect of simultaneous adverse experiences amongst the axis of BPD symptoms on a participant sample of 109 female patients. This test associated BPD criteria with the highest test scores in terms of emotional and sexual abuse. Despite the fact that numerous other research proposals indicate that parenting styles have an impact on the development of BPD, this research model did not generate any direct correlation between parenting style and the development of BPD symptoms. While parenting style may still have an impact on the development of BPD, this study asserts that childhood trauma indicates a greater risk platform for the development of the condition (2012). This study may also indicate a greater need for research in the area of etiological factors for BPD, and their associated weight in terms of precursor contributions.
A lot of the research which exists focusing on the developmental causality of BPD still revolves around adult, self-reported surveys and studies (Harman, 2005). For instance, adults of children displaying BPD symptoms are often asked to submit information to mental health professionals and researchers about their child’s temperament. A child’s attachment style is often reported by their parents or caregivers. The same goes for any learning disabilities the child may suffer. On the other hand, adults who are diagnosed with BPD are also usually the individuals to reveal precursor trauma factors they may have experienced, including sexual abuse, exposure to divorce or addiction issues within the family, illness, death, and general neglect. Even this research suggests that early intervention can play a critical role in the prevention of a firm BPD diagnosis in adolescence or adulthood (2005).
The authors of one study attempted to quantify the comorbidity of other personality disorders alongside Borderline Personality Disorder in children (Becker et al., 2000). The study included a total of 138 adolescents, of which 68 were eligible participants. The study utilized a semi-structured diagnostic interview to isolate its eligible participant base. Although older individuals typically see the comorbidity of antisocial personality disorder alongside BPD, adolescents were proven to primarily exhibit comorbidity of schizotypal and passive-aggressive personality disorder. The results ultimately postulate that an adolescent BPD diagnosis may represent a diverse range of psychopathology in adolescents (2000).
Some sources outline the difficulties in understanding the heterogeneity of BPD in adolescents (Cavelti et al., 2021). These sources describe an ongoing debate as to whether heterogeneity of BPD in adolescents is better enumerated from a qualitative (categorical) or quantitative (dimensional) perspective. One study analyzed 506 adolescent participants exhibiting risk-taking or self-harm behavior for vulnerability of BPD in an effort to determine a “degree of susceptibility.” This study utilized latent class analysis with the categorical approach, factor analysis with the dimensional approach, and factor mixture models, which would allow both aspects. The results crafted a model which allowed researchers to distinguish participants in either a majority class with high vulnerability to BPD (nicknamed the “borderline group”) or a minority class with high probability for the impulsivity and rage criteria of BPD only (nicknamed the “impulsive group”). It is noteworthy that gender impacted the latent class membership with the borderline group being mostly composed of females reporting adverse or traumatic childhood experiences. The borderline group scored higher in terms of emotional dysregulation and inhibitedness personality traits. This group’s participants were also more likely to experience internalized psychopathy. The impulsive group consisted of predominantly male participants who scored high in terms of dissocial behavior personality trait. Additionally, the impulsive group participants were more likely to experience externalizing psychopathy (2021).
Despite all of the complications related to diagnosing children and adolescents with BPD, the topic has been receiving more interest in recent years (Bellino & Bozzatello, 2022). Much recent research still argues that a validated, viable measure for detecting BPD early in an adolescent is lacking. Like many previous studies and articles, the authors of one modern editorial concur that temperament traits, attachment style, traumatic or negative childhood experiences, and neurological abnormalities should be a part of the diagnosis process. These authors also suggest the roles of guardians, teachers, and health providers in an adolescent’s life may play a large part in the early detecting of BPD in an adolescent individual. Some of the childhood traumas which are suggested in this editorial to be particularly important in early detection include emotional neglect and physical or sexual abuse. It is noteworthy that these traumatic risk factors may also coexist alongside temperament issues or contributing genetic factors (2022).
A study found in the Journal of the American Academy of Child & Adolescent Psychiatry (1996) conducted an experiment to systematically examine the affective and cognitive features of BPD in adolescents. This study utilized standardized metrics of these two constructs and the depression feature of BPD. The participant pool included 19 depressed female adolescents diagnosed with BPD and 21 non-BPD females still experiencing depression. While both groups self-reported increased levels of “anger, anxiety, depression, hopelessness, self-deprecatory attributional style, and external locus of control,” BPD-diagnosed participants subscribed to much lower self-concept scores. The authors of this study attribute this BPD-oriented characteristic to pervasive emptiness and identity disturbance issues (1996).
Although BPD may be present alongside several other conditions, it has been proposed that it is very commonly found alongside bipolar disorder (Fletcher et al., 2014). This is disconcerting, as it has already been determined controversial to diagnose an adolescent with a personality disorder, despite the fact several aforementioned research articles and studies support the concept BPD symptoms may exist in an adolescent. If an adolescent could be afflicted with both BPD and bipolar disorder, further complications may exist, as the symptoms of these two conditions overlap to some extent, which may leave a BPD diagnosis firmly to the wayside given the current climate of diagnosing an underage individual with a personality disorder. While there are significant differences between bipolar disorder and BPD symptoms, there is enough similarity to potentiate confusion amongst treatment professionals (2014); thus, it is reasonable to suggest that a mental health professional who is attempting to diagnose an adolescent may be quick to dismiss more extreme personality disorders in lieu of an easier bipolar diagnosis, leaving the adolescent to fend for themselves when it comes to the more extreme symptoms they may exhibit.
The Problem
Due to the controversial nature of diagnosing Borderline Personality Disorder in adolescents, thorough research on the etiological factors develop into symptoms during adolescence could be considered thin. While there are some sources which indicate procedures for diagnosing BPD in a youth, even the DSM clearly indicates that an individual should be at least 18 years of age to receive a formal personality disorder diagnosis. Despite this fact, it is clear that BPD symptoms can exist within an adolescent and that these symptoms commonly stem from some form of etiological factor. Additionally, much research exists which suggests some of the most common contributing risk factors for developing BPD occur in childhood (Zanarini et al., 2020). Knowing that the symptoms can be present in children and adolescents without the mental health industry firmly supporting BPD diagnoses in these age groups is a problem.
More research should be conducted which connects early childhood contributing risk factors to BPD symptoms. This will help formulate more effective treatment protocols for BPD-afflicted adolescents. A study must exist which connects the childhood etiology of BPD and the development of symptoms in order for mental health professionals to achieve more efficient treatment methods. Better understanding the contributing factors early in life, as well as the early development of symptoms, will mean identifying the formation of the condition earlier, and possibly reducing the prevalence of adult diagnoses. The etiology of the condition in childhood must be further investigated in connection with the symptoms to be able to more appropriately diagnose an adolescent individual. This is especially true in terms of the different types of BPD in terms of the groupings of symptoms (petulant, discouraged, impulsive, and self-destructive). In some cases, having a firm grasp over the symptom sets an adolescent is experiencing and exhibiting may promote more defined, customized treatment plans, which may stand a better chance at being successful in reducing the symptoms and perhaps avoiding an official diagnosis.
Purpose
Due to the fact that many adolescents are not diagnosed with BPD until early adulthood, a longitudinal study should be conducted which analyzes the prevalence of symptoms and etiological risk factors in adolescents which have not yet received a BPD diagnosis. The purpose of this study would be to determine the potentiality of an adolescent individual developing BPD. This study will determine how many adolescents display BPD symptoms, and how far in advance, preluding their diagnosis. This study will assist in suggesting that BPD can be more easily diagnosed in children than previously conceived. Additionally, one benefit of this study may be paving the way for mental health professionals to better get ahead of the symptoms as they develop early on and help younger people suffering from BPD symptoms avoid a BPD diagnosis. Three primary research questions should be investigated in this study, including “What is the potential of an adolescent individual developing BPD?”, “What BPD symptoms can be identified in an adolescent before they receive a BPD diagnosis later in life?”, and “How many adolescents display BPD symptoms, and when, before they receive a BPD diagnosis?”.
Methodology
The research methodology will include both quantitative and qualitative surveys performed as part of a longitudinal study over the course of four years. The participants will consist of individuals aged 14-15 years of age at the start of the study, projecting their age at the end of the study to be 18 years old. This will give the study a maximized chance of identifying participants who may receive a BPD diagnosis by any mental health professional at the end of the study (since the DSM sanctions diagnoses of personality disorders for individuals who are of at least 18 years of age). There will be an initial and exit survey as a part of this research study, helping researchers gauge the progression of BPD symptoms and the development of any potential BPD diagnosis.
Participants
Participants must be aged 14 to 15 years old at the beginning of the study. For this longitudinal study to be sufficient, participants will be projected to be 18 years of age or older at the end of the study. This is because the DSM requires individuals be of at least 18 years old to receive an official personality disorder diagnosis, and it is imperative to determine which participants exhibiting BPD symptoms during adolescence will mature into a full BPD diagnosis. For acute generalization purposes, participants should be from a similar demographic background, including their socioeconomic status. Despite the fact there are potentially as many male BPD victims as females, research shows there is a predominance of females amongst the BPD community, and thus it may make most sense for participants of this study to be of the female gender to more appropriately measure the symptom to diagnosis ratio. Participants may come from any type of family, meaning they may be adopted, have been raised by two parents or one, or have siblings or not.
Participants should be recruited from the same educational system, further improving the potential for acute generalization properties. In other words, if the study is conducted on females aged 14-15 at the start of the study who come from a lower socioeconomic community, who all attend the same high school, the study has a potential to be generalized to a similar construct of participants. The students recruited for the study should be consistently exhibiting at least 3 of DSM requirements for a Borderline Personality Disorder diagnosis, including a pattern of unstable and intense interpersonal relationships, alternating extremes between idealization and devaluation, and identity disturbance. Still, other symptoms should be included in the study’s surveys including intense mood swings, rapidly changing interests or values, fear of abandonment, impulsive and reckless behavior, self-harming behavior, parasuicidal and suicidal activity, chronic feelings of emptiness, trust difficulties, anger or rage issues, and feelings of dissociation.
Materials
The initial and exit surveys will collect quantitative data in the form of questions addressing the three primary research questions which allow participants to rank their response on a scale from one to five. Such questions may include items that gauge a participant’s experiences in terms of exhibiting the primary symptoms of BPD, including the age the participants first and last experienced each symptom. The quantitative portions of the study should involve a pencil and paper style survey, or an adequate electronic equivalent. This should give a participant the opportunity to quantify their symptoms, perceived (subjected) parenting style, perceived etiological factors, exposure to trauma, and their general feelings on the topic of each BPD symptom. The qualitative portions of the study should include an in-person, face-to-face interview, or a telephone interview. This component of the study will give students a voice of their own in response to similar questions about any BPD symptoms they may experience, lifestyle and environmental factors they are exposed to, and etiological factors they feel leaves them at risk for developing the condition.
Procedures
Participants of the study should be collected from the same high school in the same district allowing the participant pool to match similar sociodemographic circumstances. The participants will be asked to fill out a preliminary survey which analyzes their potential to be qualified for the study. This preliminary survey will ask participants to expose certain details about their behavior, thought pattern, and life circumstances. Selecting participants which exhibit at least 3 of the primary BPD symptoms listed in the participants section of this outline is imperative in determining the qualification of a participant for the study.
During the study itself, research participants will be asked to address a number of questions related to their exposure to BPD symptoms. They will also be asked to delineate any directly experienced BPD symptoms. The parenting styles participants have perceived in their childhood and early adolescence should be recorded. Finally, the study should outline their exposure to traumatic events, whether in childhood or adolescence, as it is a very common risk factor for the development of BPD. It is important to allow the participants to notate the age by which they experienced these symptoms, contributing factors, or environmental contributors, as to be able to later quantify how they contribute to the development of the BPD condition. Age of experience is also imperative in determining how these variables contribute to receiving a firm BPD diagnosis later in life.
Quantitative questions should address a participant’s active symptom structure, as well as the age each symptom appeared in their life. It should include a participant’s perceived parenting style, as well as when they first realized they might be experiencing claimed parenting style. It should address the participant’s general outlook on life, as well as how they perceive themselves within their own environment throughout all walks of life (homelife, peer status, school life, job life, etc.). All of this data should be collected utilizing a Likert-style scale, giving participants a degree of response.
Qualitative questions should allow participants to verbally elucidate their quantitative choices. They should be given a voice of their own, with open-ended questions that encourage dynamic response. Participants should be able to find words to explain how they perceive each independent symptom manifesting in their life. They should also be able to delineate the perceived parenting style they feel they were subjected to, as well as explain how that parenting style may or may not have contributed to their BPD symptoms.
The exit survey and interview should give participants the opportunity to self-reflect on their prior 3-4 years of living. It should include additional quantitative questions which help a participant quantify how a symptom has progressed or matured throughout the years. It should allow a participant to enumerate on any continued trauma or etiological factors they may have experienced. It should also allow participants to discuss their feelings on parenting styles throughout the study period. Finally, it should give participants a voice in terms of how any BPD diagnosis which may be present has developed from the point of the initial survey, at the beginning of the study.
Data Analysis
Both surveys included in this study demand different analysis procedures. The quantitative data should be analyzed using a Pearson Correlation Coefficient test to determine the relationships between experienced symptoms and age. These results will give researchers more applicable, viable information in terms of when symptoms in a BPD individual begin to manifest, and to what varying degree. Some of these questions will help rule out, or include, the possibility of other, comorbid conditions which may affect a BPD diagnosis or treatment plan. It will also help outline the various subtypes of BPD, which can be much more difficult to diagnose or understand.
The results should be further split into symptom categories, addressing the major types of BPD. These major types of BPD should be considered impulsive, discouraged, self-destructive, and petulant. The impulsive BPD will be quantified with scores that resonate with binging behaviors, risky and self-destructive behaviors, and aggressive behaviors. Discouraged BPD will be quantified with scores that resonate with clinginess, codependency, neediness, and anger or emotional mood swings. Self-destructive BPD will be quantified as conditions which exhibit increased energy, decreased desire to sleep, and feelings of euphoria. And finally, petulant BPD will be quantified as an increase in irritability, impatience, stubbornness, defiance, passive-aggressive behavior, and more severe mood swings. Better quantifying these subtypes of BPD will provide researchers and mental health professionals with an astronomical amount of data when it comes to developing more appropriate treatment methodology.
Additional, qualitative questions will ask participants to detail their experiences for each BPD symptom. This qualitative data will be analyzed using word clouds and chart comparisons which outline common themes between participant answers. Identifying these themes and being able to compare the data between participants will give researchers more comprehension in terms of when the symptoms begin to surface. It will also help researchers and mental health professionals better outline how to handle the symptoms which are being exhibited. It may even help catapult theories as to how to prevent the BPD condition from forming in high-risk individuals.
Qualitative data will give researchers and mental health professionals an opportunity to hear the participants responses from their own words. While it is arguably much harder to analyze qualitative data, this could offer invaluable insight into the perception of the suffering individual, especially those participants who see maturity in the symptoms, in the sense that the symptoms develop into full-blown Borderline Personality Disorder. In combination with the quantitative data, and the general ability to isolate other possible, comorbid conditions existing alongside BPD, the data could help better explain how the symptoms are experienced, and the degree of which potential treatment methods would offer success in terms of prevention or remission.
Limitations
Despite the obvious benefits to this study, there are still a few limitations worth noting. The first, is the participant size, which is relatively small in comparison to the monstrous amount of BPD diagnoses issued every year around the world. With a larger participant size, the study could be more broadly distributed. The results could also be more broadly generalized. The applications of having broader data could not easily be quantified in theory. In other words, if more validated data existed across a span of adolescents from varying demographic backgrounds, which also implicated incredible correlation between BPD symptoms in adolescence and a formal BPD diagnosis in adulthood, it could be said that better headway could exist in terms of early detection and intervention of BPD.
A separate limitation is the focus on analyzing only female participants. While female participants are easier to attain for study, since BPD has been documented as a condition which affects primarily females, it could be argued that there are too many stigmas and obstacles surrounding the development of BPD in males. In other words, men may not receive the same exploratory, treatment, or diagnosis opportunities as females. That all mentioned, BPD is not defined in a sense that it is gender-specific, and one could easily suggest that an equal number of males meet the diagnosis requirements for BPD. Thus, it is reasonable to suggest the focus on female-only participants a limitation, as a full understanding of the etiological factors behind BPD involve more generalized research, data collection, and analysis.
Another limitation could be the demographic involved in the study. If the study only focuses on one socioeconomic chapter, it will only be able to achieve limited generalization. This constricts the overall value of the study, which is why it is important the study is repeated, including varying socioeconomic statures. It could also be said that the environmental variables change alongside the demographic. With varying environmental details, the study would implode in growth, however, it will require more participants from varying demographic backgrounds.
One last, significant limitation is the lack of parental or caregiver input in terms of data collection. In other words, if the study were to be repeated utilizing quantitative and qualitative collection techniques that included a participant’s parental or caregiver input, they study would likely provide more viable data. This would help researchers obtain a better grasp in terms of an adolescent’s perceived upbringing, precursor risk factors, and behavior. Possessing shared input between the participant and their guardians could be an invaluable addition.
Conclusion
Ultimately, existing research dictates the obvious necessity for further research on how BPD symptoms manifest in an adolescent. Regardless of obtaining a diagnosis, it is arguable to suggest adolescents exhibiting BPD symptoms deserve treatment for these symptoms. Based upon existing research, it is also arguable to suggest that there could be a decline in BPD diagnoses if adolescent individuals were appropriately treated for their symptoms early on. Having the insight as to how BPD symptoms manifest in a child may help therapists and mental health professionals better understand how to treat the symptoms. It could also help this critical part of a BPD candidate’s support system learn when to address the symptoms. It is also possible that this earlier knowledge of symptoms could favorably contribute to how mental health professionals could help intervene in the development of BPD in an adolescent individual before the condition fully forms in their adult years.
This study would provide invaluable information in terms of identifying an acute generalization of BPD symptoms in an adolescent. It would help mental health professionals and researchers better comprehend how these symptoms originate. It is also noteworthy that this study would provide guidance on the maturity of these symptoms into more concrete contributing factors to receiving a BPD diagnosis as an adult. In short, the idea that these symptoms may manifest from an earlier age than which warrants a diagnosis is invaluable in predetermining individuals who may be at risk to developing the BPD condition itself. While there are some notable limitations to this study, it is an adequate “jumping off point” for future, derivative work. It is also true that this study, with the right set of eyes, could be more broadly generalized amongst the adolescent population as a whole. After all, the concept that even some of the most critical BPD symptoms could be present in an adolescent could suggest that intervention is possible.
The application of this study in future research and collection of empirical data could lead to more discoveries in how early-life BPD symptoms affect the development and maturity of the condition. It could be instrumental in the development of more effective treatment protocols, especially for younger individuals who are suffering from BPD symptoms. It is arguably imperative that mental health professionals understand that treating symptoms is just as important as treating conditions themselves, and whether a condition is diagnosed, does not mean an individual does not require treatment for symptoms of a condition. It is also arguably important that this is truer earlier in life, while the adolescent brain is still developing and learning how to cope with interpersonal interactions and environmental influences. In the end, it could be suggested that failure to detect BPD symptoms forming earlier in life, could leave an adolescent at a critical disadvantage when it comes to combating these symptoms and getting ahead of the condition.
References
APA (2012). DSM-14 and DSM-5 Criteria for the Personality Disorders. American Psychiatric Association. Retrieved from: https://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_personalidad_psicosis/material/dsm.pdf
Bandelow, B., Krause, J., Wedekind, D., Broocks, A., Hajak, G., and Ruther, E., (2005). Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiatry Research, 134, 169-179. DOI: 10.1016/j.psychres.2003.07.008
Becker, D., Grilo, C., Edell, W., and McGlashan, T. (2000). Comorbidity of Borderline Personality Disorder With Other Personality Disorders in Hospitalized Adolescents and Adults. American Journal of Psychiatry, 157, 2011-2016. Retrieved from: https://www.researchgate.net/profile/Thomas-Mcglashan/publication/12229903_Comorbidity_of_Borderline_Personality_Disorder_With_Other_Personality_Disorders_in_Hospitalized_Adolescents_and_Adults/links/56ab816608aed814bdea1ffb/Comorbidity-of-Borderline-Personality-Disorder-With-Other-Personality-Disorders-in-Hospitalized-Adolescents-and-Adults.pdf
Bellino, S., and Bozzatello, P. (2022). Editorial: Borderline Personality Disorders in Adolescents: Clinical Challenges and Recent Advances. Sec. Child and Adolescent Psychiatry. DOI: https://doi.org/10.3389/fpsyt.2022.854833
Biskin, R. (2013). Treatment of borderline personality disorder in youth. J Can Acad Child Adolesc Psychiatry, 22(3), 230-4. PMID: 23970912; PMCID: PMC3749897.
Bondurant, H., and Greenfield, B. (2004). Construct validity of the adolescent borderline personality disorder: a review. Can Child Adolescent Psychiatry Review, 13(3), 53-7. PMID: 19030500; PMCID: PMC2538734.
Bozzatello, P., Bellino, S., Bosia, M., and Rocca, P., (2019). Early Detection and Outcome in Borderline Personality Disorder. Frontiers in Psychiatry, 10. DOI: 10.3389/fpsyt.2019.00710
Cailhol, L., Gicquel, L., and Raynaud, J. (2015). Borderline personality disorder in adolescents. International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP). Geneva. Retrieved from: https://www.researchgate.net/publication/276206487_Borderline_personality_disorder_in_adolescents
Cattane, N., Rossi, R., Lanfredi, M., and Cattaneo, A. (2017). Borderline personality disorder and childhood trauma: exploring the affected biological systems and mechanisms. BMC Psychiatry, 17(221). DOI: https://doi.org/10.1186%2Fs12888-017-1383-2
Cavelti, M., Lerch, S., and Ghinea, D. (2021). Heterogeneity of borderline personality disorder symptoms in help-seeking adolescents. Borderline Personality Disorder and Emotional Dysregulation, 8(9). DOI: https://doi.org/10.1186/s40479-021-00147-9
Chanen, A., Nicol, K., Betts, J., and Thompson, K. (2020). Diagnosis and Treatment of Borderline Personality Disorder in Young People. Current Psychiatry Reports, 22. DOI: 10.1007/s11920-020-01144-5.
Chanen, A. (2015). Borderline Personality Disorder in Young People: Are We There Yet?. Journal of Clinical Psychology, 71(8), 778-791. DOI: https://doi.org/10.1002/jclp.22205
Chapman J., Jamil R., and Fleisher C., (2022). Borderline Personality Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK430883/
Coolidge, F., Segal, D., Stewart, S., and Ellett, J. (2000). Neuropsychological Dysfunction in Children with Borderline Personality Disorder Features: A Preliminary Investigation. Journal of Research in Personality, 34(4), 554-561. DOI: https://doi.org/10.1006/jrpe.2000.2298
Crick, N., Murray-Close, D., and Woods, K. (2005). Borderline personality features in childhood: A short-term longitudinal study. Development and Psychopathy. Cambridge University Press. 1051-1070. DOI: https://doi.org/10.1017/S0954579405050492
Distel, M., Rebollo-Mesa, I., Willemsen, G., Derom, C., Trull, T., Martin, N., and Boomsma, D., (2009). Familial Resemblance of Borderline Personality Disorder Features: Genetic or Cultural Transmission?. PLOS ONE. DOI: https://doi.org/10.1371/journal.pone.0005334
Fletcher, K., Parker, G., Bayes, A., Paterson, A., and McClure, G. (2014). Emotion regulation strategies in bipolar II disorder and borderline personality disorder: Differences and relationships with perceived parental style. Journal of Affective Disorders, 157, 52-59. DOI: http://dx.doi.org/10.1016/j.jad.2014.01.001
Guilé, J., Boissel, L., Alaux-Cantin, S., de La Rivière, S. (2018). Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies. Adolescence Health and Medical Theory, 9, 199-210. DOI: 10.2147/AHMT.S156565
Gunderson, J., (2007). Disturbed Relationships as a Phenotype for Borderline Personality Disorder. The American Journal of Psychiatry. DOI: https://doi.org/10.1176/appi.ajp.2007.07071125
Harman, M. (2005). Children At-Risk for Borderline Personality Disorder. Journal of Contemporary Psychotherapy, 34(3). DOI: http://dx.doi.org/10.1023/B:JOCP.0000036635.49985.d0
Hecht, K., Cicchetti, D., Rogosch, F., and Crick, N. (2014). Borderline personality features in childhood: the role of subtype, developmental timing, and chronicity of child maltreatment. Dev Psychopathol, 26(3), 805-15. DOI: 10.1017/S0954579414000406
Hernandez, A., Arntz, A., Gaviria, A., Labad, A., and Gutierrez-Zotes, J. (2012). Relationships Between Childhood Maltreatment, Parenting Style, and Borderline Personality Disorder Criteria. Journal of Personality Disorders, 26(5), 727-736. Retrieved from: https://sdrive-storage.s3.amazonaws.com/russwilson/5118d93ed72959/10445628/Hernandez2013Emotionalmaltreatment%2CparentingandBPD.pdf?response-content-type=application%2Fpdf&AWSAccessKeyId=AKIASDAFE7S6IDHFTIHG&Expires=1659830027&Signature=mm0Q4PJpadXnjdGmvx9nbt9mSSk%3D
Ibrahim, J., Cosgrave, N., and Woolgar, M. (2018). Childhood maltreatment and its link to borderline personality disorder features in children: A systematic review approach. Clinical Child Psychology and Psychiatry, 23(1), 57–76. DOI: https://doi.org/10.1177/1359104517712778
Jorgensen, M., Storebo, O., Stoffers-Winterling, J., Faltinsen, E., Todorovac, A., and Simonsen, E. (2021). Psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features—A systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis. PLOS ONE. DOI: https://doi.org/10.1371/journal.pone.0245331
Kaess, M., Brunner, R., and Chanen, A. (2014). Borderline Personality Disorder in Adolescence. Pediatrics, 134, 782. DOI: 10.1542/peds.2013-3677
Kerr, S., Penner, F., Ilagan, G., Choi-Kain, L., and Sharp, C. (2022). Maternal Interpersonal Problems and Attachment Security in Adolescent Offspring. Borderline Personality Disorder and Emotion Dysregulation, 9(18), 1-12. DOI: https://doi.org/10.1186/s40479-022-00188-8
Kerr, S., Penner, F., and Sharp, C. (2021). Interpersonal Problems in Parents and Adolescent Borderline Personality Disorder Features. Journal of Personality Disorders, 35(Supp B). DOI: https://doi.org/10.1521/pedi_2021_35_518
Larrivée M., (2013). Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry. Dialogues in Clinical Neuroscience, 15(2), 171–179. DOI: https://doi.org/10.31887/DCNS.2013.15.2/mplarrivee
Meijer, M., Goedhart, A., and Treffers, P. (1998). The Persistence of Borderline Personality Disorder in Adolescence. Journal of Personality Disorders, 12(1), 13-22. DOI: https://doi.org/10.1521/pedi.1998.12.1.13
Miller, A., Muehlenkamp, J., and Jacobson, C. (2008). Fact or fiction: Diagnosing borderline personality disorder in adolescents. Clinical Psychology Review, 28, 969-981. DOI: http://dx.doi.org/10.1016/j.cpr.2008.02.004
Paris, J., (2016). The Etiology of Borderline Personality Disorder. A Biopsychosocial Approach, 316-325. DOI: https://doi.org/10.1080/00332747.1994.11024696
Paris, J. (2014). A history of research on borderline personality disorder in childhood and adolescence. In C. Sharp & J. L. Tackett (Eds.), Handbook of borderline personality disorder in children and adolescents, 9–16. DOI: https://doi.org/10.1007/978-1-4939-0591-1_2
Paris, J., (2005). Borderline personality disorder. CMAJ : Canadian Medical Association journal, 172(12), 1579–1583. DOI: https://doi.org/10.1503/cmaj.045281
Pinto, A., Grapentine, W., Francis, G., and Picariello, C. (1996). Borderline Personality Disorder in Adolescents: Affective and Cognitive Features. Journal of the American Academy of Child & Adolescent Psychiatry. DOI: https://doi.org/10.1097/00004583-199610000-00021
Sharp, C., and Fonagy, P. (2015). Practitioner Review: Borderline personality disorder in adolescence: recent conceptualization, intervention, and implications for clinical practice. The Journal of Child Psychology and Psychiatry, 1-23. DOI: 10.1111/jcpp.12449
Sharp, C., and Romero, C. (2007). Borderline personality disorder: A comparison between children and adults. Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 71(2). Retrieved from: https://www.uh.edu/class/psychology/clinical-psych/_docs/SharpRomero.pdf
Skabeikyte, G., and Barkauskiene, R. (2021). Systematic review of the factors associated with the course of borderline personality disorder symptoms in adolescence. Borderline Personality Disorder and Emotion Dysregulation, 8(12). DOI: https://doi.org/10.1186/s40479-021-00151-z
Stead, V., Boylan, K., and Schmidt, L. (2019). Longitudinal associations between non-suicidal self-injury and borderline personality disorder in adolescents: a literature review. Borderline Personality Disorder and Emotion Dysregulation, 6(3). DOI: https://doi.org/10.1186/s40479-019-0100-9
Stepp, S., Keenan, K., and Hipwell, A. (2014). The impact of childhood temperament on the development of borderline personality disorder symptoms over the course of adolescence. Borderline Personality Disorder and Emotional Dysregulation, 1(18). DOI: https://doi.org/10.1186/2051-6673-1-18
Stepp, S., Whalen, D., Pilkonis, P., Hipwell, A., Levine, M. (2012). Children of mothers with borderline personality disorder: identifying parenting behaviors as potential targets for intervention. Personality Disorders, 3(1), 76-91. DOI: 10.1037/a0023081
Stepp, S. (2012). Development of borderline personality disorder in adolescence and young adulthood: introduction to the special section. Journal of Abnormal Child Psycholology, 40(1), 1-5. DOI: 10.1007/s10802-011-9594-3
Videler, A., Hutsebaut, J., and Schulkens, J., (2019). A Life Span Perspective on Borderline Personality Disorder. Current Psychiatry Report, 21, 51. DOI: https://doi.org/10.1007/s11920-019-1040-1
Winsper, C., Marwaha, S., Lereya, S., Eyden, J., and Singh, S. (2021). The Clinical and Psychosocial Outcomes of Borderline Personality Disorder (BPD) in Childhood and Adolescence: A Systematic Review. West Midlands Strategic Health Authority and Research and Innovation Division and the Birmingham and Solihull Mental Health Foundation Trust. Retrieved from: https://scholar.google.com/scholar_url?url=https://www.bpdcommunity.com.au/static/uploads/files/2015-clinical-and-psychosocial-outcomes-of-youth-bpd-wfxmzludmpbr.docx&hl=en&sa=X&ei=r2LtYv6kGuKSy9YPkbqe4Aw&scisig=AAGBfm1HWRnC0OnkgrcZhAYA-Rb6CfUFkg&oi=scholarr
Zanarini, M., Temes, C., Magni, L., Aguirre, B., Hein, K., and Goodman, M. (2020). Risk Factors for Borderline Personality Disorder in Adolescents. Journal of Personality Disorders, 34(Suppl B), 17-24. DOI: 10.1521/pedi_2019_33_425
Zanarini, M., (2000). Childhood Experiences Associated with the Development of Borderline Personality Disorder. Psychiatric Clinics of North America, 23(1), 89-101. DOI: https://doi.org/10.1016/S0193-953X(05)70145-3
