Signs, Symptoms, and Criteria for Borderline Personality Disorder in Teenagers

Q: “My son has attention deficit hyperactivity disorder (ADHD), though we are starting to think that he is showing signs of borderline personality disorder (BPD), too. Can BPD even be diagnosed in teenagers? If so, what does BPD look like in teens? How can we differentiate BPD symptoms from ADHD?”

As noted in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), children and adolescents may be diagnosed with a personality disorder (excluding antisocial personality disorder) in the “relatively unusual” cases in which the individual’s maladaptive personality traits are “pervasive, persistent, and unlikely to be limited to a particular developmental stage or another mental disorder.” Additionally, a child or teen must have shown symptoms for at least one year to merit a diagnosis for a personality disorder.

So while it’s possible for children and teens to be diagnosed with BPD, it’s also true that some medical circles may think that child and adolescent patients are far too young for a BPD diagnosis. Part of the reluctance may come from the sheer number of factors that could explain someone’s behaviors and traits — especially in adolescence. Puberty alone can be very emotionally dysregulating. Identity is also still forming during this stage of life.

Another consideration: A personality disorder diagnosis tends to follow an individual and become the sole lens through which clinicians view them and their mental health challenges in life. I have seen many cases where individuals were misdiagnosed with BPD for years, only to learn, after careful evaluation, that their symptoms were actually due to, say, undiagnosed ADHD instead. Still, even with a dual diagnosis, doctors still tend to overlook the importance of ADHD treatment in improving BPD symptoms.

While we caution against jumping to a diagnosis, we can still acknowledge that children and teens, even those with ADHD (which shares many symptoms with BPD) can exhibit BPD traits that should be monitored and addressed. Let’s consider a teen — an avid gamer who wants to fit in (as all teens do) — who is told by a peer that video games are for losers. If that teen has ADHD, emotional dysregulation and rejection sensitivity could cause an intense, negative reaction to the comment. The teen might feel hurt because they’ve been rejected on the grounds of an activity that they know is connected to who they are.

If the teen has BPD, the response might play out differently. While they, too, might have an intense reaction to the comment due to emotional dysregulation, they also might become confused about their identity as a gamer in response. They might abandon that part of themselves altogether. That’s not the case with ADHD, where the teen’s identity as someone who likes games remains intact, even if it causes them pain. In many ways, individuals with BPD, including teens with BPD, can be skilled social chameleons, changing to what they feel someone needs them to be. The problem, of course, is that this can seriously disrupt sense of self and increase risk for BPD.

For more information on BPD in teens, pick up Borderline Personality Disorder in Adolescents by Blaise Aguirre, M.D.

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Borderline Personality Disorder & Its Connection to ADHD” [Video Replay & Podcast #446] with Roberto Olivardia, Ph.D., which was broadcast on March 15, 2023.

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