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Case Report
Behavioural disorder or borderline personality disorder? The importance of early intervention
¿Trastorno de conducta o trastorno de personalidad límite? La importancia de la intervención precoz
Fernando Rodríguez Oteroa,
Corresponding author
fro_mfyc@yahoo.es

Corresponding author.
, Tamara del Pino Medina Dortab, Casimiro Cabrera-Abreuc
a Unidad de Media Estancia, Hospital Universitario de Gran Canaria Doctor Negrín, Las Pamas de Gran Canaria, Spain
b Complejo Hospitalario Universitario Materno Infantil, Las Palmas de Gran Canaria, Spain
c University Department of Psychiatry, Queen's University, Kingston, Ontario, Canadá
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The diagnosis of borderline personality disorder in adolescence remains a controversial topic among mental health professionals&#46; In a notable editorial published in May 2016 in the <span class="elsevierStyleItalic">American Journal of Psychiatry</span>&#44; John Gunderson commented on the need to develop a care model in the public system for patients with borderline personality disorders&#46; Gunderson began his article with an account of 17-year-old Kevin&#44; who had suffered for years from behavioural disorders associated with a break-up&#44; and reported a wholly characteristic case of borderline personality disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; although authors such as Joel Paris<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> insist on the need to consider the diagnosis in adolescence&#44; in reality&#44; as some studies have suggested&#44; there is a trend towards underdiagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This finding is significant&#44; and a parallel may be drawn between the story of Cinderella&#44; who lost her dress and her carriage when the clock struck 12&#44; and cases of adolescents with a diagnosis of behavioural disorders who have to be diagnosed with another disorder once they reach their 18th birthday&#46; The problem is that&#44; although such diagnoses have weak specificity per se&#44; one might wonder what became of the kappa coefficient<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> in matters of diagnostic reliability in adolescents with psychiatric diseases&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The following is a case report with a typical clinical course of a patient with borderline personality disorder of adolescent onset with multiple prior diagnoses&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the drafting of this case report&#44; every effort was made to conceal and safeguard the patient&#39;s identity&#46; Some elements of the patient&#39;s family and personal history were modified without altering the most important aspects of the clinical description&#44; discussion and conclusions proposed&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 16-year-old girl living at a centre for minors with behaviour disorders was admitted to the short stay unit after swallowing several razor blades&#46; She had been diagnosed with oppositional defiant disorder<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> at 12 years of age and had been in follow-up by psychology and psychiatry at the centre for minors&#44; to which she had been admitted 10 months earlier&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Notable in the chain of adverse and&#44; in some cases&#44; traumatic events constituting her biographical history was her adoption at 6 years of age along with 2 of her sisters from a home after their biological mother abandoned them when the girl was 2 years old&#46; No father figure information is available&#46; There are no data referring to difficulties in childbirth or any other significant information relating to the first few years of her life&#46; When she was 6 years old&#44; they moved to live with their adoptive family&#44; and&#44; from the start&#44; she showed difficulties in maintaining relationships with her peers and trouble bonding&#46; The girl&#39;s adoptive mother reported that the girl had a persistent inability to initiate most social relationships&#44; and that she was incapable of calming the girl whenever she had any type of anxiety&#46; The adoptive mother also reported frequent tantrums and trouble with making friends and playing with other children her age&#44; all accompanied by an excessive tendency to call attention to herself&#46; The data provided were suggestive of disinhibited social engagement disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> When the girl became an adolescent&#44; coinciding with the separation of her adoptive parents&#44; she had her first serious behaviour problems&#46; First&#44; she ran away from home&#44; became more irritable and oppositional with her family members&#44; exhibited consistent problems at the institution consisting of running away and engaging in sexual promiscuity&#44; and started to make small cuts in her arms&#46; Due to these problems&#44; she started follow-up on a leading mental health unit&#44; where she was first seen at 12 years of age&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Throughout the next year&#44; her behaviour problems increased&#46; She ran away more often and developed relationships with antisocial groups&#46; With increasing frequency&#44; she cut her arms&#44; and also her legs&#44; and she reported chronic feelings of emptiness and a great deal of difficulty in expressing her emotional states&#46; This whole time&#44; her diagnosis of oppositional defiant disorder remained unchanged&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Save for an occasional supermarket theft&#44; there were no data indicative of an antisocial disorder&#44; and at all times her emotional state was predominantly unstable&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A year after these problems began&#44; she was admitted for the first time to the short stay unit&#46; By then&#44; she was 13 years of age&#46; She was admitted for multiple cuts on her arms&#44; marked depressive symptoms and a clinical picture of psychomotor agitation in a context of family conflict&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As it was impossible for her parents to manage her behaviour&#44; the minor protection system took over her care and placed her at a centre where her behaviour could be better managed&#46; In her first year of admission&#44; despite improvement in her depressive symptoms&#44; her tendency to cut herself persisted&#44; because&#44; as she verbalised&#44; the cuts made her feel better&#46; She had persistent problems in relating to her peers&#44; swinging quickly from forming close relationships with particular people to getting angry with them and wanting no further contact with them&#46; Sometimes&#44; after problems arose in her relationships&#44; she had a tendency to pull out her hair&#44; and on one occasion she ended up swallowing a stone&#44; in a manifestation of her chronic attention-seeking behaviour&#44; and visiting the emergency department&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the following year&#44; although a certain amount of improvement was achieved at the centre where she resided&#44; she had persistent marked emotional instability&#44; showed problems with impulse control&#44; sporadically cut her arms and once ran away from the centre for 2 or 3 days&#44; during which she consumed cannabis and alcohol&#46; Ultimately&#44; in the past year&#44; her behaviour problems worsened due to problems with family reunification&#44; and she ingested 3 razor blades following a conflict with her adoptive mother&#44; for which reason she ended up being admitted to the short stay unit&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Her family dynamics were always characterised by significant emotional invalidation and a great deal of conflict between the separated parents&#44; although her sisters continued to live in that setting with those dynamics and only had mild behaviour problems&#46; As of her admission&#44; she exhibited marked emotional instability&#59; she ended up swallowing a bottle cap&#44; requiring not only gastroscopy but also close monitoring&#46; She showed notable difficulty with recognising and expressing her emotions&#44; as well as difficulty with relationships and marked impulsivity&#46; She expressed chronic feelings of emptiness&#44; which she sought to allay by cutting herself&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Given the girl&#39;s signs and symptoms&#44; a diagnosis of borderline personality disorder was suggested&#44; despite her age&#46; The seriousness of her signs and symptoms and the longitudinal course of her pathological behaviours and affective instability confirmed the diagnosis of borderline personality disorder&#46; Nevertheless&#44; several personality tests were done to refine the clinical approach and psychological and diagnostic assessment&#46; Notable among them is the Spanish version of Borderline Symptom List 23 &#40;BSL-23&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In addition&#44; the patient&#39;s social cognition was assessed using the <span class="elsevierStyleItalic">&#34;Movie for the Assessment of Social Cognition&#34; &#40;MASC&#41;</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which confirmed her tendency towards hypermentalising responses&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This was highly consistent with studies linking social cognition abnormalities to borderline personality disorder&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Review of the subject</span><p id="par0065" class="elsevierStylePara elsevierViewall">Despite the recommendations of some authors&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> there are very significant difficulties with making a diagnosis of borderline personality disorder in adolescents&#46; The data indicate that adversities in childhood&#44; both in school and at home&#44; especially in a predominantly invalidating environment&#44; are risk factors for borderline personality disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> There are few follow-up studies of residents of centres for minors&#44; but the results on personality are very conclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Various studies have also indicated that affective dysfunction&#44; hostility and interpersonal conflict in oppositional defiant disorder and impulsivity in attention-deficit&#47;hyperactivity disorder may point to early development of borderline personality disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Other studies have also referenced an inability to form a secure bond with a caregiver&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Reports of physical abuse and sexual abuse and derivative abnormalities in recognising emotions<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> as well as social cognition abnormalities may be other precursors to borderline personality disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> To conclude&#44; other studies have cited a wide range of psychiatric disorders in family members of patients with borderline personality disorder&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> especially in mothers already diagnosed with borderline personality disorder&#44; and the need for intervention for this patient profile&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion of the subject and conclusions</span><p id="par0075" class="elsevierStylePara elsevierViewall">Attachment problems from an early age&#44; along with problems with identity formation in adolescence&#44; marked by serious problems with social cognition&#44; promoted the onset of borderline personality disorder&#59; an invalidating family environment also acted as a catalyst&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Currently&#44; it is known that diagnosis of borderline personality disorder in adolescence is reliable and valid&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> as in adults&#44; with similar incidence rates between these two population groups&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> We find it necessary to pursue early intervention strategies in this type of patient&#44; using some of the models that have provided evidence in this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The need for early intervention is based on the major comorbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> associated with a diagnosis of borderline personality disorder and on the significant deterioration of social functioning and quality of life in children and adolescents with this diagnosis&#44; comparable to that seen in those with other serious mental disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> It is also known that certain personality traits are more flexible and mouldable in adolescence&#44; rendering early intervention more appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The disadvantages of early intervention include the stigma<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> that the diagnosis carries at such an early age and self-stigmatisation<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> by patients&#46; However&#44; an incorrect diagnosis not only impedes suitable treatment but also could promote polypharmacy&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The approach to abilities in dialectical behaviour therapy<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> for reducing self-destructive behaviours and the use of therapy techniques based on mentalisation<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> are two approaches from which our patient might have benefited&#46; The approach to identity diffusion in transference-focused psychotherapy is also not to be overlooked&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">We believe it is necessary to conduct a suitable study of precursors to borderline personality disorder in situations in which it could be clearly evaluated whether behaviour problems are the starting point for a personality disorder&#44; especially in adolescence&#44; and identity could be seen to be particularly damaged&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Harking back to the Cinderella parallel in the introduction&#44; we would rather precious time for intervention not have been squandered once the clock strikes midnight&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Trastorno de personalidad limite"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnosing borderline personality disorder during adolescence is usually controversial&#46; In this paper we present a clinical case in which an outline of the main characteristics of borderline personality disorder during adolescence is summarised&#46; The need of taking into consideration the precursor characteristics of borderline personality disorder in young people is also highlighted&#46; At the same time&#44; other significant behavioural disorders found in young people are emphasized as possible forerunners of a borderline personality disorder diagnosis&#46; Finally&#44; we insist upon the need to implement early intervention programmes for these patients based on current models&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico de trastorno de personalidad l&#237;mite en la adolescencia suele ser un tema controvertido&#46; A continuaci&#243;n se presenta un caso cl&#237;nico que expone las caracter&#237;sticas habituales de presentaci&#243;n en la adolescencia y se discute adem&#225;s la necesidad de tener en cuenta los factores precursores del trastorno de personalidad l&#237;mite a la vez que se relaciona la presencia de determinados trastornos de conducta como futuros precursores&#46; Se insiste en la necesidad de usar programas de intervenci&#243;n precoz para este tipo de pacientes con los modelos que existen actualmente&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez Otero F&#44; del Pino Medina Dorta T&#44; Cabrera-Abreu C&#46; &#191;Trastorno de conducta o trastorno de personalidad l&#237;mite&#63; La importancia de la intervenci&#243;n precoz&#46; Rev Colomb Psiquiat&#46; 2020&#59;49&#58;293&#8211;296&#46;</p>"
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