Fiorenzo Ranieri
Fragility and change in borderline adolescence: understanding distress, supporting growth, and fostering continuity of the self.
Borderline personality disorder (BPD) in adolescence is a complex clinical condition, often characterised by intense emotional distress, relational instability, and disorganised behaviour. When personality organisation is associated with low levels of functioning, difficulties manifest themselves with greater intensity and persistence, significantly interfering with the construction of the self, affect regulation, and developmental processes.
Diagnostic Criteria and the Concept of “Low Functioning”
The DSM-5-TR and ICD-10 recognise borderline personality disorder as a condition characterised by emotional, relational, and identity instability, impulsivity, and difficulties in affect regulation. The expression “low functioning” is used here as a clinical description/severity qualifier to indicate the extent to which the disorder affects the patient’s life. In such clinical presentations (1), the following features are more pronounced:
Poor emotional awareness and metacognition: difficulty understanding and making sense of one’s own internal states.
Difficulty benefiting from support: patients may undermine supportive relationships (with therapists, teachers, or family members) because of mistrust or fear of dependency.
Rigidity in relational dynamics: experiences of victimisation or hypersensitivity to rejection. At times, patients may engage in unconsciously manipulative behaviours.
Marked disorganisation: the adolescent may appear confused and chaotic in thought and behaviour, with dissociative features during periods of stress.
From this perspective, a diagnosis of BPD in adolescence should not be regarded as a static label, but rather as a hypothesis concerning relational and emotional functioning that needs to be explored and treated through appropriate and sustained therapeutic approaches.
Onset and Early Clinical Signs – Pre-adolescence / Early Adolescence
The first indicators often appear during pre-adolescence or the early adolescent years, with difficulties in emotional regulation, marked impulsivity, and considerable relational vulnerability. The most recurrent signs include:
Typical age of onset: between 12 and 15 years, often with early signs already present in late childhood (difficulties in emotional regulation, impulsivity, ambivalent attachments).
Unstable relationships: intense friendships or romantic relationships followed by abrupt ruptures; strong idealisation followed by devaluation.
Impulsivity: risk-taking behaviours such as self-harm (cutting, burning), binge eating, substance use, and unprotected sexual activity.
Unstable mood: rapid shifts between euphoria, despair, intense anger, and feelings of emptiness. Emotions are often experienced as unmanageable.
Fear of abandonment: excessive reactions (panic, threats of self-harm) to real or perceived separations, even minor ones.
Fragile identity: confusion regarding self-image, which is often unstable; oscillations between feeling “special” and feeling like “a complete failure”.
Ages 15–18 – Intermediate Course
Adolescence represents a crucial phase in the development of BPD. The clinical picture may take different forms, fluctuating between periods of intense crisis and periods of greater functional integration.
Recurrent crises: increased episodes of emotional dyscontrol, isolation, and impulsive aggression (towards oneself or others).
Frequent self-harm, sometimes increasing in severity or becoming chronic. It may develop into a dysfunctional strategy for affect regulation.
Suicide attempts: risk is high, particularly in situations involving rejection, loss, or humiliation. Suicide attempts may alternate with desperate requests for help.
Poor overall functioning: declining school performance, difficulty maintaining everyday routines, social withdrawal, or oppositional behaviour.
Frequent psychiatric comorbidities: major depression, anxiety disorders, substance use disorders, and eating disorders (particularly bulimia).
Ages 18–22 – Development in Late Adolescence
When structured specialist intervention is provided, the following may emerge:
- gradual improvement in emotional regulation
- greater reflective capacity
- initial experiences of identity stabilisation
- more stable and meaningful relationships
In the absence of treatment, risks include:
- chronic relational difficulties
- persistent self-harming behaviour
- vulnerability to social withdrawal or emotional dependency
- possible progression towards other personality or affective disorders
The literature suggests that the transition to young adulthood may offer considerable potential for improvement, provided that it is supported by appropriate interventions.
Effects of Residential Treatment and Intensive Interventions
Longitudinal studies (Zanarini, Paris, McGlashan, and others) indicate that intensive, multimodal interventions — particularly residential or semi-residential programmes based on psychotherapy — provide significant benefits in higher-risk cases.
Useful therapeutic interventions include:
- environmental containment and regulation of daily routines
- individual psychotherapy aimed at developing the self and improving emotional regulation
- family and psychoeducational interventions
- social skills and metacognitive training
- structured approaches (DBT, MBT, TFP, schema therapy)
Overall, the clinical course can be summarised as follows.
With residential treatment: symptoms tend to improve gradually, with greater emotional stability, improved relational skills, and fewer crises.
Without residential treatment: BPD symptoms may persist or even worsen, with difficulties in managing emotions and instability in relationships and everyday life. Without intervention, recovery is slower and more complex.
Conclusions
BPD with severe functional impairment in adolescence requires timely diagnosis, a developmental perspective, and intensive interventions capable of combining containment with a focus on development. Prognosis is not deterministic: both the literature and clinical experience show that, particularly when intervention occurs early, young people can develop more stable forms of identity and relationships with themselves and others.
The challenge is to accompany adolescents in the transition from a mind that defends itself through action to a mind that can think, fostering more inhabitable internal spaces and a greater sense of personal continuity.
Essential References
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition. DSM-5.
Kaess, M., Brunner, R., & Chanen, A. (2014). Borderline Personality Disorder in Adolescence. Pediatrics, 134(4), 782–793.
World Health Organization. ICD-10: International Classification of Mental and Behavioural Disorders.
Paris, J. (2007). The Nature and Treatment of Borderline Personality Disorder. American Psychiatric Publishing.
McGlashan, T. H. et al. (2000). Comparative studies on borderline personality disorder.
Sharp, C., Tackett, J. L., Riccardi, I., & Fiore, D. (2021). Manuale del Disturbo Borderline di Personalità nell’infanzia e nell’adolescenza. FrancoAngeli.
Zanarini, M. C. et al. (2003). The longitudinal course of borderline psychopathology. American Journal of Psychiatry.
(1) Classification: DSM-5-TR: 301.83; ICD-10-CM: F60.3. The expression “low functioning” does not constitute a diagnostic subtype of borderline personality disorder; it is used here descriptively to indicate clinical presentations characterised by more severe impairment in overall functioning.