Medical Literature

Other Common Disorders Associated with Borderline Personality Disorder

Other Common Disorders

by Dr. Leland Heller M.D. – 4/98

The borderline disorder is usually associated with other neuropsychiatric problems. Attention deficit disorder is probably the most common one. Most of these “disorders” are really not illnesses at all, but traits that had advantages in a different time and environment – but they are a serious problem for patients in today’s society and it’s pressures. Successful BPD treatment requires successful treatment of all neuropsych problems:

1) Generalized Anxiety Disorder (GAD):

the body’s “flight or fight” system seems to be on all the time, causing fear related symptoms. One can experience mostly a “thinking” anxiety problem, called the “cognitive component” of the GAD, where the person is unable to sit peacefully with a quiet mind. This diagnoses is almost always the case when medications like Paxil, Prozac and Ritalin cause increased anxiety. Treating this disorder first is often necessary before successfully treating the other diagnoses.

2) Obsessive Compulsive Personality Disorder (OCPD):

like the BPD, it’s a medical problem, not a “character disorder.” In my opinion it is a condition people are born with. The body’s automatic switch that takes over when facing a life and death situation stay’s on all the time, constantly experiencing “life and death” sensations. Symptoms include inappropriate perfectionism, difficulty making decisions, inability to prioritize, and being a pack rat – all because the person feels literally like he/she will die if an error is made.

3) Obsessive Compulsive Disorder (OCD):

an anxiety disorder (and/or symptom) characterized by excessive and intrusive thoughts and ritual behaviors that help the person cope, such as washing hands excessively, repeatedly checking the door, etc. The B vitamin inositol in high doses can be as effective as standard medications.

4) Attention Deficit (Hyperactive) Disorder:

a reduced flow of blood to the brain areas responsible for staying focused on an activity or thought, and/or to think and consider before acting or speaking. Some patients have hyperactivity as well. It appears that the “disorder” does not go away at adulthood. I suspect a high percentage, if not a majority, of untreated or undertreated ADD individuals go on to get the BPD.

5) Rejection sensitivity:

along with dysthymia (rarely depressed, rarely happy – sort of in between) and irritability they compromise a syndrome I call “fractured enjoyment” (not a true medical diagnosis!). These symptoms collectively so far are only treatable with Prozac, and are the main reason Prozac has been so successful.

6) Panic Disorder:

results when the brain incorrectly assumes the individual is being choked to death. This is a true medical problem with a high suicide risk. Experiencing the body’s last ditch effort to avoid being “choked to death” is a terrible sensation, and the victim may live in terror that he/she will experience it again (preanticipatory anxiety).

7) Phobias:

irrational fears that limit the person’s ability to function, even though he/she knows they’re irrational. They are usually treatable medically, and include claustrophobia.

8) Cyclothymia:

is a relatively common mood swing disorder, similar to bipolar but with “mini highs” and “mini lows.”

(Dr. Heller’s book “Biological Unhappiness” explains the biology and treatment of these and other conditions).

Permission by Leland M. Heller, M.D.

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A Possible New Name for BPD”

A POSSIBLE NEW NAME FOR BORDERLINE PERSONALITY DISORDER

Many people would like to change the terminology of the “borderline personality disorder” to a new term that more accurately describes the illness. The term “BPD” in and of itself is as if the whole person (and the personality) is flawed, rather than looking at the BPD as a medical problem it actually is.

The term “borderline personality disorder” implies that there is no hope for treatment as many mental health professionals unfortunately still believe. There is thought that this illness borders on schizophrenia, thus the term “borderline.”

What then is borderline personality disorder? These questions have been posed to Dr. Leland Heller, expert in treating borderline personality disorder.

Q. What do you think about the term “borderline personality disorder”?

A. “I think it’s a horrible, insulting label for a real medical illness. The name alone reduces serious research, stigmatizes victims, and implies the person is crazy. It denies the medical nature of the process, and implies simply a personality problem.”

Q. Do you think “borderline personality disorder” is an accurate description?

A. “No I don’t. It implies a character problem. While I’ve encountered many people with a bad character who had the BPD, most borderlines I’ve treated (over 2100) do not have character problems. “Borderline” means patients live “at the border” between psychosis and reality. When borderlines are well treated medically, psychotic experiences are few and far between – and can be treated well. Borderlines don’t live at that border, they simply go into psychosis too easily under stress.”

Q. What is the BPD?

A. “The BPD is a medical problem, likely a form of epilepsy (brain cells firing inappropriately and out of control). The characteristic symptoms include inappropriate moodiness, chronic anger, emptiness, boredom, dysphoria (anxiety, rage, depression and despair) and psychosis. The other criteria are symptoms related to these medical problems.

ALL neurological disorders can have an effect on the personality, such as Parkinson’s disease which isn’t called the ‘shaking personality disorder.’ ”

Q. What does this term “Dyslimbia” mean?

“ ‘Dys’ means malfunction, and limbia meaning from the limbic system.

‘Dyslimbia’ is malfunction of the limbic system. While other neuropsychiatric disorders involve malfunction of the limbic system, the limbic system dysfunction is profound in the BPD. I chose Dyslimbia for my patients to take the stigma away. The BPD needs a new name, one that emphasizes healing not labeling.

I don’t care if it’s renamed ‘Dyslimbia’ or not, but a more honest, humane, and hopeful name needs to be made for this illness. Patients deserve to get medical attention for ‘Dyslimbia’ (or an equivalent name), rather than have doctors and therapists shun them because they are ‘borderlines.’”

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Medical Treatment of the Borderline Personality Disorder – Biological Unhappiness – Dr. Leland M. Heller


This is the instruction sheet I give to my patients with the Borderline Personality Disorder. It is for information purposes only.

Leland M. Heller, M.D. January 18th, 1998

Medical Treatment of the Borderline Personality Disorder (4069 bytes)

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blubul1a.gif (257 bytes) The Borderline Personality Disorder (BPD) is a devastating neurological illness that causes enormous psychological damage, and usually destroys lives.  The suicide risk is approximately 9%.  The risks of substance abuse, auto and work accidents, divorces, AIDS, child and spousal abuse, and early death are high enough to take this disorder very seriously.  Treatment includes medication, counseling, and “retraining the brain.”  Medication is virtually always needed, and can make a profound difference. blubul1a.gif (257 bytes) SSRI’s: The main symptoms treated by SSRI’s include: mood swings, chronic anger, emptiness, boredom, and depression.  Prozac has been the most thoroughly studied and is very effective.  Alternatives include Paxil and Effexor – choosing these medicines instead of Prozac would be for other illnesses and/or side effects.  Dosage increases usually are effective very quickly, often in one day.  Dosage increases or decreases should not be more often than every week, unless directed to do so by a physician.  Side effects can include shakiness, fatigue, stimulation, insomnia, sleepiness, or nausea. blubul1a.gif (257 bytes) NEUROLEPTICS: Excess production and/or increased sensitivity to the brain chemical “dopamine” seems to be a major cause of rage, anxiety, despair, self-destructive thoughts and impulses, weird body sensations, paranoid thoughts, impulsive behavior and dysphoria (anxiety, rage, depression and despair).  There are many drugs in this class, but Haldol appears to be the best – it works quickly, with minimal side effects and in low doses (generics usually don’t work).  The antihistamine Benadryl will reverse a potential side effect where the muscles go into spasm – notify your physician(s) should this happen.  Long term chronic use, especially in the elderly and/or with high doses, can cause permanent side effects impairing muscle control.  If daily use is needed for a long time, additional medication is likely necessary. blubul1a.gif (257 bytes) Neuroleptics like Haldol should be used whenever anger, stress, paranoia, rage, or self-destructive impulses are present.  They give a BPD patient control over their illness, and can be taken before stressful events to prevent problems.  It is far better to take the medicine when in doubt than suffering the consequences of losing control.  For severe symptoms caused by temporary stress, Risperdal is the strongest and most effective emergency medicine to take as needed, but usually causes profound sleepiness. blubul1a.gif (257 bytes) EPILEPSY DRUGS: The most severe BPD symptoms are likely a form of epilepsy and include “dissociation” (unreality, body parts going numb, deja vu, etc.) and chronic “dysphoria” (anxiety, rage, depression and despair).  When neuroleptics like Haldol are ineffective, epilepsy drugs like Tegretol (carbamazepine), Neurontin, and Depakote can often stop the symptoms in hours.  Depakote (valproic acid) can also control the bipolar disorder.  Blood levels are very important to monitor, as are liver blood tests and blood counts.  Patients who are well educated about the disorder and its treatment can use extra doses when needed, however the risk of side effects (especially grogginess) is increased.

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Is There One Borderline Drug?


Is There One Borderline Drug?

No, however target symptoms are reachable. While in some patients Effexor and Depakote are useful, for most the description by Drs. Coccaro and Karoussi in 1991 remains the most useful in my experience:

Mood instability due to abnormalities in the brain’s adrenergic and cholinergic systems responds to carbamazepine (Tegretol) and lithium.

Transient (temporary) psychotic phenomena due to abnormalities in the central dopaminergic systems responds to low dose neuroleptics (such as low doses of Haldol).

Impulsive, aggressive behavior due to abnormalities in the central serotonergic systems, respond to serotonergic agents (such as Prozac).

Coccaro EF, Kavoussi RJ; “Biological and pharmacological aspects of borderline personality disorder”, Department of Psychiatry Medical College of Pennsylvania, Philadelphia. Hospital Community Psychiatry 1991 Oct;42(10):1029-33

 

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Letter to NIMH Director about the BPD and an international study

Leland M. Heller, M. D.
Okeechobee Family Practice, P. A.
1713 US Hwy 441 N, Suite E
Okeechobee, FL  34972

July 21, 1999

Dr. Steve Hyman
Director, NIMH
10 Center Drive
Bethesda, MD 20892

Re:    BPD and co-morbidity study

Dear Dr. Hyman,

I’m a Family Physician who has taken a great interest in treating borderlines. My first book on the BPD “Life at the Border – Understanding and Recovering from the Borderline Personality Disorder,” is a reference book at NIMH and was placed on their recommended reading list in 1992.

In 1988, I got interested in treating the BPD when I perceived it to be a medical problem and the psychiatrists I referred to refused to treat my patients. I’ve treated thousands of borderlines – diagnosed by strict DSM criteria – and they come from all over the country, sometimes abroad. The numbers are staggering. Unfortunately most academic and administrative people see character disordered people who also have the BPD, and have incorrectly classified the BPD as a character disorder. It’s not. A high percentage are honest, well meaning individuals who are suffering from their neurological problems. Most individuals diagnosed with bipolar have the BPD instead – they’ve never had mania or hypomania, but are diagnosed with bipolar anyway because of the mood lability. Borderlines participate in their self-destructive behaviors because they feel terrible and the behaviors stop the pain, bipolars because they feel great and invincible. It’s a huge difference.

I’m very well read on the subject. I’ve done two studies, one comparing sertraline to fluoxetine on SSRI target symptoms that I’ve observed, run a free weekly support group for patients and their families for 3.5 years, run three 6 week intensive outpatient treatment programs with outstanding results, given hundreds of talks including for physicians and mental health providers, done media and legal work, and I’ve answered nearly a thousand “ask the doctor” questions for a BPD website, along with entering scientific information such as Medline searches, literature showing medication effectiveness, medical articles I’ve written, and the fluoxetine/sertraline study. I’m scheduled to speak in Chicago this November at the APHA meeting. I’ve written a second book, “Biological Unhappiness” that was just released.

I believe the BPD is caused by damage to the brain’s “cornered animal” response. There is considerable information that limbic system dysfunction is the cause and individuals are extremely responsive to the right combination of medications. There’s more data that the BPD is a medical problem than there is for bipolar!

The keys I’ve found to successful BPD treatment are diagnosing and treating all the comorbidities – such as the GAD and attention deficit disorder, and having a formal medication plan for stress.

A telephone study in Iowa revealed 4% of the population admitted to having BPD criteria! That means the numbers are higher than that since a high percentage of those with the BPD wouldn’t admit those things to a stranger over the phone.

This is an important study you are about to do. Our society is in trouble – as the facts below show. The BPD is a major cause and epidemiology is badly needed. I strongly encourage you to add the BPD to your list of diagnoses researched. Thank you.

Sincerely yours,

Leland M. Heller, M.D.


According to the 1997 Youth Risk Behavior Surveillance System (YRBSS – a comprehensive survey of high school student health behaviors which includes data for the nation, 36 states and territories and 17 cities):

10% of our youth reported carrying guns
27% of young people frequently smoke cigarettes
21% are having sexual intercourse before age 13
36% rode in a car with a driver who had been drinking alcohol
Over 7% attempted suicide in the previous year
Over 50% had at least one alcoholic drink in the last month
33.4% had five or more drinks of alcohol on at least one occasion during the past month
26.2% used marijuana during the past month
3.3% used cocaine during the past month
16% used inhalants during their lifetime
73% of all deaths among school-age youth and young adults result from four causes:

a)    motor vehicle crashes
b)    unintentional injuries
c)    homicide
d)    suicide

Update for Previous Primary Care Physician Article

QUESTION:

Dr. Heller,

I found your article for Primary Care Physicians and intend to pass it on to the practitioners who are treating my Borderline Personality Disorder significant others. However, I noted the article is dated Nov 2, 1991. A great deal has happened in 7 years. I wonder if there are updated thoughts, research and information out on managing BPD…..

borderline personality disorder
BPD, risperdal, SSRI, ritalin, depakote

ANSWER:

There’s not a lot of scientific literature on the subject, particularly biologically based, which has been frustrating. A few medical studies have shown that SSRI’s, particularly Prozac, do indeed work for the BPD, although except for my small study on Prozac vs. Zoloft, the exact target symptoms haven’t been addressed.

There has been a study showing Depakote reduced hostility in BPD victims, however a study in 1991 showed that Tegretol was better and safer than Depakote for complex partial seizures, which many of us believe are part of the BPD.

Since I believe the BPD is correlated with glial cell malfunction, the discovery in the last two years that Prozac improves glial cell function is very exciting, and may partially explain why Prozac is so superior for BPD symptoms.

The “comorbidity” of panic disorder with the BPD and the ability of Paxil to work for the panic disorder has been a great find. Paxil, to me, works best for borderlines also experiencing panic – and the combination untreated has a 25% suicide rate. Many of my combined panic and BPD patients take both Paxil for the panic and Prozac for rejection sensitivity and the SSRI BPD target symptoms – moodiness, chronic anger, emptiness and boredom.

The most frustrating change has been the loss of brand name Haldol. Haloperidol is now only available generically, and it doesn’t work as well. It does work as well when the dose is high enough, but that makes it expensive and less predictable. In general where the brand name used to work at 0.5mg, the generic usually required 1-2mg to get the same effect.

To me the most exciting changes in the past 8 years has been the recognition of ADD as strongly associated with the BPD and the release of Risperdal. I believe as many as half of BPD victims had and continue to have ADD with their BPD. Risperdal is a powerful antipsychotic that works on more than the dopamine system, and can stop virtually all borderline dysphoria, suicidality and psychosis, although usually Prozac and Tegretol have to be in the system at the same time to get an excellent result. High doses are generally needed to accomplish this, and side effects are a problem at these high doses. Sedation (sleepiness) can be impressive, and can render some individuals nonfunctional for a few days. When in a crisis, however, grogginess is not as important as preventing a disaster. Zyprexa is a fair alternative.

In my work I’ve discovered the incredible importance of diagnosing and treating the other disorders commonly associated with the BPD – particularly panic, GAD, OCPD, OCD, ADD, and dysthymia. Very exciting for me as well is my observation that in the last 2 years every patient who felt hyper on Prozac also had the cognitive GAD – generalized anxiety disorder. The GAD appears to be due to an abnormally high serotonin at serotonin receptor site #2, which is aggravated by the SSRI class, particularly Prozac. Buspar works effectively for almost everyone who needs it to bring this down and make it possible for higher doses of Prozac to be used when necessary, and/or to add psychostimulants like Ritalin for ADD. Everything wrong has to be effectively treated for a borderline to successfully recover.

Permission by Leland M. Heller, M.D.