Comments and Controversies
Mood swings and BPD
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
Adolescent DBT Residential Program
Instructor in Psychiatry
Harvard Medical School
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.
The research Dr. Aguirre suggested is based on treatment histories and not rigorous study methodology. Most empirical evidence of personality disorders is strongly influenced by psychoanalytic literature regarding object relations, which is in flux because of emerging attention to attachment theory and progress in neurologic studies in the evaluation of temperamental variations related to the influence of mirror neurons.2
We also take issue with the comment that “BPD has a better prognosis than other serious men tal illn esses, such as bipolar disorder” There have been significant efforts in studying the role family can have in the outcomes of mood disorder treatment.3
Finally, there is evidence that in adults medication can be beneficial in treating the affective deregulation of patients with BPD who do not have comorbid disorders.4
Robert A. Kowatch, MD, PhD
Professor of Psychiatry and Pediatrics
Erin Monroe, CNS
Clinical Nurse Specialist
Division of Psychiatry
Sergio V. Delgado, MD
Associate Professor of Psychiatry
Cincinnati Children’s Hospital Medical Center
1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.
2. Zald DH, Cowan RL, Riccardi P, et al. Midbrain dopamine receptor availability is inversely associated with novelty-seeking traits in humans. J Neurosci. 2008;28(53):14372-14378.
3. Miklowitz DJ, Axelson DA, Birmaher B, et al. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry. 2008;65(9):1053-1061.
4. Stoffers J, VÖllum BA, RÜcker G, et al. Pharmacological interventions for borderline personality disorder. Cochrane Database Syst Rev. 2010;16:CD005653.-