Commentary

Mood swings and BPD


 

References

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. The mood reactivity often is triggered by interpersonal or intrapersonal conflict and rarely is long-lived.

Many children and adolescents are moody and most do not have a major psychiatric disorder. Of those who do, it is a great risk to patients’ health to not consider BPD, especially given new and empirically validated treatments, such as DBT. Astute clinicians should keep this diagnosis in mind when treating adolescents with moodiness, particularly when the mood is predominantly reactive to life’s stressors, when other features of the presentation do not fit neatly into a bipolar picture, and when multiple medications fail. On our unit, we have seen that the cognitive-behavioral strategies of DBT help patients even when BPD is not the diagnosis.

I would like to thank Dr. Kowatch and colleagues for expanding our thinking on mood swings and encourage readers to go one step further.

Blaise Aguirre, MD
Medical Director
Adolescent DBT Residential Program
McLean Hospital
Belmont, MA
Instructor in Psychiatry
Harvard Medical School
Boston, MA

References

1. Zanarini MC, Frankenburg FR, Khera GS, et al. Treatment histories of borderline inpatients. Compr Psychiatry. 2001;42:144-150.

2. Tohen M, Hennen J, Zarate CM Jr, et al. Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry. 2000;157:220-228.

3. Coryell W, Endicott J, Maser JD, et al. The likelihood of recurrence in bipolar affective disorder: the importance of episode recency. J Affect Disord. 1995;33:201-206.

4. De La Fuente JM, Goldman S, Stanus E, et al. Brain glucose metabolism in borderline personality disorder. J Psychiatr Res. 1997;31:531-541.

5. Soloff PH, Meltzer CC, Becker C, et al. Impulsivity and prefrontal hypometabolism in borderline personality disorder. Psychiatry Res. 2003;123:153-163.

6. Juengling FD, Schmahl C, Hesslinger B, et al. Positron emission tomography in female patients with borderline personality disorder. J Psychiatr Res. 2003;37:109-115.

The authors respond

We welcome comments about the importance of a thorough diagnostic evaluation to tease out possible etiologies of “mood swings, “ including psychosocial factors, as in personality disorders. Nevertheless, the debate about diagnosing personality disorders in children and adolescents is not settled. Developmentally, children and adolescents have continuous changes in biology and brain function. There is significantly more empirical evidence of reactive attachment disorders in childhood and adolescence that integrate the affective changes seen in children who live in chaotic environments. DSM defines BPD as a pervasive pattern of instability of interpersonal relationships that begins by early adulthood.1 Many children with diagnoses of posttraumatic stress disorder, mood disorder, bipolar disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, etc. also can have difficulties in relating to others caused by their neurobiologic deficits, which also may limit response to medication. Furthermore, children with learning disorders also can misperceive motives of others and thus have pervasive patterns of relational instability.

Pages

Recommended Reading

Ketamine Infusion Relieves Bipolar Depression Quickly
MDedge Psychiatry
Combo Therapy Best at Averting Bipolar Relapse
MDedge Psychiatry
Risperidone Efficacy Differs in Pediatric Patients
MDedge Psychiatry
Expert: PCOS Risk Makes Valproate the Last Treatment Option for Women With Bipolar
MDedge Psychiatry
Blog: Psychotherapy on the Great White Way
MDedge Psychiatry
Adjunctive Use of Aripiprazole Approved for Bipolar I Disorder
MDedge Psychiatry
Worldwide Bipolar Disorder Prevalence Estimated at 2.4%
MDedge Psychiatry
When is lamotrigine a good choice?
MDedge Psychiatry
Not all mood swings are bipolar disorder
MDedge Psychiatry
What to look for when evaluating mood swings in children and adolescents
MDedge Psychiatry