Early Detection of Borderline Personality Disorder in Adolescents: Breaking Stigma and Promoting Understanding

By Henry Ferrier – Social Worker and Holistic Counsellor

Understanding Borderline Personality Disorder (BPD)

“Borderline Personality Disorder (BPD) is a complex mental health condition characterised by a pattern of emotional instability, intense interpersonal relationships, and impulsive behaviour. It typically begins in early adulthood, though signs can sometimes emerge during adolescence, which is a critical period for emotional and psychological development.” (American Psychiatric Association [APA], 2022).

Stigma Associated with BPD

The stigmatisation of BPD continues to be a pervasive issue, particularly impacting young people and their access to quality healthcare. This stigma is often rooted in structural conditions shaped by organisational policies, cultural norms, and resource deficits (Klein et al., 2022).

Despite considerable research over the past two decades, there is still a reluctance to diagnose and provide early intervention for BPD during adolescence (Kaess & Cavelti, 2025).

Studies show that young people with BPD are active help-seekers, with many adolescents presenting to emergency departments during suicidal crises (Kaess & Cavelti, 2025).

People with BPD often feel stigmatised in healthcare settings, especially in emergency departments, where some clinicians describe them as ‘difficult’ (Vandyk et al., 2019). This perspective stems from a lack of understanding of how their behaviours are indicative of the BPD diagnosis itself and resource limitations (Klein et al., 2022; Vandyk et al., 2019).

The reluctance to diagnose BPD in adolescence may result in ineffective treatment planning. The prevention of timely interventions leads to “severe suffering of both the patient and their social surrounding” (Schmeck, 2022, p.192).

BPD is regarded as a disabling mental disorder, impacting a young person’s ability to reach developmental milestones as well as increasing social, economic, and physical health risks (Kaess & Cavelti, 2025). Suicide occurs in nearly 6% of individuals within this cohort; therefore, early diagnosis and treatment are crucial for supporting adolescents in accessing early intervention (Kaess & Cavelti, 2025).

There has been a noticeable change in BPD diagnosis criteria between the DSM-IV and DSM-5, with the DSM-5’s Alternative Model for Personality Disorders “removing age-based restrictions” (Kaess & Cavelti, 2025, p.4) for diagnoses of personality disorders (Greenfield et al., 2015; Schmeck, 2022).

What a Person with BPD May Experience (DSM-5 Criteria)

According to the DSM-5 (APA, 2022), the following are common experiences for individuals with BPD:

1. Frantic efforts to avoid real or imagined abandonment
   Individuals with BPD may go to great lengths to prevent feelings of abandonment, even in situations where such fears may not be realistic.
2. A pattern of unstable and intense interpersonal relationships
   These relationships can fluctuate dramatically, often moving between idealizing others (viewing them as perfect) and devaluing them (viewing them as worthless).
3. Markedly and persistently unstable self-image
   People with BPD often struggle with a consistent sense of self, experiencing confusion or uncertainty about their identity and self-worth.
4. Impulsivity in areas that are potentially self-damaging
   This can include engaging in reckless behaviours, such as excessive spending, unsafe sexual activities, substance abuse, or risky driving.
5. Recurrent suicidal behaviours or self-harming
   Individuals may experience recurrent thoughts of suicide or engage in self-injurious behaviours in response to overwhelming emotions or fears of abandonment.
6. Affective instability due to marked mood reactivity
   Mood swings in BPD can be extreme and rapid, often triggered by interpersonal events or internal stressors.
7. Chronic feelings of emptiness
   Individuals may experience a persistent sense of emptiness or disconnection from themselves, often linked to feelings of loneliness.
8. Inappropriate, intense anger or difficulty controlling anger
   Outbursts of anger are often disproportionate to the situation, leading to challenges in managing conflicts.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
   Under stress, individuals may experience moments of paranoia or a sense of detachment from reality.

Treatments for BPD in Adolescence

BPD is the most common personality disorder, with psychotherapy recommended as first-line treatment (Crotty et al., 2024).

Evidence supporting the efficacy of pharmacotherapies as a standalone treatment is limited and not recommended by the APA (Crotty et al., 2024).

Research comparing the effectiveness of tailored therapeutic supports lacks evidence to determine a specific therapeutic modality as superior (Crotty et al., 2024).

Talk-based therapy options include:

• Dialectical Behaviour Therapy (DBT)
• Schema Therapy
• Transference-Focused Psychotherapy (TFP)
• Cognitive Behavioural Therapy (CBT)
• Mentalisation-Based Therapy (MBT)
• Acceptance and Commitment Therapy (ACT)

All these modalities can improve the severity of BPD symptoms and functioning.

Transparency in communication about the diagnosis is recommended despite the stigmatisation of the diagnostic label (Kaess & Cavelti, 2025). Honest diagnostic communication enables clear treatment planning and provides patients and their families with clarity regarding treatment pathways.

Early intervention can establish adaptive coping mechanisms and prevent or mitigate long-term negative outcomes associated with BPD (Kaess & Cavelti, 2025).

Final Thoughts

BPD is a debilitating mental illness that is recognisable and potentially treatable by early intervention in adolescence (Schmeck, 2022).

BPD is stigmatised within social, cultural, and healthcare settings due to lack of understanding and resource deficits, highlighting the need for significant improvement in service delivery (Vandyk et al., 2019).

Patients and their families are best supported when provided with honest communication, which leads to clear treatment planning and realistic expectations of recovery.

About the Author

Henry Ferrier, MSW
Henry is a social worker and Senior Mental Health Clinician at a youth-focused NGO. He provides private counselling at The Health Lodge and is currently pursuing advanced training in borderline personality disorder treatment. Henry combines clinical experience and evidence-based therapies to support adolescents and families, promoting early intervention and improved long-term outcomes.

References

1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed.). Pearson.
2. Crotty, K., Viswanathan, M., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Wines, R., Ratajczak, P., & Gartlehner, G. (2024). Psychotherapies for the Treatment of Borderline Personality Disorder: A Systematic Review. Journal of Consulting and Clinical Psychology, 92(5), 275–293. American Psychiatric Association . https://psycnet.apa.org/fulltext/2024-19816-001.pdf
3. Greenfield, B., Henry, M., Lis, E., Slatkoff, J., Guilé, J.-M., Dougherty, G., Zhang, X., Raz, A., Eugene Arnold, L., Daniel, L., Mishara, B. L., Koenekoop, R. K., & de Castro, F. (2014). Correlates, stability and predictors of borderline personality disorder among previously suicidal youth. European Child & Adolescent Psychiatry, 24(4), 397–406. Springer Nature Link. https://doi.org/10.1007/s00787-014-0589-9
4. Kaess, M., & Cavelti, M. (2025). Research Review: What we have learned about early detection and intervention of borderline personality disorder. Journal of Child Psychology and Psychiatry , 1–19. ACAMHA. https://acamh.onlinelibrary.wiley.com/doi/epdf/10.1111/jcpp.70011
5. Klein, P., Fairweather, A. K., & Lawn, S. (2022). Structural stigma and its impact on healthcare for Borderline Personality disorder: A scoping review. International Journal of Mental Health Systems, 16(1). Pubmed. https://doi.org/10.1186/s13033-022-00558-3
6. Schmeck, K. (2022). Debate: Should CAMHs professionals be diagnosing personality disorder in adolescents – “No rationale to deprive adolescents of effective treatment.” Child and Adolescent Mental Health, 27(2). https://doi.org/10.1111/camh.12553
7. Vandyk, A., Bentz, A., Bissonette, S., & Cater, C. (2019). Why go to the emergency department? Perspectives from persons with borderline personality disorder. International Journal of Mental Health Nursing, 28(3), 757–765. Wiley. https://doi.org/10.1111/inm.12580

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