Living from Day to Day – Qualitative Study on Borderline Personality Disorder in Adolescence

Abstract

Objective:

The purpose of this study was to assess how far identity and self-image disturbances are features of borderline personality disorder (BPD) in adolescence.

Method:

Face-to-face interviews were carried out with a total of 50 adolescents with BPD and 50 controls, with a median age of 16 (SD 1.1; range 13 to 18) years. Data was analysed using a qualitative methodology, interpretative phenomenological analysis (IPA). Thematic statements representative of adolescents’ lived experience were extracted from the interviews.

Results:

Four main themes representing the day-to-day experiences of adolescents with BPD were identified: emotional experiences characterised by the feelings of fear, sadness and pessimism; interpersonal relationships characterised by the feelings of solitude and hostility from others; a conformist self-image characterised by a feeling of normality and difficulty in projecting into time; and, a structuring of discourse characterised by discontinuity in the perception of experiences.

Conclusion:

This qualitative study suggests that the day-to-day experiences of adolescents with borderline personality disorder is centred on the experience of the present. Discontinuity in self-image, alongside marked dysphoric manifestations, leads to distress and hinders compliance with care. These issues are highly relevant in psychotherapy and could lead to more effective treatment of the disorder in adolescents.

Introduction

Borderline personality disorder (BPD) is a public health challenge, both on account of its prevalence and because of the risks of co-morbidity that it entails. Prevalence is estimated to be 6% in the general population (Grant et al., 2008). Among adolescents, the prevalence is estimated to be 10% among boys and 18% among girls aged 13 to 20 in France (Chabrol, Montovany, Chouchia, Callahan, & Mullet, 2001). These figures are well above those reported for adults even if prevalence of BPD is difficult to assess (Stepp, 2012) because of the variability of standardized diagnostic criteria and algorithms used in the studies (Trull et al., 2010). The seriousness of BPD in terms of morbidity and mortality is well-established. The consequences have been widely described in the scientific literature: 10% increased risk of self-harm (Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994), suicidal ideation and behaviours (Paris, 2002), and Axis I disorders or other personality disorders (Chanen, Jovev, & Jackson, 2007). Present classifications such as the DSM-IV (American Psychiatric Association, 2000) identify symptom patterns in BPD subjects in which issues of self-perception, identity and emotional experience are prominent. These classifications have been complemented in recent years by results derived from qualitative research aiming to explore the subjective experience of these individuals. Major research on adults with BPD has shown in particular the singularity of the self-image, in which distress, despair (Dammann, Hügli, & Selinger, 2011), feelings of inadequacy (Miller, 1994), and impressions of peer hostility, particularly perceived in group settings (Chiesa & Drahorad, 2000), predominate. Raewyn Bassett, the Flanagan team and the Shuval team have recently shown how qualitative research can help to assess practitioner and patient experiences to develop empathic bridges, an important predictor of positive treatment relationships and outcomes (Bassett, 2010; Flanagan, Davidson, & Strauss, 2007; Shuval et al., 2011). However, to our knowledge, no qualitative study so far has investigated the experience of self among adolescents with BPD. The aim of the present study was to explore the subjective experience of adolescents with BPD using a qualitative research method, according to two axes: childhood, and future. In this manner we want to contribute to a better understanding of BPD specifically in adolescents.

Methods

Study population

The participants in this study were drawn from a European research project investigating the phenomenology of BPD in adolescence (European Research Network on Borderline Personality Disorder, EURNET BPD) (see Speranza et al., for more details concerning the design of EURNET BPD) (Speranza et al., 2011). The research network was composed of five university psychiatric centres in France, Belgium, and Switzerland. During the period between January and December 2007, all consecutively admitted adolescents aged 13 to 18, both in and out-patients, were clinically screened by the consulting psychiatrists to look for a diagnosis of BPD according to the DSM-IV criteria. Adolescents meeting a clinical diagnosis of BPD were then referred to the research team for a further assessment and confirmation of the diagnosis of BPD using the Structured Interview for DSM-IV Personality (SIDP-IV) (Pfohl & Blum, 1997). Interrater reliability for SIDP-IV was calculated from independent ratings of ten videotaped interviews. For the purposes of the present study, a sub-sample of 50 BPD adolescents and 50 controls (recruited by advertisements in schools and matched for age, gender and socioeconomic status) were invited to participate in a qualitative study exploring the subjective experience of adolescents according to two main axes: their perceptions of childhood and of the future. Exclusion criteria for patients were a persistent psychotic disorder, a serious somatic illness or an inability to respond to the interviews. Control subjects were excluded if they had a well-established history of psychiatric disorders.

Data collection

Face-to-face interviews were used to explore the adolescents’ perspectives. They were based on two open questions: “How do you remember yourself as a child ?,” and “How do you see yourself in the future?.” A group of experienced clinicians chose these perspectives, considering that talking about one’s childhood and one’s future was a means of accessing the experience of self. Subjects were asked to talk freely about their perceptions of childhood and the future. The interviewers were instructed not to probe for further information from the adolescents and were blinded to the patients’ status. This approach was adopted to avoid the interviewers artificially introducing themes and preconceived ideas.

All the interviews were conducted by three skilled doctoral or master’s level interviewers without clinical involvement in the care of the adolescents. The researchers disclosed their expectations concerning the themes broached. Because these interviews could raise unanticipated emotional issues, in cases of distress, the instruction were to put the respondents’ needs first. Parents were able to ask questions and receive a referral to a mental health professional. Audio recording of the interviews and their full transcription made it possible to render the data anonymous.

Data analysis

The lack of empirical studies on BPD self-image in literature lead us to choose qualitative methodology to have a more direct access to BPD adolescents’ lived experiences. The first stage of analysis consisted in the interviewers checking the transcripts for accuracy against tape recordings. To analyse the data, we used Interpretative Phenomenological Analysis (IPA), an established qualitative methodology used to explore in depth individuals’ perceptions of particular situations that they are facing (Smith, Flowers, & Larkin, 2009). Individual transcripts were repeatedly read and coded to identify initial themes, which were annotated in margins. This was close to being a free textual analysis. Each reading had the potential to bring new insights. Recurrent themes were then identified across transcripts; these recurrent themes reflect a shared understanding of the phenomena in question among participants. This stage involved a more analytical ordering, as researchers tried to make sense of the connections between themes. Some of the themes were clustered. The researchers were in fact disciplined to discern returning patterns, but they also integrated new issues that emerged, thus integrating both convergences and divergences in the data. Separate identification and extraction of themes by the principal investigator (MS) and a qualitative research expert (ARL) ensure the validity of the results and helped to find both known and new topics. A discussion of the discrepancies with a third skilled analyst (MC) until a consensus was reached ensured reliability. Attention was paid to the emergence of new themes, surprising findings, and contradictory results. Finally, the last stage produced a coherent ordered table of the themes.

Ethics statement

This study was approved by the ethics commitee of the Hôtel Dieu Hospital in Paris (authorization n 0611256). Results were collected in an anonymous database according to the requirements of the French national commitee for private freedoms. All participants, adolescents and parents, signed informed consent after receiving a full description of the study, an explanation of its purpose, and information about the confidentaiality of the data.

Results

Results from qualitative research cannot be statistically projectable to a wider population. However they can lead to context-dependent generalizations or generalizations to a broader theory.

Social data

The research sample was composed of 50 BPD adolescents and 50 matched controls. The mean age of the participants was 16 years (SD 1.1) with a range of 13 to 18 (88% of the participants were girls). They were all in secondary school. 87% of the sample were living with their families. 68% of the parents belonged to the executive category and 32% were workers. None of these variables distinguished the BPD group from the controls. The mean SIDP-IV score for the sample of adolescents with BPD was 16.4 (SD 3.9). The highest criteria were emotional instability: 2.24 (SD 1.0), inappropriate anger: 2.4 (SD 1.0), impulsivity: 2.4 (SD 0.8) and suicidal or self-mutilating behaviour 2.28 (SD 0.9).

Themes derived from the interviews

The use of IPA made it possible to determine four main themes in the daily living experience of the adolescents with BPD and the controls: emotional experiences; interpersonal experiences; the representation of self; and, the structuring of discourse (Table 1). The homogeneity of the themes identified in the groups was great, regardless of age, gender or socio-economic status of the adolescents. Belonging to the BPD group of adolescents as opposed to the control group was not determining in the emergence of any one theme. The themes remained transverse in the two populations and differences were found in the way these general themes were reported.

Table 1.

Illustrative examples of verbatims summing up the themes and dimensions identified

ADOLESCENTS IN THE BPD GROUP	ADOLESCENTS IN THE CONTROL GROUP
EMOTIONAL EXPERIENCES
Fear	Joy
Sadness	Optimism
Pessimism
“After awhile, it was sadness even so that got the upper hand.” (P15)	“Well, I remember myself...a little girl, sort of a nice little girl...You know, enjoying life and all that.” (T7)
“I tend to see the future as dark, so...I can’t really see anything good that could happen.” (P20)	“I don’t really have any worries. Everything is going OK, so I don’t see why things should change.” (T16)
“I’m scared. I really think I haven’t got much of a future. Well, I get the feeling that my life is a complete failure, and that it’s sort of irrevocable.” (P34)	“I’m going to stay happy, with my mates and all that.” (T45)
RELATIONAL ISSUES
Loneliness	Enjoyment of relationships in leisure settings
Solitude
Day-to-day hostility
“I can see myself as being alone.” (P26)	“Continuing horse-riding, and even, well, having my own horse, and things like that.” (T4)
“I was very independent. That is to say that very early on I got my own meals. I washed on my own. I occupied myself, well, on my own. That is, I watched videos all day because my mother was asleep or whatever...So I was very much on my own.” (P31)	“Well, swimming...and the scouts.” (T16)
“Teenagers together are...well, they’re...rather difficult and...and nasty to people.” (P42)	“I love reading, and, well, it’s true that I’d like to set up a sort of café, a café cum-bookshop cum-library, where people would come and read a good book and maybe have a bite to eat, and...I’d like that!” (T43)
SELF-IMAGE
Self-devaluation	Positive self-image
Desire for normality	Desire for normality
Conformism emerging from sub-themes for the question on the future: professional future, family life	Conformism emerging from sub-themes for the question on the future: professional future, family life
“I’m really useless. I fail in everything I do.” (P3)	“I’m as normal as you get.” (T11)
“I see myself as normal, really.” (P10)	“I reckon I’m a, well, normal child. No problems.” (T20)
“For my job in the future, I’ll always have the feeling, well, that anyway I could have done better.” (P16)	“I’d like to be, to train as a doctor.” (T32)
“So at any rate, it’s difficult for me to project into the future, for the job I will have.” (p19)	“Well, I can see myself as...um...a hairdresser with my own hairdresser shop.” (T36)
“I will have divorced, or maybe I won’t have married, but at any rate I’ll be separated.” (P25)	“For a start, professionally I’ll be a physiotherapist, and family-wise, married with three children.” (T48)
“I can’t see myself married in the future, and as for children, I don’t know.” (P27)	“In the future, well, married. Because I like everything to do with institutions, marriage and all that...It’s a nice ideal world, it’s pretty. And then several children. Yes. Maybe three at most. But at any rate not an only child.” (T49)
STRUCTURING OF DISCOURSE
Discontinuity	Continuity childhood - adolescence - adulthood
Concerns centered on the present	Ability to reflect on self
“How I remember myself. Well, well, how do I remember myself when I was a child? Like...I didn’t really like it, being a child. There were times it was OK, but...I really like...and anyway I always...well, wanted that. I’ve always been, well, pff...Anyway I always admired my mother. She was very good-looking. So I wanted to be grown up...and then...Yes, you see. I liked films. Well, anyway, I’ve always been attracted by grown-ups, you see. It wasn’t children I was interested in. So there it is. And well...and so...It’s getting a bit hard, here.” (P6)	“Meeting more people, and continuing to see the people I know now.” (T9) “Anyway, of course, I’d like to meet other people, but I would like to keep the friends I have now, and stay in contact with the people I like.” (T17) “Wow! It’s really hard to talk like that!” (T43)
“I try to live from one day to the next. Living from one day to the next.” (P10)	“No! I think it’s hard to analyze the questions and really understand what I’m supposed to answer. So in fact it’s more like the story of my childhood than anything else. I really need to make a sort of draft!” (T49)
“I remember I had my gang of girl friends. There was a business that really struck me for years, because...I felt very guilty that I had done it. I stole a bracelet from a little girl, and I went to the supervisor and said that, that she wanted to steal it from me. All my friends were on my side. Anyway, there it is. There were girls with short hair, so I didn’t want to be friends with them. Think of it! A girl, well, not very nice to people.” (P32)
“So you see, for example, we’ll take an example like Christmas. So there, my mother was...She’d ended up dead drunk with my grandparents. I remember the day I lost my first milk tooth. There was a so-called friend of my mother’s, and I knew him quite well. Well, I mean, maybe it’s two or three years since I realised that the man, that friend, was in fact her drugs dealer.” (P35)

In this table, extracts of respondents’ verbatim accounts have been chosen as exemplifying the underlying recurrent themes.

The verbatim has been freely translated into English, attempting to preserve the essential meaning and tone.

The interviews with the control subjects were more “dense” – on average 838 words per interview compared to 682 for the BPD group, or a difference of 23% (156 words).

1. Emotional experiences

This theme is the most constant component in the material collected.

A. Adolescents in the borderline group: experience of fear, sadness and pessimism

In response to both questions, on childhood and on the future, the adolescents in the BPD group talked repeatedly about their pain or distress. This mainly took the form of feelings of fear and sadness, underpinned by a pessimistic representation of the future. The tone of the overall discourse was sad, and often morbid. The level of dispair was heterogenous but reached heights such as described by one of the participants who for the first question responded “An abyss of suffering. This is my life.”

B. Adolescents in the control group: experience of joy and optimism

The analysis of interviews in the control group showed, from the outset, a much more joyous tone in the discourse. Mood description was homogenous and despite minor expressions of anxiety, confidence and optimism contrasted singularly with the intensity of sadness of the adolescents in the BPD group. This difference in the general “colour” of their experience is even more marked in responses to the second question concerning the future. One of the controls described her furure plans of “having fun and partying on the beaches around the world with her buddies.”

2. Relational experiences

A. Adolescents in the BPD group: loneliness and solitude, and day-to-day hostility

The feeling of loneliness and solitude among adolescents with BPD was a recurrent theme when they talked about their day-to-day interpersonal relationships. It can be noted that the parents were more frequently mentioned than peers. When they did mention peers, it was to talk about their dissatisfaction. They tended to compare themselves to their peers, and these comparisons were very often to their disadvantage. The descriptions they gave of other adolescents reflect a constant oscillation between jealousy and hostility. One of the adolescents describing her classmates: “In my class, I hate to see them laugh. They have everything and I have nothing.”

B. Adolescents in the control groups: enjoyment of relationships in leisure settings

For adolescents in the control group, relational experiences led to the frequent mention of leisure activities. These are positively connoted, and occupy a significative place in adolescents’ life (while they were never mentioned by adolescents in the BPD group). References to peers are numerous and the feelings of hostility described by adolescents in the BPD group are not noted here. The repetition of the expression “having fun” was one of the singularites of the control participants.

3. Self-image

A. Adolescents in the BPD group: self-devaluation, desire for normality and conformism

The analysis showed that adolescents in the BPD group had a poor image of themselves. However the desire for normality regularly fills the gap that separates them from others. The desire to be normal is pervasive, and relatively conformist. Indeed two theme sub-categories are frequently mentioned, mainly with respect to the future: professional situation, and family life. It’s important to note that for these two, future perspectives remained fairly imprecise and pessimistic among participants interviewed: “I suck. My work is like family and it is useless,” answered a 15 year-old participant about his future.

B. Adolescents in the control group: positive self-image, desire for normality and conformism

The adolescents in both groups talked about being “normal.” The theme sub-categories are the same regarding the future: professional situation and family life. However the controls described their representations of the future in these two large categories in more precise manner. Their self-image remained globally positive throughout the interviews, whatever the question asked.

4. Structuring of discourse

We found major differences with respect to the quality of the structuring of discourse depending on whether or not the adolescents had BPD.

A. Adolescents in the BPD group: discontinuity, and concerns centred on the present

The first striking result concerns the organisation of discourse. The analysis of all the interview material from the BPD group showed a lack of structuring in their discourse. Sentences were short, a few isolated words linked without any clear coordination with the rest of the discourse. The absence of a thread of meaning gave the impression of a fragmented patchwork of sound. These adolescents seemed to be more centred on their present experience. A 17 year-old girl answering the first question: “My childhood? I survive living from day-to-day.”

The second result for this theme concerns the relationship with temporality. There was a more frequent use of the present tense. Narratives did not use the difference between past, present and future. When BPD adolescents managed to talk about their future, it was to talk about the contrary of their present experience. There was a better organisation of discourse when these adolescents narrated memories with an emotional charge, where it can be wondered if there was not a trauma to be explored.

B. Adolescents in the control group: continuity, and the ability to reflect on self

The use of markers enabling the discourse to be situated in a time scale is much more characteristic of the control group. The continuity past-present-future was operational, alongside a self-image that is continuous through the different phases of life. This structured the discourse. The controls talked about impressions of continuity from one life phase to the next. They used verbs in past and future tenses. Reference to memories or places made it easier to situate the experience narrated. Discourse took the form of a narrative, giving an impression of fluidity, very different from the fragmentation observed in the BPD group. The controls commented and reflected on what they were saying to the interviewer. The ability to switch to a different viewpoint, from experience to narrative, was a specific feature of the control group as for example this 17 year-old boy who answered about his future: “As a scientist, I think you know that at my age adolescents as me hesitate between several scientific careers.”

Discussion

To our knowledge this is the first qualitative study to have conjointly explored the experience of borderline adolescents and adolescents from a general population sample. Several important results have been derived: the experience reported by the adolescents in the two groups differs qualitatively, but the themes that emerge from their experience are identical. Emotional experiences, relational experiences, and self-image appear to be central in what the adolescents said about their experience, independently from BPD status. However, we noted marked differences between the two groups in the way in which discourse was structured, and in intrinsic aspects of the experiences reported. For participants with BPD recalling childhood memories, as well as projecting into the future, was much more difficult as if they were “living from day-to-day.”

Firstly, regarding emotional experience, we observed numerous similarities with what has previously been described on the subject of the dysphoric experience of BPD patients. In 1998, the Zanarini team demonstrated the central position of emotional experiences such as fear or sadness in an adult BPD population, concluding to a dysphoric core in BPD (Zanarini & Frankenburg, 1998). The results of our study on a sample of adolescents are in line with this view. As in the qualitative study by Damman in 2011, in which “negative emotions and affects, like sadness, despair, anger and anxiety” are cited (Dammann et al., 2011), we also observed these negative emotional experiences: fear, sadness and pessimism. This continuity in experience between adolescence and adulthood partially provides an answer to the debate raised by Miller on the scope for extrapolating knowledge about the BPD experience to different periods of life (Miller, Muehlenkamp, & Jacobson, 2008). None of the experiences or emotions described by the patients in our study was specific to adolescence. The question of the interweaving of the depressive experience and the borderline experience, however, is not settled, and remains an important research perspective (Silk, 2010).

Secondly, the interview content highlighted relational issues in which solitude and perceptions of hostility were prominent. The persecution experience could increase the feelings of solitude and loneliness, and lead to marginalisation (Miller, 1994), and to relational difficulties that can result in drop-out of care (Chiesa & Drahorad, 2000). Unlike the adolescents in the control group, the absence of mention of leisure activities in the BPD group is striking. This could increase the feeling of loneliness of these adolescents. The study by Nehls showed how far the feeling of being alone could lead to difficulty in access to care (Nehls, 1999). If the data on relational experience and on negative emotional experience are considered jointly, it is easier to understand how the synergy between feelings of persecution and dysphoric affects can increase the risk of suicide described in adults by authors with BPD (Links et al., 2007).

Thirdly, regarding self-image and the structuring of discourse, the discontinuity that is noted both in time and in the representation of self is the most original result. It clearly differentiates the group of adolescents with BPD from the control group, as well as from results obtained by studies among adults. The experience of adolescents with BPD remains centred on the present. “Living from one day to the next” – this phrase returned several times as a leitmotiv in the interviews with borderline adolescents. In form and in content, this phrase seems to us the perfect reflection of the borderline experience. It is a phrase that invites a focus on the present. It demonstrates a day-to-day experience of discontinuity that hinders the construction of identity. In addition it was observed that adolescents in the BPD group had a blurred view of themselves both in childhood and in the future. This relative difficulty in expressing themselves, and the fragmented representation that they have of themselves, confirms the hypothesis proposed by Fuchs of “fragmented selves” in BPD (Fuchs, 2007), and adds to the observations by Damman on “difficulties describing themselves coherently” (Dammann et al., 2011). The discontinuity in the self-image, and the difficulty in seeing themselves in a continuity of time, alongside marked dysphoric manifestations, hinder the continuity of care and favour dropout from treatment, while it is known that the duration of the therapeutic involvement conditions prognosis (Waldinger & Gunderson, 1984). This original result has important consequences, both for understanding the psychopathology of adolescents with BPD, and for the way in which they are catered for. Psychotherapeutic approaches aiming to establish continuity in self-representation among adolescents could enable a more favourable evolution in the medium-and long-term, by avoiding early dropout. Approaches oriented towards mentalization are a very interesting option among adolescents, because they are liable to develop the “ability to pursue life goals” (Bateman & Fonagy, 2008). In addition, transference-focused therapy can improve both narrative coherence and reflective function (Clarkin, Levy, Lenzenweger, & Kernberg, 2007).

Systematic and rigorous qualitative research has definitely much to offer child and adolescent psychiatry (Bassett, 2010). Further investigations on BPD in adolescence are called for, implementing qualitative methods and comparing the results with those derived from a group of adolescents with a different pathology, so as to ascertain that the hypotheses raised here do not coincide with features of other psychiatric pathologies in adolescence. One worthwhile line of research to pursue these issues would be a comparison with a group of adolescents experiencing a depressive episode. This would enable confirmation or otherwise of the specific nature of our main results.