History
In contrast to borderline personality disorder (BPD) in adulthood, BPD in childhood has not been consistently and clearly categorized.
In the 1940s and 1950s, several researchers categorized this disorder in children in the realm of childhood psychoses or schizophrenia. [15, 23] Clinical observations included fluctuations in ego states, primitive regressions, disturbed interpersonal relationships, and severe anxiety.
Anna Freud described children with deep levels of regression, massive developmental arrests, withdrawal of libido from the object world and displacement onto the body or self, inability to receive comfort from others, and numerous specific ego deficits. [24]
In 1982, Pine developed a working nosology of borderline syndromes in children. [3] These clinical subgroupings remain highly relevant.
Patients with BPD may have failures in developmental lines associated with major ego functions or central aspects of object relationships. They are often unable to soothe themselves adequately, demonstrating overemotionality and maladaptive attempts at self-soothing. They also may have an unstable sense of self that manifests as maladaptive attempts to fulfill their needs by means of suicide threats, self-harm, and angry behavior.
BPD has historically been considered to be on the border between psychosis and neurosis. The following findings are characteristic:
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BPD is characterized by marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing
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Patients with BPD may manifest overwhelming anger when in a state of crisis
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Psychotic symptoms, when present, are short-lived, circumscribed, or accompanied by good reality testing
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Individuals with personality disorders are frequently dissatisfied with their marked and sustained impairment in social, occupational, or academic functioning
In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), [4] the diagnosis of BPD is based on the following (see Overview):
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A pervasive pattern of instability of interpersonal relationships, self-image, and affects
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Marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least 5 of 9 diagnostic criteria
In a small study, 18 patients with BPD underwent a modified version of the Iowa Gambling Task while an electroencephalogram (EEG) was recorded. The results indicated that patients with BPD are impaired with respect to decision-making. This impairment which might be related to a dysfunctional use of feedback information, in that the patients did not learn to avoid harmful choices even though they were aware of the negative consequences. [25]
Physical Examination
No consistent physical findings are specific for BPD or borderline pathology in children. Individuals may, however, have scars from self-cutting. The diagnosis is based on clinical observations of behaviors and on patient-reported symptoms.
The mental status examination should include the following:
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General appearance and behavior - Grooming, height and weight, dress, and any abnormal movements
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Attitude toward interview, including eye contact
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Psychomotor activity
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Range of affect
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General mood and if it is appropriate to the situation
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Speech - Rate, volume, and prosody
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Thought process - Any sign of a thought disorder, thought blocking, flight of ideas, loose associations, or ideas of reference; tangentiality; goal focus
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Thought content - Obsessions, suicidality, homicidality, or paranoia
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Hallucinations
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Delusions
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Orientation - Person, place, and time
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Memory - Short- and long-term
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Attention and concentration
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Insight and judgment
