Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

Jean Marc Guilé,1,2,3 Laure Boissel,1,2 Stéphanie Alaux-Cantin,1,2 Sébastien Garny de La Rivière1 1Child and Adolescent Psychiatry Services, Amiens-Picardie University Medical Centre, Amiens, France; 2Psychiatry Residency Program, University of Picardie-Jules Verne, Amiens, France; 3Department of Psychiatry, McGill University, Montreal, Quebec, Canada Abstract: Using the same Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-V) criteria as in adults, borderline personality disorder (BPD) in adolescents is defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation. BPD can be reliably diagnosed in adolescents as young as 11 years. The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3%. The clinical prevalence of BPD ranges from 11% in adolescents consulting at an outpatient clinic to 78% in suicidal adolescents attending an emergency department. The diagnostic procedure is based on a clinical assessment with respect to developmental milestones and the interpersonal context. The key diagnostic criterion is the 1-year duration of symptoms. Standardized, clinician-rated instruments are available for guiding this assessment (eg, the Diagnostic Interview for Borderlines-Revised and the Childhood Interview for DSM-IV-TR BPD). The assessment should include an evaluation of the suicidal risk. Differential diagnosis is a particular challenge, given the high frequency of mixed presentations and comorbidities. With respect to clinical and epidemiological studies, externalizing disorders in childhood constitute a risk factor for developing BPD in early adolescence, whereas adolescent depressive disorders are predictive of BPD in adulthood. The treatment of adolescents with BPD requires commitment from the parents, a cohesive medical team, and a coherent treatment schedule. With regard to evidence-based medicine, psychopharmacological treatment is not recommended and, if ultimately required, should be limited to second-generation antipsychotics. Supportive psychotherapy is the most commonly available first-line treatment. Randomized controlled trials have provided evidence in favor of the use of specific, manualized psychotherapies (dialectic-behavioral therapy, cognitive analytic therapy, and mentalization-based therapy). Keywords: borderline personality, adolescence, prevalence, assessment, treatmen

Adolescent binge-like alcohol alters sensitivity to acute alcohol effects on dopamine release in the nucleus accumbens of adult rats

RATIONALE: Early onset of alcohol drinking has been associated with alcohol abuse in adulthood. The neurobiology of this phenomenon is unclear, but mesolimbic dopamine pathways, which are dynamic during adolescence, may play a role. OBJECTIVES: We investigated the impact of adolescent binge-like alcohol on phasic dopaminergic neurotransmission during adulthood. METHODS: Rats received intermittent intragastric ethanol, water or nothing during adolescence. In adulthood, electrically-evoked dopamine release and subsequent uptake were measured in the nucleus accumbens core at baseline and after acute challenge of ethanol or saline. RESULTS: Adolescent ethanol exposure did not alter basal measures of evoked dopamine release or uptake. Ethanol challenge dose-dependently decreased the amplitude of evoked dopamine release in rats by 30–50% in control groups, as previously reported, but did not alter evoked release in ethanol-exposed animals. To address the mechanism by which ethanol altered dopamine signaling, the evoked signals were modeled to estimate dopamine efflux per impulse and the velocity of the dopamine transporter. Dopamine uptake was slower in all exposure groups after ethanol challenge compared to saline, while dopamine efflux per pulse of electrical stimulation was reduced by ethanol only in ethanol-naive rats. CONCLUSIONS: The results demonstrate that exposure to binge levels of ethanol during adolescence blunts the effect of ethanol challenge to reduce the amplitude of phasic dopamine release in adulthood. Large dopamine transients may result in more extracellular dopamine after alcohol challenge in adolescent-exposed rats, and may be one mechanism by which alcohol is more reinforcing in people who initiated drinking at an early age

A role for histone acetylation mechanisms in adolescent alcohol exposure-induced deficits in hippocampal brain-derived neurotrophic factor expression and neurogenesis markers in adulthood

Binge drinking during adolescence is a risk factor for neuropsychiatric disorders that can develop later in life. Histone acetylation is an important epigenetic mechanism that contributes to neurodevelopment. We investigated the effects of adolescent intermittent ethanol (AIE) exposure, as opposed to normal saline (AIS) exposure, on histone acetylation-mediated regulation of brain-derived neurotrophic factor (BDNF) expression and developmental stages of neurogenesis (proliferating and immature neurons) in the hippocampus in adulthood. AIE exposure increased whole hippocampal histone deacetylase (HDAC) activity and decreased binding protein of cyclic adenosine monophosphate response element binding protein (CBP) and histone H3-K9 acetylation levels in the CA1, CA2, and CA3 regions of the hippocampus. BDNF protein and exon IV mRNA levels in the CA1 and CA3 regions of the hippocampus of AIE exposed adult rats were decreased as compared to AIS exposed adult rats. AIE induced anxiety-like behaviors and deficits in histone H3 acetylation at BDNF exon IV promoter in the hippocampus during adulthood, which were reversed by treatment with the HDAC inhibitor, trichostatin A (TSA). Similarly, neurogenesis was inhibited by AIE in adulthood as demonstrated by the decrease in Ki-67 and doublecortin (DCX)-positive cells in the dentate gyrus, which was normalized by TSA treatment. These results indicate that AIE exposure increases HDACs and decreases CBP levels that may be associated with a decrease in histone H3 acetylation in the hippocampus. These epigenetic changes potentially decrease BDNF expression and inhibit neurogenesis in the hippocampus that may be involved in AIE-induced behavioral abnormalities, including anxiety, in adulthood

Adolescent Alcohol Exposure Amplifies the Incentive Value of Reward-Predictive Cues through Potentiation of Phasic Dopamine Signaling

Adolescent alcohol use remains a major public health concern due in part to well-established findings implicating the age of onset in alcohol use in the development of alcohol use disorders and persistent decision making deficits in adults. We have previously demonstrated that moderate adolescent alcohol consumption in rats promotes suboptimal decision making and an associated perturbation in mesolimbic dopamine transmission in adulthood. Dopamine-dependent incentive learning processes are an integral component of value-based decision making and a fundamental element to many theoretical accounts of addiction. Thus, we tested the hypothesis that adolescent alcohol use selectively alters incentive learning processes through perturbation of mesolimbic dopamine systems. To assess incentive learning, behavioral and neurochemical measurements were made during the acquisition, maintenance,extinction, and reacquisition of a Pavlovian conditioned approach procedure, in adult rats with a history of adolescent alcohol consumption. We show that moderate adolescent alcohol consumption potentiates stimulus-evoked phasic dopamine transmission, measured in vivo by fast-scan cyclic voltammetry, in adulthood and biases individuals toward a dopamine-dependent incentive learning strategy. Moreover, we demonstrate that animals exposed to alcohol in adolescence are more sensitive to an unexpected variation in reward outcomes. This pattern of phasic dopamine signaling and the associated bias in learning may provide a mechanism for the well documented vulnerability of individuals with early-life alcohol use for alcohol use disorders in adulthood

Targeting the intracellular signaling "STOP" and "GO" pathways for the treatment of alcohol use disorders.

In recent years, research has identified the molecular and neural substrates underlying the transition of moderate "social" consumption of alcohol to the characteristic alcohol use disorder (AUD) phenotypes including excessive and compulsive alcohol use which we define in the review as the GO signaling pathways. In addition, growing evidence points to the existence of molecular mechanisms that keep alcohol consumption in check and that confer resilience for the development of AUD which we define herein as the STOP signaling pathways. In this review, we focus on examples of the GO and the STOP intracellular signaling pathways and discuss our current knowledge of how manipulations of these pathways may be used for the treatment of AUD