Emma* was a sophomore in high school struggling with severe social anxiety, recurring suicidal thoughts and self-harm behaviors. She became very upset in specific classes where she had issues with her peers, and it became disruptive to the learning environment. Emma also had difficulty completing assignments, and would often skip class, leading to failing grades. Her teachers had no idea how to help, reporting Emma’s struggles to the school based support team.

When school administrators met with Emma’s parents, they learned Emma had recently been diagnosed with Borderline Personality Disorder (BPD), and was at high risk for suicidality.  Emma’s parents asked the school for support services, but with only one social worker for all the students, and a lack of information about BPD accommodations, the school was unsure how to proceed. They were concerned about Emma’s safety, and her ability to manage the demands of high school along with her symptoms.  

This is the situation many educators find themselves in when confronted with students diagnosed with BPD. BPD is a complex and debilitating mental disorder, found to be affecting 3% of adolescents (Guilé et al., 2018), characterized by emotional dysregulation, impulsivity, identity confusion, difficulty with interpersonal relationships, and suicidality. BPD is defined by any five of the nine criteria (See Table 1) in the Diagnostic and Statistical Manual for Mental Disorder, Fifth Edition (American Psychiatric Association, 2013).   

Table 1: DSM-5 Diagnostic-Criteria for BPD

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• Frantic efforts to avoid real or imagined abandonment

• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

• Identity disturbance: markedly and persistently unstable self-image or sense of self

• Impulsivity in at least 2 areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating)

• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

• Affective instability due to a marked reactivity of mood (eg. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

• Chronic feelings of emptiness

• Inappropriate, intense anger or difficulty controlling anger (eg. frequent displays of temper, constant anger, recurrent physical fights)

• Transient, stress-related paranoid ideation or severe dissociative symptoms

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Over the past decade, there has been increasing evidence that BPD should be diagnosed and treated during adolescence when symptoms often emerge. Children as young as eleven have been diagnosed with BPD, with prevalence in diagnosis increasing with age (Guilé et al., 2018), and peaking in early adulthood (Kaess et al., 2014). 

New research about the neurobiology and developmental trajectory of BPD reveals that diagnosing and treating BPD in adolescence can improve long-term outcomes. Treating symptoms as early as possible with BPD specific treatments and early intervention are critical for recovery. The earlier treatment for BPD can occur, the more successful the results will be, since an adolescent’s brain is still developing and malleable (Kaess et al., 2014).

Leaving BPD untreated, however, can be associated with serious consequences. 50-80% of those with BPD have a co-occuring substance use disorder (Trull et al., 2018), and 10% of those with BPD will die by suicide (Soloff & Chiappetta, 2012). Moreover, Adolescents with BPD have higher rates of self harm and suicidal behavior, as compared to adults (Kaess et al., 2014).

Educators can be on the front lines of recognizing the symptoms of BPD. While those with BPD are often highly intelligent and creative, symptoms can impair their learning and daily functioning in school. A student impacted by BPD may have a significantly more difficult time than a typical teenager managing relationships, academic pressures or anxiety.  It is critical for educators to be aware of the symptoms of BPD and how it may manifest in the school setting. 

Common areas of concern for a student with a BPD diagnosis may include test taking, group projects and class presentations, recess and lunch time, teacher expectations, communication with teachers and peers, and lateness and truancy. These challenges are often caused by the student’s emotional sensitivity and regulation issues, interpersonal and communication difficulties, impulsivity, or anxiety, medication side effects, and sleep disturbances. The earlier a student is recognized as needing extra support, the sooner the school can work with them through a lens of understanding and compassion, rather than blame and punishment. 

Emotions Matter Inc., a 501c3 non-profit organization to support those impacted by BPD, created a new resource which offers individuals, parents and professionals information on how to to understand BPD in the school environment. This resource offers an introduction to the process of seeking accommodations for a student with BPD, first-hand testimonials from those with lived experience, and strategies for handling transitions and interruptions to education. 

"Receiving accommodations for my disabilities including BPD has helped provide a structured, accessible, and supportive learning experience.  In part due to my accommodations, I have found school  to be a wonderful and enjoyable experience." - Student with BPD

“My daughter had tremendous social anxiety with BPD.  Accomodations made her feel good about herself and interact with others.”  - Parent of Child with BPD

Although balancing the demands of academics and treatment can be challenging for students, schools can support BPD recovery by providing daily motivation, socialization, and structure, mitigating isolation often associated with suicidality.  Schools can build students’ self-esteem through creative, active and academic pursuits, fostering their unique identity as individuals whose lives will continue beyond the stigmatizing psychiatric diagnosis of BPD. 

The vast majority of those diagnosed with BPD recover and live meaningful lives.  Support from educators can play a vital part in their long-term recovery.

This resource is available as a free downloadable PDF here, or in print here.

For more information, email outreach@emotionsmatterbpd.org. 

* This is a fictional story that represents a common profile of an adolescent with BPD. 

 

This article, written by Emotions Matter, Inc. first appeared in Healthy Young Minds, a publication of the MHANYS School Mental Health Resource and Training Center in February 2020

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA.

Guilé, J. M., Boissel, L., Alaux-Cantin, S., & de La Rivière, S. G. (2018). Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies. Adolescent health, medicine and therapeutics, 9, 199–210. doi:10.2147/AHMT.S156565

Kaess, M., Brunner, R., & Chanen, A. (2014). Borderline Personality Disorder in Adolescence. Pediatrics, 134(4), 782–793. doi: 10.1542/peds.2013-3677

Soloff, P. H., & Chiappetta, L. (2012). Prospective predictors of suicidal behavior in borderline personality disorder at 6-year follow-up. The American journal of psychiatry, 169(5), 484–490. doi:10.1176/appi.ajp.2011.11091378

Trull, T. J., Freeman, L. K., Vebares, T. J., Choate, A. M., Helle, A. C., & Wycoff, A. M. (2018). Borderline personality disorder and substance use disorders: an updated review. Borderline personality disorder and emotion dysregulation, 5, 15. doi:10.1186/s40479-018-0093-9