Brian Greenfield Institut d'été 2016

1. Correlates, stability and predictors
of borderline personality disorder
among previously suicidal youth
Brian Greenfield Amir Raz
Melissa Henry L. Eugene Arnold
Eric Lis Londa Daniel
Josh Slatkoff Brian L. Mishara
Jean-Marc Guile Robert K. Koenekoop
Geoffrey Dougherty Filipa de Castro
Xun Zhang
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

2. Acknowledgments
Thanks to Hogg Family Foundation
Thanks to NHRDP
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

3. Borderline Personality Disorder (BPD)
Somewhat recognized during adolescence :
DSM-5 (< 18 years old)
(Yen S, Gagnon K, Spirito A, 2013; Miller AL, Muehlenkamp JJ, Jacobson CM, 2008)
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

4. How to distinguish adolescent BPD
from Hall’s “storm and stress”
o Distress
o Fleeting Identity Confusion
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015
G. Stanley Hall
1846-1924

5. How to distinguish adolescent BPD
from Hall’s “storm and stress”
When does “storm and stress” exceed a
threshold into an enduring personality
disorder?
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

6. Gunderson et al. (2011)
Ten year follow-up adult BPD:
o 85% remission
o 12% relapse
o Severe persistent impairment
(Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, Zanarini
MC, Yen S, Markowitz JC, Sanislow C, Ansell E, Pinto A, Skodol AE, 2011)
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

7. Prevalence
o 5.9% non-clinical adult samples
o Community adolescents
(15% male; 17.2% female)
o 22% adolescent outpatients
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

8. Measurement
o Adult-based criteria
o Variable measures
o Inclusions of “storm and stress”
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

9. Distress
o Many BPD sufferers attempt suicide
o 10% commit suicide
(Paris J, 2002)
o Attempt during adolescence
o Suicide > 30 years old
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

10. American/Canadian suicide rates
(2009/2010) ages 15-19 years old:
7.5 / 1000 and 9.0 / 100, 000
(Statistics Canada, 2009; Centre for Disease Control and Prevention, 2012)
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

11. What we did
o Large cohort
o Vulnerable early adolescent patients
o Followed to late adolescence
o Correlates of BPD
o Stability to late adolescence
o Predictors of outcome
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

12. Goals
o Early identification
o Distinguish BPD from the ‘condition’
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

13. Hypothesis I
Group differences are apparent between
previously suicidal adolescents with and
without BPD at ages 14 and 18 years with
respect to clinical and demographic
variables at baseline and follow-up
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

14. Hypothesis II
o BPD among suicidal adolescents is
heterogeneous
• Persisting
• Emerging
• Remitting
o BPD demonstrates temporal stability
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

15. Hypothesis III
Persisting BPD driven by:
• Drug use
• Prior hospitalization
• Mood disorders
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence

16. Procedure
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

17. Sample
286 T1
263 (92%) T3
at 6 months
229 (80%) T4
219 (77%)
Completed measure
204 (71%)
Completed data (T1 & T4)
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

18. Dropouts similar to participants
o Age (14.6 years)
o Female (70.7%)
o % BPD
o ↓ Depression (34 vs. 53%)
o ↓ ETOH (37 vs. 55%)
o ↓ IFR
o ↑ Suicide (2.7 vs. 2.25)
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

19. Measures
o DISC MOOD
CD
o Spectrum of Suicide Behavior
o CGAS
o Substance abuse
o Coddingtom
o IFR
o Ab-DIB
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence

20. Results Hypothesis I
Significant Differences between BPD & Non BPD
Recruitment
o Depression ↑
o Conduct disorder ↑
o CGAS ↓
o Drug use ↑
o Coddington ↑
o IFR ↑
o Prior hospitalizations ↑
o Previous visits to ER ↑
Follow-Up
o Depression ↑
o Conduct disorder ↑
o CGAS ↓
o Suicide ↑
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

21. Results Hypothesis II
T1 T4
YES
NO
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015
Persisting 76% (155/204)
Never 7.4% (15/204)

22. Results Hypothesis III
BPD at follow-up predicted by:
 Older age at first presentation
 Lower level of functioning
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

23. Results
o 17 (7.8%) of 219 patients remained
suicidal at T4, 16 (94.1%) meeting BPD
criteria
o No sex differences with respect to BPD
diagnosis
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

24. Discussion
Suicidal adolescents with BPD:
o Drug use
o Stressful life events
o Family Dysfunction
o Major Depression
o CD
o ↓ functioning
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence

25. Discussion
Like adults with BPD, adolescents
CGAS=59
( ↑ of 20 from T1 but impaired functioning)
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence

26. Discussion
o BPD stable = 76% (155/204) of suicidal
youth over 4 year follow-up
o Compatible with BPD traits in the
community (46-73%)
(Wingrad G, Cohen P, Chen H, 2008; Bornovalova MA, Hicks BM, Lacono WG, McGue M, 2009)
o Higher than reports of BPD threshold
(14-23%)
(Mattanah JJ, Becker DF, Levy KN, Edell WS, McGlashen TH, 1995; Meijer M, Goedhart AW, Treffers, 1998)
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

27. Discussion
o BPD baseline, 8x > non-BPD baseline
→ BPD follow-up
o BPD can be diagnosed by age 14
o BPD persistent and BPD emerging may
→ BPD adulthood
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

28. Discussion
o 16.7% BPD only once =
o Predictors may distinguish BPD from
condition
o ↓ Function + ↑ Age = Predictors
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015
“storm and stress”

29. Discussion
No gender differences
• Does bifurcation occur > 18 years?
• Are measures not discerning adult male
BPD?
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

30. Discussion
o Suicide occurs more commonly > 30
o Most adolescent suicidality associated
with BPD – persisting
o Help adolescents with suicidality may ↓
adult BPD suicidality
o Only 7.8% adolescent BPD remain
suicidal but 76% of our sample remain
BPD hence, BPD not synonymous with
suicide
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

31. Limitations
o Only reporting on 71% of original cohort
o Subtract 29% from stability = 48% (still
very stable)
o Our subjects did not suicide!
o Excluded medically and surgically
unstable suicidal adolescents
o Evaluation = therapy
o Used the Ab-DIB
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

32. Take home points
o Adolescent BPD may likely be
diagnosable by age 14
o Adolescent BPD is highly stable
o Adolescents remaining suicidal are likely
to suffer from BPD
o Persisting BPD can be predicted by later
age (>14) and by poorer functioning at
the time of presentation to emergency
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015

33. Take home points
o Most suicidal adolescents are no longer
suicidal 4 years later
o Adolescent BPD has no gender bias
Brian Greenfield, MD
Fifty Shades of Borderline Personality Disorder in Adolescence
ISSPD XIV October 14, 2015