Medical Literature

Is This the Right Combination for my Daughter?

QUESTION:

Hi Dr. Heller,

My daughter is 20 and currently in the state mental hospital. She has recently been diagnosed with depression with psychotic features and borderline personality disorder. They have her on 1000mg. Depakote and 30 mg. Paxil.

She is like a zombie and they just keep telling her to “relearn new skills”. She can’t function and sleeps most of the day. She then misses out on her groups and then loses her privileges. She has had many different diagnoses throughout her life, from ADHD to Bi-Polar. Do you think this med. combo is the wrong one and how long should the Dr. wait before changing it?

Thank You.

 

ANSWER:

If she is “like a zombie” and not doing well, the medication regimen isn’t a good one. Blood levels of medications are far more important than the actual dose. I consider Depakote and Paxil secondary medications for the BPD.  They can be effective, but they’re not the best for most patients.

The most important issue here is what exactly her diagnoses are. I doubt if only one diagnosis is present. There are a number of diagnoses that need to be addressed. BPD, bipolar, and ADHD are just a few. The screening test, official criteria, and “Is it bipolar, BPD or ADHD” will undoubtedly be useful to you.

I can’t understate the importance of making all the diagnoses. The generalized anxiety disorder is particularly important. I have a few adolescents who are extraordinarily difficult to manage, and my heart goes out to you, the child, and the dedicated people trying desperately to succeed with her. I encourage you to get as much information as you can.

Drs. & Therapists Who Treat BPD’s

There are many locations to find the names of individuals treating those with the borderline disorder. The National Institute of Mental Health has one, the website BPD Central has one, and the BPD Sanctuary has one.

The biggest problems are that many don’t believe the BPD is a medical problem, that many believe psychoanalysis is the best option, that most don’t believe in making all the diagnoses and treating them comprehensively, and that most do not prescribe medications as needed.  I would be thrilled to hear of any like minded physicians/therapists who would like me to include their names and information on a list of mine, and/or have a professional dialogue.

Can a Psychiatrist Have the BPD?

    Can a Psychiatrist Have the BPD?

    QUESTION:

    Dr. Heller,

    Have you ever heard of a Psychiatrist being borderline?? I have had a 7 year relationship with this man. I am 52, he is 61 and both have had previous marriages. I have done extensive reading and am convinced that he is afflicted with this problem.

    When our relationship is on track, everyone we know envies us and considers us to be the perfect couple- true soul mates. About 7 times, perhaps a few more- he would rage at me for the most ridiculous reasons (actually no reason) and become so verbally abusive that once he even called the local police to have me removed from his clinic while I was trying to talk some sense into him about his accusations. Unlike a normal relationship where the two parties can have a dialogue, his rages are strictly a monologue.

    Two weeks prior to the final rage, we were out of town at a family wedding (his side of the family) and he sang my praises – telling of how I was the most important person in the world to him – to his family and telling me in private that he was afraid that I was going to leave him for a younger man. A couple of days after Xmas, I found out through other means that he was lying to me about who we were spending New Year’s Eve with and because I am by nature a pacifist and because I am afraid to put him into a rage – I very gingerly approached the subject – like – is there something that you are uncomfortable about that perhaps we should talk about?? He screamed that he never wanted to see me again and he was tired of my “splitting.” From that moment on, I figured that he must know that he is borderline.

    Under the circumstances of his being a health professional, do you think that he knows what is going on here?? Do borderlines ever have remorse or fond memories of their significant other?? Do they ever try to make amends? He is incapable of saying that he is sorry. I did get a CD of love songs placed in my mailbox which I know came from him. I ignored it.

    Also, Dr., I have one more question. Do borderlines have a particularly difficult time with control and their children. The man in question has two adult adopted children whom he will not let out of his control. The boy and his wife even live with him – for no apparent reason – especially not financial. We are both attending the wedding of a friend’s daughter and I am really fearful about what to expect. To this point, he has come into my business and will not acknowledge that I am alive. I don’t know if I should ignore him, be civil. I don’t know what to do.

    Thanks so much for listening.

     

    ANSWER:

    1) There is no reason an individual with the BPD can’t be found in any profession. I have treated many in the mental health professions for the BPD. Whether it’s appropriate for the individual to be functioning in a profession depends upon the individual’s perception of stress and therefore their ability to handle it. Studies show that untreated borderlines tend to do well in employment situations over time – particularly if they are smart and have financial resources.

    2) He may or may not be aware of what’s happening. If he perceives the BPD is a death sentence, that it only fits self-mutilators, and that it can’t afflict doctors or other mental health professionals then it’s unlikely he’d recognize the disorder in himself. They can try to make amends, and it appears the love song CD was an example, although many people are extremely afraid of admitting a mistake or of being wrong.

    3) Borderlines often have remorse and fond memories, but it depends upon what psychotic interpretations developed. If he/she believes someone truly behaved terribly, he/she will treat that individual with contempt subsequently whether that person is “guilty” or not.

    4) The usual situation is problems with children. Control issues are common, and misinterpretation issues are extremely common. It’s rarely due to lack of good intentions. There’s a high likelihood that behaviors begun when they were small children will continue as adults, although it’s highly variable.

    5) I can’t make any specific recommendations about what you should do, but there is a question I often ask my patients: “If your child was in your exact position, what would you recommend?” It’s usually smart to take your own advice.

 

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I’m Driving Others Crazy

QUESTION:

Doctor Heller-

My wife firmly believes that I have BPD after reading the information in your web page. I am not so sure. Based on your screening test I have some symptoms from several sections, but seem to fall into ADD more than the rest. I am moody, have a lack of joy, am a pack rat as far as tools, nuts and bolts, anything that could be used to fix something is involved. I quit drinking almost 20 years ago. I mention that because when I drank I did have the highs and lows, but since then I have had mostly “neutral” feelings, but I do have some depression that seems to work in about a 3 month cycle. I take B complex for the depression, and it does help.. I used to get feelings of doom, but haven’t had that in 6 or 7 years. I have to always be doing something, my mind is always working, am good at coming up with plans for business and stink at execution, I get lost in the details. On the DISC personality test I score High D/ High I. I also seem to drive everyone else “crazy”. I am 49 and have been this way all of my life. I guess I’m at the age where it’s wearing me out too. I hope that I have given you enough detail to form some opinion. Thanks for your web page–it’s very informative.

 

ANSWER:

You might have the OCPD and the GAD as well. You may be thinking you have to “choose” which diagnosis you have, like a multiple choice question. It doesn’t work that way. The criteria for many disorders can be found on this Website, and my new book “Biological Unhappiness” goes into them at length, including why they happen and how they can be treated. You may have a thyroid or B12 problem as well, which can be checked with a simple blood test – and is often not performed as part of routine labwork. . You can have a terrific life, successful in every area. You have to get all the diagnoses comprehensively treated and retrain the brain. I’m sure this Website will be of help to you in this regard. There is no question that being vitamin deficient causes problems. I will shortly have a section on this Website on what you can do to be healthy.

Can Doxepin Make You Agitated?

QUESTION:

Dear Dr. Heller,

My PCP just prescribed Doxepin to control itching.  I swear that it made me extremely agitated.  I had been agitated for two days and I had started it two days prior.  When I stopped it, I found I was not agitated at all the next day.  Then I took it again one night and I became extremely agitated the next day.  Do you think there might be a connection?  I am afraid to take it (he prescribed 30 with 3 refills) and I stopped itching (probably a food allergy, but PCP thought I was allergic to Wellbutrin as I had started it two weeks prior to the itching and couldn’t think of any strange foods I ate).  But if itching comes back I am afraid to take it.  What should I do?  The Doxepin is taken one at night and then two Allegra in daytime (but I was only taking the Doxepin after the 1st day).

 

ANSWER:

Doxepin (Sinequan) and Elavil (amitryptilline) are very similar tricyclic antidepressants.  A study published in 1986 showed that Elavil made borderlines paranoid, aggressive, and agitated (Garbutt, J; George, A: “Paradoxical Effects of Amitriptyline on Borderline Patients.” Am J Psychiatry 143:12 December 1986). I’ve had many patients tell me the same thing.  There are many other antidepressants that can be taken instead.

What Can Be Done For My Mood Swings?

    What Can Be Done For My Mood Swings?

    QUESTION:

    Dear Dr. Heller,

    I am 49 years old, physically healthy, educated, and have a wonderful spouse and stepchild along with children of my own.  My spouse and I recently gave up the corporate life to start our own business because we wanted more flexibility and to have more control of our future.  We both were victims of corporate down-sizing.  Together we have a great opportunity for success.  However, I seem to be unable to clearly address the normal everyday stresses, and experience wide mood swings.

    I read your description of BPD and it struck a nerve.  I could have written the description of symptoms if I was asked to explain how I feel.  Things have gotten so out of kilter at home and in our office that it has been suggested that I am not capable of handling the situation.  Some of it comes from me.  The rest from my spouse and our co-workers.  It is obvious to me that there is a problem that I am not being able to correct using normal stress reducing activities and self control exercises.

    Early in my life, I tried to use antidepressants without success.  The side effects were worse than the condition for which they were prescribed.  But that was many years ago and we now have more information and better treatments, not to mention a huge array of new medications.  I began taking St Johns Wort last year and it seemed to help stabilize the slight mood swings but it did not eliminate them.  I stopped using it about six months ago when I began to develop sensitivity to sunlight.  I found it difficult to be outdoors without getting rashes on exposed skin.  Therefore, I discontinued use.  Since then, with the added stress of moving, starting a new business, and the usual day to day activities, I am at a point where I can’t relax and constantly feel agitated, overly sensitive, and rejected.  I sometimes search for out of the way places to just be alone so I won’t feel so uptight.  Can you comment?  I have too much to lose if I don’t find a way to get control of the emotional roller coaster that I feel I am on.

    By the way, thanks for the website!?

     

    ANSWER:

    I suspect the stress of starting your own business has triggered the BPD symptoms to worsen.  To me, Prozac is clearly the best medication for the BPD – stopping the inappropriate mood swings, chronic anger, emptiness, and boredom.  http://pks.947.myftpupload.com/20a.htm explains the symptoms I try to treat medically.  If Prozac causes agitation or increased anxiety, the generalized anxiety disorder may need to be treated first, with BuSpar.  http://pks.947.myftpupload.com/AskDoc/First-Do.htm will also give you information that you need to get started.

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