Borderline Personality Disorder Isn’t Only a Concern for the Young

The typical understanding of borderline personality disorder (BPD) is that it is a condition that first makes its appearance in either late adolescence or early adulthood. Many popular characterizations of BPD reinforce this image and, indeed, much of the research on BPD in academic psychology also uses early life as its starting point.

A more lifespan-oriented approach to BPD regards it as a diagnosis that can contribute to difficulties in adjustment in the key roles of relationships and work. The so-called “stress generation effect” of BPD implies that the chaos caused by emotional dysregulation and other BPD symptoms multiplies exponentially across adulthood. Again, the starting point for this is seen as young adulthood.

A New Understanding of Late-Life BPD

According to a new study by Rachel Jo of the Spectrum Personality Disorder and Complex Trauma Service (Australia) and colleagues (2022), there is growing evidence that “core BPD symptoms such as chronic dysphoria, emptiness, interpersonal difficulties, and affective instability may persist and increase vulnerability to re-emergence of BPD in later life,” reflecting “a dynamic pattern of change in personality disorder expression across the lifespan” (p. 2).

However, there is also evidence that BPD may show up for the first time among people whose lives were stable and productive until they experienced a late-life associated change, either based on physiology (e.g., hormonal changes) or some significant change in life circumstances. Substance abuse and the development of an anxiety or mood disorder could also serve to trigger BPD symptoms later in adulthood.

Given that BPD may be seen as out of the question in older individuals, an individual seeking treatment for what are palpably its symptoms will likely either receive an incorrect diagnosis or perhaps no diagnosis at all. As a result, they may fail to get the treatment that would help alleviate their symptoms.

If, in fact, it is possible for BPD to appear for the first time in later life, the question then becomes "Why?" The authors suggest that one possibility is that the individual actually had so-called “subsyndromal” signs of it for decades, but doesn't manifest the disorder until a trigger occurs due to a combination of “biopsychosocial” factors such as loss of a partner or exposure to salient stressors. Prior to that point, the individual was able to mitigate against early vulnerability through compensation or protective factors such as a stable family or job situation.

Uncovering Late-Life BPD

Defining “later life” BPD as emerging after the age of 30 (which, in a relative sense, might be late for BPD), the Australian research team sought to identify cases of newly diagnosed BPD among the 1,200 client records at their disposal. The final sample of 23 eligible cases (three males) averaged 45 years old, with three over the age of 60. Nearly one-third had no previous mental health diagnoses, but, among those with a prior condition, the largest group had major depressive disorder followed by bipolar disorder; 15 had a history of substance use disorder.

Prominent in the history of all 23 patients was early life trauma, with 17 of those in the study having suffered sexual assault during childhood. All 23 reported emotional and/or verbal abuse as well as emotional neglect. However, it wasn’t until later in adulthood that these vulnerabilities translated into the manifestation of BPD symptoms after being provoked by a psychosocial stressor.

Six themes emerged among the cases that fit the criteria for one of these psychosocial stressors ranging from relationships with their own children (13 of the 23) to problems at work including workplace bullying. In 19 of the 20 cases with identifiable precipitators, the themes centered around some type of interpersonal difficulty.

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What This New Understanding of BPD Means

The Jo et al. findings highlight the importance of considering BPD as a possibility for individuals showing mental health difficulties in middle and later life. Moreover, just as younger individuals with BPD seem to share an early life filled with trauma, these later-life participants also reported a childhood history of mistreatment by the adults in their lives.

However, it’s also important to recognize that prior to the BPD diagnosis, these individuals also had a range of psychiatric diagnoses, including substance use disorders. Thus, they were not sailing through adulthood with no mental health challenges at all.

As the authors speculated at the outset of their investigation, the patient sample may have inherited genetic vulnerabilities, with 60 percent reporting a family history of psychological disorders. However, on the positive side, the late-life BPD patients were more likely to have received advanced educational degrees, higher levels of employment, and longer-term intimate relationships than is typically reported among BPD populations. Loss of one or more of these protective factors “often preceded a crisis and the first emergence of BPD symptoms” (p. 7).

Also notable was the large percentage of interpersonal problems centering around parenting issues. The women in the Jo et al. study reported difficulties in becoming a mother, handling problems with a child, losing the mother role when the children left the home, and experiencing the death of a child. As the authors concluded, “This likely reflects the well-known association between BPD and attachment trauma” (p. 8).

This last finding is particularly important for understanding late-life BPD. The ordinary way to think about “attachment trauma” in BPD is as a reflection of the individual’s mistreatment by their own parents. Women in midlife and beyond can have their own form of attachment trauma leading BPD to become manifest when they lose the “containing” factor of their relationship with their children or when that relationship devolves.

Even as these precipitating factors should be recognized when an individual presents with BPD-like symptoms past the traditional age of 30, the Jo et al. study also points to the need to recognize that certain factors can serve to protect individuals against manifesting these symptoms until a late-life stressor appears. The patients in this study managed to achieve high levels of education, stable employment, and long-term close relationships, despite possible genetic vulnerability and early childhood trauma. It would be worthwhile to learn what particular strengths and resources allowed them to avoid the “stress generation” effect that can so severely limit the fulfillment of other individuals with lifetime diagnoses of BPD.

To sum up, BPD may be a diagnosis most often observed in young adults. However, when the symptoms in later life suggest the possibility of a newly developed condition, the Australian study shows the value of recognizing them for what they are as a first step to helping these individuals find the path to effective treatment.

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