Medical Literature

BPD, ADD & Combining Medications

QUESTION:

Hello,

I have several questions: I am suffering from both ADD and BPD, and whether the BPD came as a result of the untreated ADD is not known. There definitely is a genetic predisposition considering my parents. As a child I experienced a lot of trauma due to my impulsive & disruptive behavior, and also lost my parents at an early age. Emotional training was definitely lacking. I am now 27 and trying to get my life in order. I am very determined, as my inner life is complete hell. . I have recently started taking Prozac, and am scouting for a specialist in BPD/ADD to discuss medical and psychological treatment. Before starting Prozac I was on BuSpar for anxiety (for 8 weeks). The BuSpar was stopped now. Can BuSpar be taken with Prozac? What about one of BuSpar’s side-effects – nightmares? At the moment I am suffering from disturbing dreamscapes, something which started 4 months ago when I moved countries. It seems that my whole past and life issue that I have never been aware of or dealt with are coming up with an incredible force. You advise Tegretol at night. What dosage? will it makes me drowsy the next day? Do the dreamscapes eventually subside and I can stop taking Tegretol, or is Tegretol merely a prevention? As for the trouble with ADD: I have had considerable success with combining Piracetam with Choline (1800mg/500mg three times a day) to help with concentration, though this does not calm me. Would this be safe to take with Prozac? Also, I have tried taking Ritalin before I took Prozac, found the concentration and calming effect very beneficial, but the up/downs were too drastic and I stopped. Apparently combining Prozac with Ritalin has been successful in a lot of patients, but how will this affect the BPD? I am especially concerned about the dopamine issue, as this seems to be related to the minipsychosis one experiences. I can’t seem to figure out though whether it is a lack of dopamine or an increase of dopamine that cause psychosis and severe dysphoria. Getting up in the mornings is a painful experience, but I seem to be able to face the world a bit more and have less disruptive thought patterns after a strong cup of coffee…

Thank you for your time.

 

ANSWER:

1) BuSpar can absolutely be taken with Prozac, although some patients need to take BuSpar for a while first before they can take Prozac or they may experience severe temporary anxiety from the Prozac.

2) I’ve never encountered anyone getting nightmares just from BuSpar, although clearly those with a severe GAD (generalized anxiety disorder) problem will get increased anxiety in the early stages of taking BuSpar. This can worsen anxiety related dreams. This is one of the few situations that benzodiazepines are indicated, particularly temporarily to stop those nightmares.

3) If the individual has the BPD, Tegretol at night after being on Prozac for a week is often very effective without causing morning grogginess. Sometimes individuals need to take the medication early in the evening, or at a lower dose, to prevent grogginess.

4) Sometimes the nightmares end, sometimes they continue, sometimes they worsen. It’s hard to predict. Retraining the brain makes a huge difference. By lowering the perception of stress, the individual has less of a stress induced dysphoria and/or nightmares. It’s both a treatment and prevention in the right individual.

5) I don’t know about Piracatem. If it’s a benzodiazepine like Valium, there is no problem taking it with Prozac. Choline is fine, and I take it myself because of literature that it may prevent age related memory loss. I don’t know of any significant short term benefits. Prozac can safely be taken with virtually every medication.

6) The comorbidities are crucial. One small study on bulimics with BPD showed they did better with Ritalin. I don’t believe Ritalin should be used to treat the BPD. It has a miraculous effect on borderlines who also have comorbid ADD. Since borderlines can’t trust their feelings, they need to depend on their thinking abilities. With ADD, they lose the ability to think before acting or speaking. This impulsivity gets borderlines into trouble. Ritalin can trigger BPD dysphoria in those who have the generalized anxiety disorder untreated.

7) It’s not clearly understood yet whether it’s a dopamine increase or increased sensitivity to dopamine that causes the problem, but it’s not a deficiency state. Additionally, I don’t believe that it’s a neurotransmitter problem, but a brain process that’s abnormal. Dopamine is responsible for many, many things including motor control (control of the body).

8) The strong cup of coffee is likely an attempt to treat ADD. I strongly recommend you do the screening test and see what diagnoses fit you. It’s more common to have many diagnoses rather than just one. Treating them all is crucial.

Any Suggestions for Closure With My Mother?

QUESTION:

Dear Dr. Heller–

I have written you several times over three years ago. Your insight and guidance has been very valuable to me in dealing with BPD issues with my mother. Since then, I have kept current with the literature on BPD and have done extensive research on my mother’s illness. Having some professional experience in mental health issues (I am a pediatric dentist) it has been most helpful in understanding my mother’s plight, and understanding my role within my own family’s dynamics.

After almost 8 years of no communication with my family, my father telephones to inform me that my BPD mom is in end stage renal failure secondary to polycystic kidney disease. Without a transplant, my mom will not survive. To my knowledge, my mom’s BPD has still not been formally diagnosed. One large problem is that my mom self-medicates. Her physicians should know about this, as this problem may affect the outcome of a potential transplant. My father is a physician and will not disclose any of this to her caregivers. Since I am one who “triggers” my mother’s rages, my input is not welcome.

After several telephone calls and dialysis sessions, my mom appears to feel better, and again has become verbally abusive, blaming me for the expense of 5 years of her psychologic therapy, and not being compassionate about her illness! These conversations were in the form of questions on my part about my mom. I was glad she was finally getting help. I politely ended the conversation, and have not spoken to her since. It is obvious, due to my mother’s condition, some closure must be brought to this relationship, however I am not willing to do this in a setting, where I will be verbally abused by both parents. I have offered to provide a mediator to establish a dialogue, however my parents have declined, and continue blaming me for the severed relationship.

Any suggestions?

 

ANSWER:

It doesn’t appear you will get closure with her, you may have to do it yourself. The book “Toxic Parents” by Susan Forward may be of help to you. It may be of help to you to genuinely recognize that she’s very ill, and it affects how she sees things – no different than if she was in a coma. If you’re powerless to make things better, and dealing with the situation in person makes everyone worse, it may be in your best interests to stay away and make peace in your heart instead of in person.

Many children don’t have the opportunity for a prolonged parental dying process to enable them to make peace, and have to make peace without the parent present. One area where many individuals like you have problems is with the commandment “Thou shalt honor thy father and thy mother.” Honoring a toxic parent can be very difficult. You can honor her in an important way, however. Imagine that a magic pill became available that made her totally and completely mentally well. You need to be the kind of person she would then be immensely proud of. In other words, you can honor your toxic parent by being the kind of person he/she would be proud of if he/she were able to see things clearly and rationally. Sometimes this comfort is all you can get.

Can You Help My Chest Pain After Surgery (from Sweden)?

    Can You Help My Chest Pain After Surgery (from Sweden)?

    QUESTION:

    Hi!

    I suffer from something bad. It affects my life to 100%. I can not work today. It may have to do with an operation I had. I suffered from blushing and had ETS {ETS=endoskopic thoracic sympthomatic} (ganglion T1, T2 and T3) done. Blushing got 90% better.

    Some months later I felt this strange feeling in neck. As soon I was gonna do something demanding, study or something else, I felt the feeling coming. Today I can have it all day. I feel best on mornings. When I sit and write this I have this heavy feeling in neck. The more I stress the deeper it gets and eventually hurts badly. I simply don’t manage anything. It could be globus hystericus but I don’t think so. When I drink or eat I don’t feel it at all. (when food/liquid is passing gullet).

    It can begin when I have some heavy thought. I would say it is some sort of depression? I was a top student before and would like to go on study but this ruins everything. My thoughts about this is that the ETS have changed the way I react on stress from increased heartbeats to this horrible feelings.

    What do you think?

    Medications now: Edronax (noradrenaline/norepinephrine) helps not. BuSpar helped greatly against my anxiety I’m also on Levaxin (thyroid hormone)

     

    ANSWER:

    You likely had nerve damage that’s greatly affected by your mood state. RSD (reflex sympathetic dystrophy) may be present. BuSpar working implies that the generalized anxiety disorder may be present. The key for you is obvious – you need all your diagnoses made and comprehensively treated.

    The screening test I use for my patients may be useful in this regard. Epilepsy medications such as Tegretol (carbamazepine) and Neurontin (gabapentin) can be particularly useful for individuals with your problems.

Separator (Biological Unhappiness

 

2000 March Questions

 

Ask the Doctor

 

Is Adderall With Risperdal Safe In Children?

QUESTION:

Dr. Heller,

What if an eight year child was on Risperdal and Adderall, is that a common combination?  What side effects are to be expected?  And what have the results of studies (if any) shown?  Thank you.

 

ANSWER:

It appears to be a safe combination, especially compared to the risks of out of control behavior.  The key issue is always risks versus the benefits. Risperdal has been studied with many other medications and rarely has had problems.  I’m not aware of any specific studies with Risperdal and Adderall together.

Is It A Phase Or Is Something Wrong?

QUESTION:

Dear Dr. Heller,

I was wondering if you could assist me with a situation.  I am a fourth grade teacher.  One of my students has recently been going through some changes.  I just say, “It’s probably just a phase.” But his mother is quite concerned.  She calls me often, and I do not know the answers to her questions.  She asks me, “What is wrong with my boy?”, and I do not know.  He is a loveable boy.  Recently he has been lying at home and at school a little.  He said a swear word and then insists that he did not.  This kind of thing is going on at his home also.  He does something that is unlike him or inappropriate, and then he denies the actions.  Also he has been very quiet with his classmates.  His handwriting is getting sloppier and sloppier.  His grades are declining fast, and he was an A/B student.  Also, over the weekend, he ripped out half of his eyebrow.  What could this be?  Nerves?  A phase?  Please e-mail me with any conclusions or thoughts.

Thank you.

 

ANSWER:

Ripping out half of one’s eyebrow is not a phase.  The most likely diagnosis is childhood onset bipolar disorder.  http://pks.947.myftpupload.com/BiPlrKid.htm shows the questions I ask when trying to make a diagnosis.  The book “The Bipolar Child” by Dr. Papolos is invaluable. There may be other diagnoses going on, but childhood onset bipolar is the most concerning possibility.

How Could it Not be a Character Disorder?

QUESTION:

Dr. Heller, I think you’re full of it to say borderline isn’t a character disorder. I’ve been emotionally and physically abused by my ex-wife who was a flaming borderline. She has lied about me to my friends, in court and my kids. My kids won’t have anything to do with me and all I’ve done is try to help. The courts always take her side, and won’t listen. Why is it like that and how can you possibly say being borderline isn’t being bad character?

 

ANSWER:

I know too many wonderful human beings with the BPD to believe it’s a character disorder. When you combine character problems with the BPD, however, bad things do happen.

What individuals believe while psychotic seems as real as reality. There is an air of believability about them, particularly in court. This is especially true when alleging abuse – since the individual with BPD believes so passionately what they misinterpreted while dysphoric. They can also behave in ways that make their fears seem true, like a self-fulfilling prophecy. It’s the “cornered animal” response that’s broken, and things interpreted while the body experiences terror are unlikely to be objective and accurate.

I repeatedly tell my BPD patients that they absolutely cannot trust their bad interpretations or memories. While they may be valid, they also may not be. Sometimes negative interpretations need to be evaluated by an objective observer, such as a therapist or clergy. A sign that an individual with the BPD has good character is how they deal with this issue. If they discard good friends and close family members because of these interpretations, and refuse to challenge their incorrect beliefs, they will likely be very lonely and bitter people over time. This is why over time borderlines are said to get better in the work environment, but not in their social life. Borderlines can have a great social and family life, but they must have all their chronic medical and psych problems treated, have a medical plan for stress, and absolutely work vigilantly to retrain the brain and challenge bad memories and beliefs. Those who fail to do this will cause lots of pain to themselves and others.