Q. My 21-year old daughter who has Down Syndrome, has been diagnosed with BPD by one psychiatrist and had another consulting psychiatrist hesitate to give that diagnosis, though he thought something more than Down Syndrome was going on. A previous psychiatrist thought she had Munchaussen and seemed to think that her problem was quite intractable. For the past two years she has been in and out of psychiatric hospitals due to suicidal threats. Prior to that she would go to hospital emergency rooms saying she had abdominal pain. She has hospital and ambulance bills of over $150,000 over the past year and a half.

In looking at the characteristics of BPD, she seems to have the feelings of emptiness and problems with self image (she has worried, despaired of having Down Syndrome since the age of 6---looks for cures, says she doesn't want to have it anymore). She has developed "crushes" on older men and calls them to the point that they feel stalked, but she does not have the extreme feelings of love and then hate in any of her personal relationships. She had friends at elementary school, but has not had any same-age friends in the years since then. She does not really have mood swings, but may be depressed. She will go along with many activities but does not initiate much, as she did as a younger child. She rarely gets angry. Last year she set three or four trash can fires at her school, saying she needed to get out of the previous home she was living in.

She calls 911 so often that the police are threatening action against her. The agency that supports her is trying to get her to agree to certain procedures to follow if she feels she has to go to the hospital, but with only some success so far. She finds creative ways around the agreements, gets others to call 911 for her. It is difficult, when she threatens suicide, for people to refuse to send the police or ambulance. Many of those around her, for years, have treated these issues as behavior problems that could be handled by a good behavior plan and her cooperation. She is seen by many as manipulative, though charming. Most people like her and comment on how smart she is.

She has been on many, many different medications (it seems that the psychiatrists in the hospitals feel the need to change her medication every time she goes in). She has been on depakene the longest, though I'm not sure it has really done the job of inhibiting her problematic impulses.

Does this sound like BPD to you? Is there information about people with Down Syndrome and BPD and how it might look? Could you refer me to articles that might help those of us supporting her to understand how we might frame an approach to these issues?

A. I am not aware of any BPD-Downs Syndrome articles being out there in print. I have seen something similar once before in my own practice, but the patient's mother would not allow medication usage, so I have no clinical lore to pass on about my case study of one.

There are so many central nervous system changes in Downs patients, that it is hard to say how any medication will work. I would try the standard BPD meds under a good psychiatrists direction and see if they help.