Adolescent borderline personality disorder linked to high risk of ADHD, schizophrenia in later years

Credit: Unsplash / sigmund

Approximately half of a pool of adolescent patients who previously presented with borderline personality disorder (BPD) were undergoing psychological and/or pharmacological therapy 5 years later, according to new findings.¹

A new study published by a team of Denmark-based investigators showed that adolescents with BPD are likely to develop clinical syndromes including schizophrenia or depression, as well as ADHD or functional impairment, within the next half-decade. The findings suggest BPD diagnosis and other personality pathologies in teenaged years may be a critical indicator of subsequent mental disorder into young adulthood.

A team of investigators led by Mie Sedoc Jorgensen, of the Psychiatric Research Unit and Mental Health Services, Region Zealand, sought to describe the psychopathological and functional status of adolescent participants from a previous trial who were diagnosed with BPD, 5 years later. BPD has been considered a “polymorphous disorder” since its conception, the team wrote, with fluctuations in phenomenology and an ill-evidenced association with various other disorders. As such, its diagnosis is frequently delayed past the early course of disease, and late-stage intervention is frequent in patients with BPD.

“BPD has its clinical onset from puberty, reaches its peak prevalence in adolescence and young adulthood, and is associated with functional disability early in the course of the disorder,” investigators wrote. “While the stability of the categorical BPD diagnosis is low over relatively short periods, rank-order stability (i.e., the degree to which interindividual differences are preserved over time) remains high.”

A randomized controlled trial compared mentalization-based group therapy (MBT-G) to control standard treatment in 111 adolescents with BPD pathology from the Region Zealand mental health services team in 2015. The M-GAB trial, as it was named, assessed treatment efficacy in young patients with BPD; Jorgensen and colleagues returned to the cohort recently to interpret the progression of psychopathology in patients.²

“Because our previously published analyses did not find any significant differences between MBT-G and TAU at any previous time point, we did not expect to find any between-group differences at the five-year follow-up,” the team wrote.¹ “Therefore, we chose to focus upon outcomes for the whole cohort, rather than investigating between groups differences that might be explained by a ‘sleeper effect’ for treatment.”

Eligible patients in the M-GAB trial included those aged 14 – 17 years old diagnosed with BPDand referred to 1 of 4 outpatient clinics from 2015 – 2017. Patients were excluded if they met diagnosis criteria for other conditions including learning disability; anorexia nervosa; schizophrenia; recent substance dependence, and more. They additionally were excluded if any other mental disorder than BPD was the primary diagnosis, and if they were receiving inpatient therapy at the time of their recruitment.

In this follow-up study, all patients were >18 years old. Investigators assessed for a number of clinical conditions, including psychopathology; personality disorders; ADHD; alcohol, substance and tobacco use; PTSD; and functioning impairment.

The final follow-up assessment cohort included 97 patients; all but 1 (99%) were female. Mean patient age was 21.5 years old; two-thirds (n = 62) were currently employed, in education or in training. Another 43 were on psychotropic medication; approximately half (n = 49) were either overweight or obese, per BMI.

The most prevalent clinical syndromes in the cohort included:

• Anxiety disorder (n = 36)
• Depressive disorder (n = 31)
• Schizophrenia (n = 15)

Another 23 maintained their BPD diagnosis; 46 reported any personality disorder. The most common comorbid condition was self-reported ADHD (n = 57). A majority (n = 65) used tobacco in the last 30 days; mean daily cigarettes were 15.9.

Per the Work and Social Adjustment Scale (WSAS), 37 reported moderate functional impairment, and 24 reported severe functional impairment.

The team derived 3 key takeaways from the trial. The first was a clear trend of continued and significantly impaired general functioning among the cohort. Next, a majority of the cohort remained clinically symptomatic from their adolescent diagnosis. And lastly, the rate of mental disorders was high and diverse among the cohort.

“In short, despite only 16% of the M-GAB sample not meeting criteria for one or more mental disorders at five-year follow up, the prevalence of threshold level mental disorders was lower than that found among other BPD samples,” investigators wrote. “This finding might be due to the current sample having been detected and treated in the early course of the disorder, because of the natural developmental course of BPD, or regression towards the mean.”

Jorgensen and colleagues concluded their data suggest a common “heterotypic continuity” in patients diagnosed with BPD in adolescence, with the presentation of the condition seeming to serve as an “expression of the severity of general maladjustment and early stage development of psychopathology.”

The current longitudinal study illustrates that individuals not only tend to meet criteria for the diagnosis of interest at study inclusion, but also for other diagnoses over time, shifting between internalizing, externalizing, and thought disorders,” the team wrote. “Importantly, younger age of onset of disorder, coupled with ‘comorbidity’ signals the risk for serious and adverse mental disorder life history, which is consistent with the findings of the present study.”

References

1. ^{Jørgensen MS, Møller L, Bo S, et al. The course of borderline personality disorder from adolescence to early adulthood: A 5-year follow-up study. Compr Psychiatry. 2024;132:152478. doi:10.1016/j.comppsych.2024.152478}
2. ^{Beck E, Bo S, Jørgensen MS, et al. Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial. J Child Psychol Psychiatry. 2020;61(5):594-604. doi:10.1111/jcpp.13152}