ADOLESCENT MENTAL HEALTH DIAGNOSIS BIPOLAR DISORDER OR BORDERLINE PERSONALITY TRAITS ?

There is a fair amount of confusion among lay people about the difference between these two particular disorders in teenagers. In addition to having names that sound similar, they both involve a fair amount of emotional disregulation. However, they are quite different. Bipolar Disorder is a biological disorder comprised of periods of depression, mania, and normalcy. It requires medication to manage it over the course of one’s lifetime. Borderline Personality Disorder is a complex of traits or tendencies that are dysfunctional and problematic, creating difficulty in many areas life. While it may be helped by medication, medication is not required. Talk therapy, particularly DBT (Dialectical Behavioral Therapy) that focuses on learning a set of coping skills to assist with regulating mood and behavior, is the treatment of choice. In addition, teenagers with Borderline Personality traits or tendencies, tend to get somewhat better just with age and maturity, even without treatment. However with treatment, they can overcome the disorder. With both Bipolar Disorder and Borderline Personality Disorder, education about the disorder as well as how to manage it is extremely helpful.

One of the diagnostic criteria for Borderline Personality Disorder, and all of the personality disorders in fact, is that it cannot be diagnosed until it has exhibited itself for a number of years. For that reason, most clinicians wait until an adolescent is eighteen or older to make this diagnosis. However, if someone under eighteen has clearly exhibited the symptoms for a number of years prior to the age of eighteen, the diagnosis can be given.

Diagnosis for Bipolar Disorder is often difficult, because no one ever sees the entire disorder at any given time. Since it involves longer episodes of depression or mania and often periods of normalcy in between, a person with Bipolar Disorder is sometimes misdiagnosed with having a Major Depression instead. For that reason, it is important to get a thorough history of the teenager’s symptomology including any earlier periods of depression or mania. It is also important to look at family history since Bipolar Disorder has a genetic component to it. One reason it is important to have a more accurate understanding of whether a person is experiencing a Major Depressive Disorder or a Depressive Episode within a Bipolar Disorder, is the fact that an anti-depressant medication alone can trigger a manic episode in someone that has Bipolar Disorder. If someone has a history of Bipolar Disorder in their family and are experiencing a Major Depression, it would be important for them to have a mood stabilizer in addition to an anti-depressant medication to avoid the possibility of triggering a manic episode.







According to the DSM-IV TR (Diagnostic and Statistical Manual for Mental Disorders) the criteria for the depressive and manic episodes of Bipolar Disorder are:

Major Depressive Episode:

1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In child and adolescents, can be irritable mood.
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4) Insomnia or hypersomnia nearly every day.
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6) Fatigue or loss of energy nearly every day.
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Manic Episode:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood, lasting at least one week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have been present
to a significant degree:

1) Inflated self-esteem or grandiosity
2) Decreased need for sleep (e.g., feels rested after only three hours of sleep).
3) More talkative than usual or pressure to keep talking.
4) Flight of ideas or subjective experience that thoughts are racing.
5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
7) Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The symptoms do not meet criteria for a Mixed Episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment(e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.


According to the DSM-IV the criteria for Borderline Personality Traits are:
1) Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3) Identity disturbance: markedly and persistently unstable self-image or sense of self.
4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).
7) Chronic feelings of emptiness.
8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9) Transient, stress-related paranoid ideation or severe dissociative symptoms.

The Dialectical Behavior Therapy (DBT) group.

The Dialectical Behavior Therapy (DBT) group at Sorenson’s Ranch School has been busy. Students recently finished the interpersonal relationship section and have been demonstrating skills to assist them in being compliant and less defiant in their relationships with others. Skills included learning direct ways to communicate and to listen to others in communication, as well as learning to problem solve and negotiate.
Students in the DBT group are currently on the Emotion Regulation Unit. In this unit students learn about how their emotions are experienced and influence their behavior. For the past three weeks students have been learning about different emotions and how they are experienced. Students have participated in small group activities in which they have been able to role play different emotions and use specific emotion words to describe their emotions instead of using broad categories of happy, sad, and depressed.
During the Emotion Regulation Unit students will be learning how to reduce vulnerability to negative emotions by learning techniques to stay out of the emotional mind. These techniques are basic, but powerful and include taking care of oneself by treating physical illness, balancing their eating, avoiding mood altering drugs, balancing sleep, getting proper exercise and building mastery. Building mastery is a skill that helps students to gain control through developing new skills and talents as well as strengthening their abilities.
Students have been completing homework assignments, which are designed to assist them in learning to identify and express their emotions appropriately as well as learning to identify the aftereffects and functions of their emotions.
Learning to identify emotions and understand the ways emotions are experienced and the impact they play in the individuals life are key in students learning to handle behavior problems including defiance, conduct disorder as well as being able to understand and work through issues of depression and other mood disorders.
For parents who have students in DBT group be sure to ask your student about the skills they are learning and using, and how these skills are helping them to reach their treatment plan goals.

Changing Negative Thought Patterns

Sorenson’s Ranch School helps troubled teens learn how to change negative thought patterns. We all have that little voice inside our heads that attempts to hold us back through the use of self-despairing statements. Whether the statements are about our looks, abilities, or the core of who we are, these statements become part of who we are and keeps us from becoming who we can be. These negative self-talk statements are worse for people who have depression and for those with low self-esteem, because these statements keep the person trapped and do not allow them to move forward easily.
Replacing negative thought patterns is addressed through the use of the DBT (Dialectical Behavior Therapy) and in individual therapy. The Sorenson’s Ranch School DBT group addresses identifying negative thought patterns by introducing the idea of cognitive myths and teaching the students to challenge these myths that they say to themselves. An example of a myth that students learn to challenge is: “It will kill me if he does not talk to me.” A possible challenge is: “I won’t like it, but I will move on if he does not talk to me.” Other myths include, “It does not matter; I don’t really care.” This one is generally used to avoid sharing feelings and managing emotions. Many students challenge this one with “I really do care and this is why.” Students are then taught to identify their own myths and challenge these and use these challenges every time that myth comes to mind. They practice replacing that thought with the challenge.
The next step in the Sorenson’s Ranch School DBT group is to learn about cheerleading statements. Students are taught to make their own cheerleading statements to give themselves encouragement and to empower themselves. These statements are particularly helpful for overcoming fears and helping the student to feel better about their self and to build upon their strengths.
Learning to change negative thought patterns is a very powerful tool in learning to feel better about oneself and in turn change behaviors. Remember our thoughts are directly related to our behaviors.

Distress Tolerance Skills

Sorenson’s Ranch School’s behavior modification program offers students many opportunities to engage in basic fun, entertaining, and educational activities as they learn to change and manage their behaviors. All of these activities have a purpose in assisting teenagers in managing their behaviors. Managing their behavior is a skill they can learn with help from dedicated therapists and staff.
Sorenson’s Ranch School facilitates a skills group entitled Dialectical Behavior Therapy (DBT) developed by Marsha Linehan. The DBT group focuses on teaching skills to assist with developing Core Mindfulness, Interpersonal Relationships, Emotion Regulation, and Distress Tolerance. The majority of students at Sorenson’s Ranch School have difficulty in at least one of these areas; therefore, learning the DBT skills can be an important part of their therapy.
Distress Tolerance Skills are skills for tolerating painful events and emotions when you cannot make things better right away. Distress Tolerance Skills were developed to assist individuals who have a difficult time managing their emotions in handling situations that they cannot fix quickly, including: death of a loved one, intruding thoughts of a trauma, getting along with others, and tolerating a situation in which they are not getting their way. Many of the students at Sorenson’s Ranch school have difficulty managing their emotions, and are impulsive and defiant. The DBT Distress Tolerance skills are designed to help students manage life changing events and daily stress.
The Distress Tolerance skills focus on teaching students crisis survival strategies through learning distracting skills, which include joining in activities and contributing to others through service. Sorenson’s Ranch School provides daily activities for students to use these Distress Tolerance skills. A few of the activities include educational fieldtrips, campouts, cookouts, fishing, boating, fun games such as capture the flag, organized sports, and service projects on campus and in the community. These activities are designed to teach social skills, help them learn to have fun while sober, and offer the opportunity to leave one’s worries and problems behind for the moment, until they can be appropriately worked through.
What might look like just a fun, time-consuming activity for your student is really a well thought-out and planned activity that has a purpose in teaching your student lifelong skills to manage their behaviors and emotions. If you would like to learn more about the DBT Distress Tolerance Skills be sure to ask your teenager’s therapist.
Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderlines Personality Disorder. N.Y.: The Guilford Press.