Mood Swings and BPD

Article excerpt

I thought Dr. Kowatch and colleagues took an important first step in pointing out that not all mood swings in children and adolescents are symptoms of bipolar disorder ("Not all mood swings are bipolar disorder," Current Psychiatry, February 2011, p. 38-52). They reviewed some of the other psychiatric conditions known to cause labile moods. One glaring omission is borderline personality disorder (BPD). I am the medical director of a specialized unit that uses dialectical behavioral therapy (DBT) to treat children and adolescents with BPD. We have treated approximately 300 young women on the residential unit and many present similarly: multiple hospitalizations, multiple robust yet failed medication trials, severe and recurrent self-injury suicide attempts, and a large degree of hopelessness. Most arrive with previous diagnoses of mood disorder not otherwise specified, bipolar disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, and others. It is when their outpatient psychiatrists and mental health teams have grown frustrated at the lack of enduring progress and are faced with the treatment demands of the borderline patient that a BPD diagnosis is considered. Even though research suggests that BPD--or at least some of its symptoms--begins in the late latency period of childhood, (1) treatment typically is not sought until late adolescence. This is the case despite the fact that BPD has a better prognosis than other serious mental illnesses, such as bipolar disorder. (2), (3) Adult BPD patients almost universally recognize that their inability to regulate their mood started in late childhood and early adolescence. Structural and functional neuroimaging has revealed a dysfunctional network of brain regions that seem to mediate important aspects of BPD symptomatology. (4-6)

These children have marked mood swings and great difficulty regulating their moods. The mood swings of BPD are not responsive to current medication unless there is comorbid bipolar disorder, in which case treatment with mood stabilizers helps improve vegetative symptoms such as sleep and energy; and reduce racing thoughts, pressured speech, and irritability. What these medications do not treat is the "reactive" mood swings that are characteristic of BPD. …