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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: J Pers Disord. 2019 Mar 28;34(Suppl B):17–24. doi: 10.1521/pedi_2019_33_425

Risk Factors for Borderline Personality Disorder in Adolescents

Mary C Zanarini 1, Christina M Temes 1, Laura R Magni 2, Blaise A Aguirre 1, Katherine E Hein 3, Marianne Goodman 4
PMCID: PMC7584111  NIHMSID: NIHMS1556042  PMID: 30920936

Abstract

The objective of this paper was to assess the association between variables reflecting childhood adversity, protective childhood experiences, and the Five Factor Model of Personality and BPD in adolescents. Two groups of adolescents were studied: 104 met criteria for BPD and 60 were psychiatrically healthy. Adverse and protective childhood experiences were assessed using a semi-structured interview. The five-factor model of personality was assessed using the NEO-FFI. Eight of nine variables indicating severity of abuse and neglect, positive childhood relationships, childhood competence, and the personality factors studied were found to be significant bivariate risk factors for adolescent BPD. However, in a multivariate model, severity of neglect, higher levels of Neuroticism, and lower levels of childhood competence were found to be the best risk factor model. Taken together, the results of this study suggest that all three types of risk factors studied are significantly associated with BPD in adolescents.

Keywords: borderline personality disorder, childhood abuse, childhood neglect, positive relationships, competence, personality traits, risk factors, adolescents

Research regarding the etiology of borderline personality disorder (BPD) in adults has primarily focused on the role of adverse childhood experiences. Both multiple forms of abuse (Herman, Perry, & van der Kolk, 1989; Links, Steiner, Offord, & Eppel, 1988; Ogata et al., 1990; Paris, Zweig-Frank, & Guzder, 1994a; Paris, Zweig-Frank, & Guzder, 1994b; Salzman et al., 1993; Shearer, Peters, Quaytman,& Ogden, 1990; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989; Zanarini et al., 1997) and emotional neglect (Links et al., 1988; Zanarini et al., 1989; Zanarini et al., 1997) have been found to be more common among adults with BPD than comparison subjects with a variety of diagnoses (e.g., depression, personality disorders other than BPD). A smaller number of studies have found the same pattern in adolescents (Atlas, 1995; Horesh, Ratner, Laor, & Toren, 2008; Horesh, Sever, & Apter, 2003; Infurna et al., 2016; James, Berelowitz, & Vereker, 1996; Stepp, Whalen, Scott, Zalewski, Loeber, & Hipwell, 2014; Westen, Ludolph, Misle, Ruffins, & Block, 1990).

In contrast, little research has been conducted on competence and other protective factors that may serve to lessen the severity of these symptoms in both adults (Skodol et al., 2007) and adolescents with BPD (Borkum et al., 2017). In addition to these studies of adverse childhood experiences and protective childhood experiences, numerous studies have found a strong association between five factor traits, particularly Neuroticism, and the presence of BPD or BPD symptoms in adults (e.g., Hopwood et al., 2009). In addition, a smaller body of research has found this same association in adolescents (Stepp, Keenan, Hipwell, & Krueger, 2014).

Most of the studies mentioned above are descriptive in nature. However, studies in the field of child development suggest a more complicated model between these adverse and protective factors and aspects of temperament. More specifically, they suggest that temperament moderates the effects of parenting efforts particularly for children with a highly reactive phenotype (Boyce & Ellis, 2005; Pluess & Belsky, 2010).

The current study has two main aims, the results of which will fill a gap in the literature concerning the risk factors for BPD in adolescents. First, it will assess the risk associated with the severity of two adverse childhood factors (abuse and neglect), two protective childhood factors (number of emotionally sustaining relationships and childhood competence), and the five factors of personality in adolescents with BPD and a psychiatrically healthy comparison group. These analyses will be both bivariate and multivariate in nature. Second, this study will assess the role of temperament in moderating the effects of childhood adversity and protective factors in the development of BPD in adolescents.

Method

The methodology of this study has been presented before in detail (Zanarini et al., 2017). All study procedures were approved by the institutional review boards at the participating institutions.

Adolescents (aged 13–17) with presumptive BPD were recruited from four units at McLean Hospital and one unit at Mount Sinai Medical Center between the dates of August 2007 and September 2012. During the same timeframe, same-aged adolescents without a history of any psychiatric disorder were recruited using online advertisements. Parents provided consent and adolescents provided assent. They were then interviewed using the following diagnostic interviews: 1) the Structured Clinical Interview for DSM-IV Childhood Diagnoses (KID-SCID; Matzner, Silva, Silvan, Chowdhury, & Nastari, 1997), 2) the Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989), and 3) the Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD; Sharp, Ha, Michonski, Venta, & Carbone, 2012).

Inclusion in the borderline group of adolescents required meeting DIB-R and DSM-IV criteria for BPD. In addition, all forms of comorbidity were allowed except for schizophrenia, schizoaffective disorder, and bipolar I disorder. The psychiatric comparison subjects were only included in the study if they did not meet lifetime criteria for any psychiatric disorder.

To assess adverse and protective childhood experiences reported to have occurred before age 18, all participants were administered the Revised Childhood Experiences Questionnaire (CEQ-R). The CEQ-R is a semi-structured interview whose psychometric properties have been described elsewhere (Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989). This instrument assesses four forms of abuse and seven forms of neglect by full-time caretakers of both genders (typically parents) and additionally, sexual abuse by non-caretakers of both genders (e.g., siblings, neighbors). It also assesses five types of emotionally supportive relationships (e.g., male and female friends and siblings) and eight types of childhood competence, such as academic success, athletic success, and popularity. For each type of experience, interviewers record a dichotomous rating to indicate the presence or absence of the experience during three periods in the participants’ childhood: 0–5 years of age, 6–12 years of age, and 13–17 years of age. For an item to be given a positive (present) rating, participants must provide detailed information about the event. This instrument also yields two continuous scores for childhood adversity (abuse and neglect) and two continuous scores for protective childhood experiences (positive relationships and childhood competence). These scores are derived by summing the total number of affirmative ratings for each type of experience across each age period and emotionally important adult (for childhood adversity). For example, the maximum severity score for neglect is 42, because the presence/absence of seven different neglect experiences are assessed for three age periods and two caretakers, typically a subject’s mother and father. A similar scoring system was used for the five forms of emotionally supportive relationships and the eight types of childhood competence studied.

Participants then took the NEO Five-Factor Inventory (NEO-FFI) (Costa & McCrae, 1992), a 60 item self-report measure with proven psychometric properties. Each of the five factors was assessed with 12 items scored on a five-point Likert rating scale. Reported t-scores generally range from 20 to 80, with 50 being the median score.

Statistical Analyses

Between-group differences in demographic variables were assessed using Student’s t-test for continuous variables and Pearson chi-square for binary variables. Analyses of the severity of childhood adversity, childhood protective factors, and NEO scores were conducted using logistic regression controlling for age and significance was adjusted for multiple comparisons to p<0.006 (0.05/9).

We also conducted exploratory logistic regression analyses to assess the role of Neuroticism as a moderator of the effects of the two childhood adversity variables and two childhood protective factors on risk of developing BPD. We hypothesized that higher levels of Neuroticism will magnify the effects of adverse life experiences and attenuate the effects of protective life experiences.

Results

Participants

One hundred and four participants were adolescents between the ages of 13 and 17 who met DIB-R and DSM-IV criteria for BPD. Sixty were psychiatrically healthy comparison subjects in the same age range. We chose to study these groups as many clinicians do not believe that BPD can be fully present in adolescence and many mental health professionals believe that BPD symptoms in adolescence are only a manifestation of normal adolescence.

Demographic characteristics have also been described previously (Zanarini et al., 2017). Briefly, adolescents with BPD were significantly more likely to be female than psychiatrically healthy adolescents. However, adolescents with BPD were very similar to psychiatrically healthy adolescents in terms of race (about a third non-white) and socioeconomic background (mean of about 2.3/2.4 on a 1=highest and 5=lowest scale). In addition, adolescents with BPD were significantly older than psychiatrically healthy adolescents (by about a year—15 vs. 14).

Table 1 details the mean scores on nine variables as well as their standard deviations in logistic regression models taking each variable in turn. All between-group differences were significant at the p<0.05 level. More specifically, borderline adolescents had significantly higher scores on the severity of childhood abuse and neglect as well as the Neuroticism and Openness factors from the NEO. They also had significantly lower scores on the NEO’s Extraversion factor, Agreeableness factor, and Conscientiousness factor as well as significantly lower scores on the number of positive childhood relationships and the degree of childhood competence. However, at the Bonferroni corrected level of p<0.006, Openness was no longer significant.

Table 1.

Bivariate Risk Factors for the Development of BPD in Adolescents

Adolescent BPD Psychiatrically Healthy Adolescents Adolescent BPD vs. Healthy Adolescents
Mean SD Mean SD Odds Ratio Z-value P-value 95%CI
Childhood Adversity
Severity of Abuse (0–30) 2.4 3.3 0.2 0.8 2.74 3.91 <0.001 1.65, 4.53
Severity of Neglect (0–42) 5.6 6.7 0.4 1.3 1.84 4.32 <0.001 1.40, 2.44
NEO Five Factors
Neuroticism Factor 68.9 7.2 48.6 9.2 1.27 6.21 <0.001 1.18, 1.37
Extraversion Factor 46.6 12.2 56.9 9.2 0.97 −4.17 <0.001 0.90, 0.96
Openness Factor 54.2 11.2 49.4 10.2 1.03 2.06 0.039 1.00, 1.07
Agreeableness Factor 39.9 11.9 52.3 11.7 0.91 −5.27 <0.001 0.88, 0.94
Consciousness Factor 34.5 10.9 45.9 10.9 0.92 −4.96 <0.001 0.89, 0.95
Positive Childhood Experiences
Number of Supportive Relationships (0–30) 11.5 5.4 17.1 5.6 0.82 −5.00 <0.001 0.77, 0.89
Degree of Childhood Competence (0–24) 8.6 4.0 13.8 3.9 0.72 −5.86 <0.001 0.64, 0.80
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Analyses controlled for age and significance was p<0.006

We next tested the significance of the mean scores of the eight variables that were significant in bivariate analyses. Three of these variables were found to be significant as a model of risk factors for BPD in adolescents (see Table 2). These variables are: severity of childhood neglect, higher Neuroticism score, and lower level of childhood competence.

Table 2.

Significant Multivariate Risk Factors for the Development of BPD in Adolescents

Risk Factor Odds Ratio Z-score P-value 95%CI
Severity of Childhood Neglect 1.71 3.00 0.003 1.21, 2.44
Level of Neuroticism 1.30 4.28 <0.001 1.15, 1.46
Degree of Childhood Competence 0.67 −3.74 <0.001 0.54, 0.83
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Analyses controlled for age and significance was p<0.006

Our exploratory analyses of the moderating effects of Neuroticism did yield a significant interaction between Neuroticism and severity of neglect but no significant interactions with the other three risk/protective factors. However, counter-intuitively and not supportive of our hypothesis, this interaction indicated that higher levels of Neuroticism attenuate the effect of adverse life experiences. Specifically, the odds ratio for severity of neglect was 1.85 (z=3.42, p=0.001, 95% CI=1.30–2.63) for those with higher levels of Neuroticism (1 SD above the T-score mean for levels of Neuroticism) whereas the odds ratio was 4.34 (z=3.27, p=0.001, 95%CI=1.80–10.47) for those with lower levels of Neuroticism (1 SD below the T-score mean).

Discussion

Three main findings emerge from the results of this cross-sectional study. First, the severity of childhood neglect (mostly emotional in nature) has been found to be a significant multivariate risk factor for the development of adolescent BPD. This finding is consistent with the results of adult studies of childhood adversity, which have found that emotional neglect is more strongly associated with BPD in adults than the severity of childhood abuse (Zanarini et al., 1997). However, many clinicians believe that childhood abuse, particularly sexual abuse, is the most important factor in the etiology of BPD. The severity of abuse was significant in bivariate but not multivariate analyses, suggesting that clinicians would be wise to consider a broader array of possible etiological factors than childhood sexual abuse.

Second, heightened Neuroticism was found to be a significant multivariate risk factor for BPD in adolescents. Previous studies of adults and adolescents with BPD have also found this relationship between the personality trait of negative emotions and BPD (Hopwood et al., 2009; Stepp et al., 2014). This association is not surprising given the multiple dysphoric states (inappropriate anger and chronic feelings of emptiness) that are part of the DSM-IV criteria set for BPD. It is also not surprising given the fact that this criteria set includes affective instability (i.e., the rapid movement from one dysphoric affective state to another). As for the other factors, they confirm the results of earlier studies in adults (Morey et al., 2002). More specifically, Extraversion, Agreeableness and Conscientiousness were found to be relatively low in those with BPD and Openness was found to be relatively high.

Third, the results of this study indicate that a more limited degree of childhood competence spanning eight factors is also a significant multivariate risk factor for BPD in adolescents. It may be that emotional neglect by parents and a high degree of trait negative emotionality join to affect the degree of childhood competence that those with BPD as adolescents manifest. It may also be that being less competent than psychiatrically healthy adolescents joins with trait neuroticism to make adolescents with BPD more susceptible to the effects of parental emotional neglect.

Taken together, the results of this study are consistent with studies of child development which suggest that temperament moderates the effects of parenting efforts (Boyce & Ellis, 2005; Pluess & Belsky, 2010). However, the significant moderating effect of Neuroticism that we found is in the opposite direction to what was hypothesized; as a result, we strongly caution against overinterpreting this result until it has been replicated in another study or independent dataset.

Limitations

One limitation of the current study is that all adolescents with BPD were inpatients. Thus, our results may not generalize to adolescents with less severe psychopathology. Another is that our healthy adolescents had no history of any psychiatric disorder. Thus, our results may not generalize to community-dwelling adolescents with one or more lifetime psychiatric disorders.

Conclusions

Taken together, the results of this study suggest that all three types of risk factors studied are significantly associated with BPD in adolescents. They also suggest that the severity of childhood neglect, the personality trait of Neuroticism, and lower levels of childhood competence are more strongly associated with BPD in adolescence than the severity of childhood abuse.

Acknowledgments

Supported by NIMH grants MH47588 and MH62169 (Dr. Zanarini).

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