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. Author manuscript; available in PMC: 2016 Jun 1.
Published in final edited form as: J Adolesc. 2015 Apr 16;41:157–161. doi: 10.1016/j.adolescence.2015.03.009

Brief Report: Borderline Personality Symptoms and Perceived Caregiver Criticism in Adolescents

Diana J Whalen 1, Mallory L Malkin 1, Megan J Freeman 1, John Young 2, Kim L Gratz 1,*
PMCID: PMC4420664  NIHMSID: NIHMS675654  PMID: 25889821

Abstract

Despite findings of an association between adolescent psychopathology and perceived parental criticism, the relation between adolescent borderline personality disorder (BPD) symptoms and perceived parental criticism has not been examined. Given the centrality of interpersonal sensitivity to BPD (relative to other forms of psychopathology), we hypothesized that adolescent BPD symptoms would be uniquely related to perceived caregiver criticism, above and beyond other forms of psychopathology and general emotion dysregulation. Adolescents (N = 109) in a residential psychiatric treatment facility completed self-report measures of BPD symptoms, perceived caregiver criticism, emotion dysregulation, and symptoms of depression, anxiety, and posttraumatic stress disorder. Results revealed a unique relation of adolescent BPD symptoms to perceived caregiver criticism, above and beyond age, gender, and other forms of psychopathology. Findings suggest that adolescent BPD symptoms may have unique relevance for adolescents’ perceptions of caregivers’ attitudes and behaviors, increasing the likelihood of negative perceptions.

Keywords: borderline personality disorder, adolescence, parenting, expressed emotion, perceived criticism

Dysfunctional relationships are a hallmark feature of borderline personality disorder (BPD), with the caregiver-child relationship having particular significance in childhood and adolescence (Stepp et al., 2014). One aspect of the caregiver-child relationship that may be especially relevant to BPD symptoms is the parental criticism facet of familial expressed emotion (EE). Defined as family members’ criticism, hostility, and/or emotional over-involvement toward an individual, the EE construct has been linked to numerous forms of psychopathology throughout development (Hooley, 2007), with the parental criticism factor in particular evidencing relations to BPD in adulthood and mood and anxiety disorders in childhood (Cheavens et al., 2005; Hooley, 2007; McCarty, Lau, Valeri, & Weisz, 2004; Silk et al., 2009). Although much of this research examines the impact of parental criticism on psychopathology, emerging research highlights a bidirectional relation between parental criticism and psychopathology (with the latter influencing both parents’ actual behaviors and children's perceptions of parental behaviors; Hale III, Keijsers, et al., 2011; Hale III, Raaijmakers, Hoof, & Meeus, 2011). Given evidence that perceptions of parental criticism are just as important to the caregiver-child relationship as the actual level of criticism a parent displays (Nelemans, Hale III, Branje, Hawk, & Meeus, 2013), research examining the relation of adolescent psychopathology to perceived parental criticism is needed.

BPD symptoms may be especially likely to influence perceptions of parental criticism. Specifically, given evidence of heightened interpersonal sensitivity in BPD (Stanley & Siever, 2009), adolescents with BPD symptoms (vs. other forms of psychopathology) may be particularly sensitive to criticism from their caregivers. Indeed, perceiving high levels of criticism from caregivers may be one manifestation of interpersonal sensitivity in BPD (Gunderson & Lyons-Ruth, 2008). Despite the theoretical relevance of BPD symptoms to adolescents’ perceptions of parental criticism, no studies have examined this relation. This study sought to extend extant research by examining the relation of BPD symptoms to perceived caregiver criticism in a high-risk sample of adolescents in a residential psychiatric treatment facility (found to have high levels of psychopathology and relationship difficulties; Chin, Ebesutani, & Young, 2013). Given evidence of the unique role of interpersonal sensitivity in BPD (relative to other forms of psychopathology; Stanley & Siever, 2009), BPD symptoms were expected to evidence a unique relation to perceived caregiver criticism beyond other forms of psychopathology theoretically and/or empirically linked to perceived caregiver criticism or caregiver-child relationship difficulties, including depression, anxiety, posttraumatic stress disorder (PTSD), and emotion dysregulation (Han & Shaffer, 2014; Morris, Gabert-Quillen, & Delahanty, 2012; Nelemans et al., 2013).

Method

Participants

Participants were 109 adolescents in a residential psychiatric treatment facility in Mississippi. Referrals to this facility stem from unsuccessful maintenance of youth in a less restrictive level of care, often due to aggressive behaviors or chronic school failure. See Table 1 for participant demographic and diagnostic characteristics.

Table 1.

Demographic and Diagnostic Characteristics of Adolescents

Demographic Characteristics M (SD) or % (n)
Age 14.28 (1.38)
Gender: Female 46.7% (n = 51)
Race/Ethnicity
    African-American/Black 56% (n = 61)
    White 34.9% (n = 38)
    Asian-American 0.9% (n = 1)
    Other 8.3% (n = 9)
Psychiatric Diagnosesa
    Mood Disorder, NOS 34.9% (n = 38)
    Oppositional Defiant Disorder 17.4% (n = 19)
    Major Depressive Disorder 12.8% (n = 14)
    Attention-Deficit/Hyperactivity Disorder 9.2% (n = 10)
    Bipolar Disorder 7.3% (n = 8)
    Depressive Disorder, NOS 5.5% (n = 6)
    Adjustment Disorder, with Mixed Disturbance of Mood and Conduct 4.6% (n = 5)
    Impulse Control Disorder 1.8% (n = 2)
    Intermittent Explosive Disorder 1.8% (n = 2)
    Acute Stress Disorder 0.9% (n = 1)
    Conduct Disorder 0.9% (n = 1)
    Dysthymic Disorder 0.9% (n = 1)
    Posttraumatic Stress Disorder 0.9% (n = 1)
    Schizophrenia 0.9% (n = 1)
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Note. N = 109 adolescents.

a

Primary psychiatric diagnosis assigned by the attending psychiatrist at intake.

Procedure

All procedures were approved by the university Institutional Review Board and Facility Review Board. Parental/guardian consent and adolescent assent were obtained prior to participation (n=5 declined participation). Participants completed questionnaires assessing baseline symptoms, family experiences, and life events. Assessments were conducted by clinical psychology interns.

Measures

The Revised Child Anxiety and Depression Scale (RCADS-25)

The RCADS-25 is a brief measure of youth anxiety and depressive symptoms (Ebesutani et al., 2012). Evidence supports its reliability and validity (Ebesutani et al., 2012). Example items include “I feel sad or empty” and “I worry what other people think of me.”

Child PTSD Symptom Scale (CPSS)

The CPSS is a developmentally-appropriate measure that assesses the presence and severity of DSM-IV PTSD symptoms (e.g., “trying not to think about, talk about, or have feelings about the event”) and related impairment (Foa, Johnson, Feeny, & Treadwell, 2001). Evidence supports its reliability and validity (Foa et al., 2001).

Difficulties in Emotion Regulation Scale (DERS)

The DERS (Gratz & Roemer, 2004) is a 36-item measure of emotion dysregulation, or maladaptive responses to emotions. The DERS demonstrates good reliability and construct and predictive validity in adult and adolescent samples (Gratz & Roemer, 2004; Gratz & Tull, 2010; Neumann, Lier, Gratz, & Koot, 2010). An example item is “I have no idea how I am feeling.”

BPD symptoms (BPFS-C)

The BPFS-C (Crick, Murray-Close, & Woods, 2005) is a 24-item questionnaire that assesses four features of borderline personality in youth (Affective Instability, Identity Problems, Negative Relationships, and Self-harm). The BPFS-C demonstrates adequate reliability and convergent validity in ethnically-diverse youth (Crick et al., 2005). Responses to items (e.g., “I want to let some people know how much they've hurt me”) are scored on a 5-point Likert-type scale.

Perceived Criticism Scale (PCS)

The PCS is a 4-item index of the emotional family climate modified for use with youth (Hooley & Teasdale, 1989). Items (e.g., “how critical do you think your caregiver was of you?”) are rated on a 10-point scale. Evidence supports the PCS as an acceptable method of assessing the parental criticism facet of EE (Hooley & Parker, 2006).

Results

Preliminary Analyses

Descriptive information and intercorrelations for all study variables are provided in Table 2. As expected, all forms of adolescent psychopathology and emotion dysregulation were significantly related to perceived caregiver criticism. Thus, the primary analysis examining the unique relation of BPD symptoms to perceived caregiver criticism controlled for all other psychiatric symptoms and emotion dysregulation (as well as gender and age).

Table 2.

Descriptive Statistics and Bivariate Correlations

Variable α Mean (SD) or % (n) Range 1. 2. 3. 4. 5. 6. 7. 8.
1. Gender (female) 46.7% (51) ---
2. Age 14.28 (1.38) 12-17 −0.03 ---
3. Depression Symptoms 0.74 7.43 (4.92) 0-22 −0.28** −0.02 ---
4. Anxiety Symptoms 0.76 9.93 (6.37) 1-30 −0.26** −0.16 0.55** ---
5. PTSD Symptoms 0.90 15.70 (11.35) 0-39 −0.29** −0.06 0.61** 0.67** ---
6. Emotion Dysregulation 0.92 91.16 (22.43) 45-146 −0.07 0.04 0.46** 0.40** 0.50** ---
7. BPD Symptoms 0.85 66.54 (14.47) 31-99 −0.18 −0.01 0.44** 0.44** 0.60** 0.62** ---
8. Maternal Criticism 0.75 20.54 (9.96) 4-40 −0.12 0.14 0.27** 0.34** 0.39** 0.28** 0.47** ---
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Note. α = Cronbach's a for each measure. Correlations presented for gender are point biserial correlations. PTSD = posttraumatic stress disorder. BPD = borderline personality disorder.

**

p < .01.

Primary Analysis

A hierarchical multiple regression analysis examined the unique relation between BPD symptoms and perceived caregiver criticism, above and beyond age, gender, emotion dysregulation, and other psychiatric symptoms (Table 3). The addition of BPD symptoms in Step 3 accounted for an additional 7.6% of the variance in perceived caregiver criticism. Only BPD symptoms were significantly associated with perceived caregiver criticism in the final model1.

Table 3.

Hierarchical Multiple Regression Analysis Examining Perceived Caregiver Criticism (N = 109)

Variable B SE(B) β ΔR2
Step 1 0.02
    Gender −1.83 2.19 −0.10
    Age 0.66 0.78 0.10
Step 2 0.18**
    Gender 1.05 2.26 0.06
    Age 0.96 0.74 0.14
    Depression 0.12 0.27 0.07
    Anxiety 0.29 0.21 0.20
    PTSD 0.17 0.13 0.20
    Emotion Dysregulation 0.03 0.06 0.07
Step 3 0.08**
    Gender 1.57 2.18 0.08
    Age 1.10 0.71 0.16
    Depression 0.10 0.26 0.06
    Anxiety 0.30 0.20 0.21
    PTSD 0.04 0.14 0.05
    Emotion Dysregulation −0.05 0.06 −0.12
    BPD symptoms 0.27 0.10 0.42**
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Note. PTSD = posttraumatic stress disorder. BPD = borderline personality disorder. For the final model, F(7, 67) = 3.56, Adjusted R2 = 0.20, p < .01.

**

p < .01.

Discussion

This study examined the relation of BPD symptoms to perceptions of caregiver criticism in a high-risk sample of adolescents in a residential psychiatric treatment facility. Extending past research, results revealed a unique relation of adolescent BPD symptoms to perceived caregiver criticism, above and beyond emotion dysregulation and symptoms of depression, anxiety, and PTSD (all of which were related to perceived criticism at a bivariate level).

This study is the first to provide support for a link between BPD symptoms in adolescents and perceptions of caregivers. Findings suggest that BPD symptoms may influence adolescents’ perceptions of their caregivers, increasing the likelihood of negative perceptions. Such perceptions may be an early expression of the interpersonal sensitivity in BPD (Gunderson & Lyons-Ruth, 2008). Specifically, adolescents with BPD symptoms may perceive their caregivers as more critical (even if their caregivers do not actually exhibit high levels of criticism) – a perception that may negatively influence their interactions with and behaviors toward these caregivers. As such, perceptions of caregiver criticism (regardless of caregiver's actual attitudes or behavior) may, over time, exacerbate relationship difficulties and maintain symptoms of BPD. Alternatively, in response to certain BPD symptoms, caregivers of youth with BPD pathology may in fact display heightened levels of criticism. Adolescents with BPD symptoms may also be more aware of caregiver criticism more quickly and at lower levels (potentially exacerbating their reactions to the actual or perceived criticism of their caregivers). Future research is needed to clarify the precise nature and direction of the relation between BPD symptoms in youth and perceived criticism in caregivers. In particular, longitudinal research examining both caregiver and adolescent critical behaviors and perceptions of criticism (their own and the other's) may elucidate the ways in which perceptions and behaviors interact over time to predict BPD pathology and related relationship dysfunction.

This study has several limitations. Given the cross-sectional nature of the study, it is not possible to determine the direction of the relation between adolescent BPD symptoms and perceived parental criticism, or the extent to which this changes across time (Hale III, Raaijmakers, et al., 2011; Nelemans et al., 2013). Future research examining caregiver criticism and child BPD symptoms and perceptions of caregiver behaviors from middle childhood through late adolescence are needed to assess their precise interrelations over time. Another limitation is the assessment of psychiatric symptoms in the adolescents only. Given that maternal psychopathology has been found to relate to more critical EE (Gravener et al., 2012), it is likely that the presence of maternal psychopathology would predict more criticism. Thus, caregiver psychiatric symptoms may moderate the relation between adolescent BPD symptoms and perceived caregiver criticism. Finally, although adolescents’ perceptions of their caregivers (regardless of their caregivers’ actual behaviors) were of primary interest in this study, the absence of measures of caregiver-reported and/or observed critical EE precludes determination of the accuracy of the adolescents’ reports and the extent to which these reports map onto caregiver behavior. Future studies should address this limitation by including both caregiver questionnaires and EE recordings in the laboratory. The multi-method assessment of caregiver criticism would provide a more thorough and comprehensive evaluation of this construct.

Despite these limitations, results suggest that adolescent BPD symptoms may have unique relevance to adolescents’ perceptions of their caregivers, increasing the likelihood of negative perceptions above and beyond other relevant psychopathology.

Highlights.

  • Borderline personality disorder (BPD) is associated with interpersonal sensitivity

  • Adolescents with BPD symptoms may be sensitive to criticism from caregivers

  • We examined the relation of adolescent BPD symptoms to perceived parental criticism

  • These relations were examined among adolescents in residential psychiatric treatment

  • BPD symptoms were uniquely related to perceived parental criticism

Acknowledgments

Dr. Whalen is now at the Department of Psychiatry, Washington University. Dr. Malkin is now at the Department of Psychology, Mississippi University for Women. Dr. Whalen's work was supported by grant T32 MH100019 to Drs. Deanna Barch and Joan Luby from the National Institutes of Health.

Footnotes

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1

Findings did not change when the presence of an externalizing disorder was included in Step 2 of the model. Specifically, whereas the presence of an externalizing disorder was not significantly associated with perceived caregiver criticism in Step 2 or 3 of the model (βs = 0.03 and 0.09, ps > .10), BPD symptoms remained uniquely associated with perceived caregiver criticism in the final step of the model (β = 0.44, p < .01).

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