Journal of Personality Disorders, 34, Supplement B , 17–24, 2020

© 2020 The Guilford Press

RISK FACTORS FOR BORDERLINE

PERSONALITY DISORDER IN ADOLESCENTS
Mary C. Zanarini, EdD, Christina M. Temes, PhD,
Laura R. Magni, PhD, Blaise A. Aguirre, MD,
Katherine E. Hein, MHS, and Marianne Goodman, MD

The objective of this study 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 semistructured 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, Franken-
burg, & 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 found the same pattern in adolescents (Atlas, 1995;

From McLean Hospital, Belmont, Massachusetts, and Harvard Medical School, Boston, Massachusetts
(M. C. Z., C. M. T., B. A. A.); McLean Hospital (K. E. H.); St. John of God Research Centre, Brescia, Italy
(L. R. M.); and James J. Peters Veterans Affairs Medical Center, Bronx, New York, and Icahn School of
Medicine at Mt. Sinai, New York, New York (M. G.).
This research was supported by NIMH grants MH47588 and MH62169 (Dr. Zanarini).
Address correspondence to Dr. Mary C. Zanarini, McLean Hospital, 115 Mill St., Belmont, MA 02478.
E-mail: zanarini@mclean.harvard.edu

G4884.indd 17 9/23/2020 12:32:46 PM

 18 ZANARINI ET AL.

Horesh, Ratner, Laor, & Toren, 2008; Horesh, Sever, & Apter, 2003; Infurna
et al., 2016; James, Berelowitz, & Vereker, 1996; Stepp, Whalen et al., 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 pro-
tective childhood experiences, numerous studies have found a strong associa-
tion 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 child-
hood 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, Belmont, Massachusetts, and one unit at Mount
Sinai Medical Center, Bronx, New York, between August 2007 and September
2012. During the same time frame, same-aged adolescents without a history
of any psychiatric disorder were recruited using online advertisements. Parents
provided consent and adolescents provided assent. The adolescents were then
interviewed using the following diagnostic interviews: (1) the Structured Clini-
cal 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

G4884.indd 18 9/23/2020 12:32:46 PM

 RISK FACTORS FOR BPD IN ADOLESCENTS 19

allowed except for schizophrenia, schizoaffective disorder, and bipolar I dis-

order. 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 Child-
hood Experiences Questionnaire (CEQ-R). The CEQ-R is a semistructured
interview whose psychometric properties have been described elsewhere
(Zanarini, Gunderson, Marino et al., 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 emo-
tionally 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 (pres-
ent) 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
is 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 Stu-

dent’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 < .006 (.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.

G4884.indd 19 9/23/2020 12:32:46 PM

 20 ZANARINI ET AL.

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 psychiatri-
cally 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, ado-
lescents 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 stan-
dard deviations in logistic regression models taking each variable in turn. All
between-group differences were significant at the p < .05 level. More specifi-
cally, 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 Extra-
version factor, Agreeableness factor, and Conscientiousness factor as well as

TABLE 1. Bivariate Risk Factors for the Development of BPD in Adolescents

Psychiatrically
Adolescent BPD 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 < .001 1.65, 4.53
Severity of Neglect (0–42) 5.6 6.7 0.4 1.3 1.84 4.32 < .001 1.40, 2.44
NEO Five Factors
Neuroticism Factor 68.9 7.2 48.6 9.2 1.27 6.21 < .001 1.18, 1.37
Extraversion Factor 46.6 12.2 56.9 9.2 0.97 -4.17 < .001 0.90, 0.96
Openness Factor 54.2 11.2 49.4 10.2 1.03 2.06 .039 1.00, 1.07
Agreeableness Factor 39.9 11.9 52.3 11.7 0.91 -5.27 < .001 0.88, 0.94
Consciousness Factor 34.5 10.9 45.9 10.9 0.92 -4.96 < .001 0.89, 0.95
Positive Childhood
Experiences
Number of Supportive 11.5 5.4 17.1 5.6 0.82 -5.00 < .001 0.77, 0.89
Relationships (0–30)
Degree of Childhood 8.6 4.0 13.8 3.9 0.72 -5.86 < .001 0.64, 0.80
Competence (0–24)
Note. Analyses controlled for age and significance were p < .006.

G4884.indd 20 9/23/2020 12:32:46 PM

 RISK FACTORS FOR BPD IN ADOLESCENTS 21

significantly lower scores on the number of positive childhood relationships

and the degree of childhood competence. However, at the Bonferroni corrected
level of p < .006, Openness was no longer significant.
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.
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. How-
ever, 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 = .001, 95% CI [1.30, 2.63]) for those with higher levels of neu-
roticism (1 SD above the t score mean for levels of Neuroticism) whereas the
odds ratio was 4.34 (z = 3.27, p = .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 associ-
ated 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 etiologi-
cal 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

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 .003 1.21, 2.44
Level of Neuroticism 1.30 4.28 < .001 1.15, 1.46
Degree of Childhood Competence 0.67 -3.74 < .001 0.54, 0.83
Note. Analyses controlled for age and significance were p < .006.

G4884.indd 21 9/23/2020 12:32:46 PM

 22 ZANARINI ET AL.

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 Neuroti-
cism, and lower levels of childhood competence are more strongly associated
with BPD in adolescence than the severity of childhood abuse.

REFERENCES
Atlas, J. A. (1995). Association between history of
abuse and borderline personality disorder for
hospitalized adolescent girls. Psychological
Reports, 77(Suppl. 3), 1346. https://doi.
org/10.2466/pr0.1995.77.3f.1346
Borkum, D. B., Temes, C. M., Magni, L. R., Fitzmau-
rice, G. M., Aguirre, B. A., Goodman, M., &
Zanarini, M. C. (2017). Prevalence rates of
childhood protective factors in adolescents
with BPD, psychiatrically healthy adoles-
cents, and adults with BPD. Personal Mental
Health, 11, 189–194.
Boyce, W. T., & Ellis, B. J. (2005). Biological sensitivity
to context: I. An evolutionary-developmental

G4884.indd 22 9/23/2020 12:32:46 PM

 RISK FACTORS FOR BPD IN ADOLESCENTS 23
theory of the origins and functions of stress
reactivity. Development and Psychopathol-
ogy, 17, 271–301.
Costa, P. T., & McCrae, R. R. (1992). Revised NEO
Personality Inventory and NEO Five-Factor
Inventory Professional Manual. Odessa, FL:
Psychological Assessment Resources.
Herman, J. L., Perry, J. C., & van der Kolk, B. A.
(1989). Childhood trauma in borderline
personality disorder. American Journal of
Psychiatry, 146, 490–495. https://doi.org/
10.1176/ajp.146.4.490
Hopwood, C. J., Newman, D. A., Donnellan, M.
B., Markowitz, J. C., Grilo, C. M., Sanislow,
C. A., . . . Morey, L. C. (2009). The stabil-
ity of personality traits in individuals with
borderline personality disorder. Journal of
Abnormal Psychology, 118(4), 806–815.
https://doi.org/10.1037/a0016954.
Horesh, N., Ratner, S., Laor, N., & Toren, P. (2008).
A comparison of life events in adolescents
with major depression, borderline person-
ality disorder and matched controls: A
pilot study. Psychopathology, 41, 300–306.
https://doi.org/10.1159/000141925
Horesh, N., Sever, J., & Apter, A. (2003). A compari-
son of life events between suicidal adoles-
cents with major depression and borderline
personality disorder. Comprehensive Psychi-
atry, 44, 277–283. https://doi.org/10.1016/
S0010-440X(03)00091-9
Infurna, M. R., Brunner, R., Holz, B., Parzer, P.,
Giannone, F., Reichl, C., . . . Kaess, M.
(2016). The specific role of childhood abuse,
parental bonding, and family functioning in
female adolescents with borderline person-
ality disorder. Journal of Personality Disor-
ders, 30, 177–192. https://doi.org/10.1521/
pedi_2015_29_186
James, A., Berelowitz, M., & Vereker, M. (1996).
Borderline personality disorder: A study in
adolescence. European Child & Adolescent
Psychiatry, 5, 11–17.
Links, P. S., Steiner, M., Offord, D. R., & Eppel, A.
(1988). Characteristics of borderline person-
ality disorder: A Canadian study. Canadian
Journal of Psychiatry, 33, 336–340.
Matzner, F., Silva, R., Silvan, M., Chowdhury, M.,
& Nastari, L. (1997). Preliminary test-retest
reliability of the KID-SCID. Paper presented
at the annual meeting of the American Psy-
chiatric Association.
Morey, L. C., Gunderson, J. G., Quigley, B. D.,
Shea, M. T., Skodol, A. E., McGlashan, T. H.,
. . . Zanarini, M. C. (2002). The representa-
tion of borderline, avoidant, obsessive-com-
pulsive, and schizotypal personality disorders
by the five-factor model. Journal of Personal-
ity Disorders, 16(3), 215–234.
Ogata, S. N., Silk, K. R., Goodrich, S., Lohr, N. E.,
Westen, D., & Hill, E. M. (1990). Childhood
G4884.indd 23
sexual and physical abuse in adult patients
with borderline personality disorder. Amer-
ican Journal of Psychiatry, 147, 1008–
1013. https://doi.org/10.1176/ajp.147.8
.1008
Paris, J., Zweig-Frank, H., & Guzder, J. (1994a).
Psychological risk factors for borderline per-
sonality disorder in female patients. Compre-
hensive Psychiatry, 35, 301–305.
Paris, J., Zweig-Frank, H., & Guzder, J. (1994b).
Risk factors for borderline personality in
male outpatients. Journal of Nervous and
Mental Disease, 182, 375–380.
Pluess, M., & Belsky, J. (2010). Differential suscep-
tibility to parenting and quality child care.
Developmental Psychology, 46, 379–390.
Salzman, J. P., Salzman, C., Wolfson, A. N., Albanese,
M., Looper, J., Ostacher, M., . . . Miyawaki,
E. (1993). Association between borderline
personality structure and history of child-
hood abuse in adult volunteers. Comprehen-
sive Psychiatry, 34, 254–257.
Sharp, C., Ha, C., Michonski, J., Venta, A., & Car-
bone, C. (2012). Borderline personality dis-
order in adolescents: Evidence in support of
the Childhood Interview for DSM-IV Bor-
derline Personality Disorder in a sample of
adolescent inpatients. Comprehensive Psy-
chiatry, 53, 765–774.
Shearer, S. L., Peters, C. P., Quaytman, M. S., &
Ogden, R. L. (1990). Frequency and cor-
relates of childhood sexual and physical
abuse histories in adult female borderline
patients. American Journal of Psychiatry,
147, 214–216.
Skodol, A. E., Bender, D. S., Pagano, M. E., Shea,
M. T., Yen, S., Sanislow, C. A., . . . Gunderson,
J. G. (2007). Positive childhood experiences:
Resilience and recovery from personality dis-
order in early adulthood. Journal of Clinical
Psychiatry, 68, 1102–1108.
Stepp, S. D., Keenan, K., Hipwell, A. E., & Krueger,
R. F. (2014). The impact of childhood temper-
ament on the development of borderline per-
sonality disorder symptoms over the course of
adolescence. Borderline Personality Disorder
and Emotional Dysregulation, 1(1), 18.
Stepp, S., Whalen, D., Scott, L., Zalewski, M.,
Loeber, R., & Hipwell, A. (2014). Recip-
rocal effects of parenting and borderline
personality disorder symptoms in adoles-
cent girls. Development and Psychopathol-
ogy, 26, 361–378. https://doi.org/10.1017/
S0954579413001041
Westen, D., Ludolph, P., Misle, B., Ruffins, S., &
Block, J. (1990). Physical and sexual abuse in
adolescent girls with borderline personality
disorder. American Journal of Orthopsychia-
try, 60, 55–66.
Zanarini, M. C., Gunderson, J. G., Frankenburg,
F. R., & Chauncey, D. L. (1989). The Revised
9/23/2020 12:32:46 PM
 24 ZANARINI ET AL.
Diagnostic Interview for Borderlines: Dis-
criminating BPD from other Axis II disor-
ders. Journal of Personality Disorders, 3,
10–18.
Zanarini, M. C., Gunderson, J. G., Marino, M. F.,
Schwartz, E. O., & Frankenburg, F. R. (1989).
Childhood experiences of borderline patients.
Comprehensive Psychiatry, 30(1), 18–25.
Zanarini, M. C., Temes, C. M., Magni, L. R.,
Fitzmaurice, G. M., Aguirre, B. A., &
Goodman, M. (2017). Prevalence rates of
G4884.indd 24
borderline symptoms reported by adolescent
inpatients with BPD, psychiatrically healthy
adolescents and adult inpatients with BPD.
Personal Mental Health, 11(3), 150–156.
Zanarini, M. C., Williams, A. A., Lewis, R. E., Reich,
R. B., Vera, S. C., Marino, M. F., . . . Fran-
kenburg, F. R. (1997). Reported pathological
childhood experiences associated with the
development of borderline personality dis-
order. American Journal of Psychiatry, 154,
1101–1106.
9/23/2020 12:32:46 PM