Medical Literature

Does My Father Have BPD?

QUESTION:

Dear Dr. Heller,

My question is about my father.  Ever since I can remember, my father has experienced extreme mood swings – from a calm easy going person to absolute rage.  He will often reflect back on instances that happened as much as ten years in the past and enrage himself.  Most of the time it is clear that he has misinterpreted the motive of the person he is raging about.  This usually occurs in stressful situations.  He often avoids social gatherings and does not have many friends.  My father is suspicious of almost everybody.  Recently my father was treated for severe headaches and consequently become addicted to vicodan, and has been now for two years.  He is also taking Xanax and Remeron.  These are the only medications that I know he is taking for sure, because he has shut the family out and refuses to discuss his medical affairs.  Within the past year he has began chanting and making loud shrieking outbursts.  Most of the time he chants “mama”.  Before the headaches he only had many of the symptoms of BPD that you describe in your website (anxiety, rage, occasional depression, misinterpretation of motives etc.).

Firstly, does this sound like BPD?  If so how do I approach him with it?  What can I do for him?  My grandfather was an alcoholic and verbally abusive.  Could this have amplified his problems?  Secondly, I see some of the traits you have described in myself (such as a feeling of incompetence, anxiety, a mind that never stops, and feeling like something is medically wrong).  Are they due to genetics or the environment that my father created while I was growing up?  If so, what should I do and how can I break the cycle?

 

ANSWER:

I don’t know if your dad has BPD, but his symptoms are consistent with it.  He probably has other diagnoses as well.  http://pks.947.myftpupload.com/AskDoc/q1.htm will help you with how to tell him. The BPD appears to be 50% genetic so the same answer would apply to you: Get your medically treatable diagnoses treated.  The screening test should be of help. It’s critically important to recognize that most of these problems are biologically based, often genetic, and medically treatable.  I believe strongly in mind/body/spirit – so every aspect needs to be healed.

How Do I Discuss My BPD Diagnosis With My Psychiatrist?

    How Do I Discuss My BPD Diagnosis With My Psychiatrist?

    QUESTION:

    Dear Dr. Heller,

    I was listening to a local radio talk show on my way to school.  Your description of BPD caught my attention.  I have been treated for depression and GAD for many years.  I very much fit the profile for BPD, however.  How can I present this to my psychiatrist without appearing to be self diagnosing?  Also, are there certain facts that I should prepare ahead of time to explain the reason that I believe that I may be suffering from BPD?

     

    ANSWER:

    A cooperative open minded physician welcomes good information that could be of assistance.  There are two things that may be of help: 1)    Go through the DSM criteria, and write down numerous examples of the ones you fit and go over them with your psychiatrist. 2)    Go through some of the medical studies with the psychiatrist.  This article backs up my medication approach.  There is good scientific literature to back up the use of Prozac, Tegretol and as needed low doses of Haldol.

Separator (Biological Unhappiness)

 

2001 April Questions

 

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Why Would The BPD Diagnosis Be Missed?

QUESTION:

Dear Dr. Heller,

I think I have BPD.  I have all the symptoms and also am taking several medications associated with BPD: Neurontin, Risperdal, antidepressants (Celexa and Wellbutrin) and Ativan.  My doctors diagnosed me with depression.  If it is only depression I am suffering from – why am I taking these other meds, and is there a reason they would miss this diagnosis?

 

ANSWER:

Many health care professionals consider the BPD to be a character disorder, and don’t want to “label” patients with this diagnosis.  Many others don’t recognize the medical basis of the disorder, so informing the patient seems either hurtful or of little use.  Individuals with the BPD are virtually always depressed.  The depression experienced during dysphoria (anxiety, rage, depression and despair) is neurologically a different phenomenon than a regular depression.  The medications that have been prescribed are very reasonable, but in my experience won’t work well for the BPD.  You can read about the medications I prescribe and why at http://pks.947.myftpupload.com/20a.htm.

Is This BPD?

QUESTION:

Dear Dr. Heller,

I was diagnosed with ADD, OCD and BPD by my former therapist who terminated me from therapy.  The termination was followed by several months of me pleading with her to take me back and refusing to go to another therapist.  A similar scenario occurred sixteen years prior where I was also terminated from therapy (I stayed away from therapy altogether between these incidents).  Six months after being terminated from therapy, I gave in and accepted a referral to a new therapist.  Finally, I am feeling a little better.  I am also seeing a psychiatrist and taking Celexa.  I’m wondering if the BPD diagnosis sounds correct and if I should be taking different medication.  Also, I have an underlying problem that haunts me: Even though I am an adult in years, I feel like a child emotionally.  I even spend a good deal of time fantasizing that I am a young child and a perfect mother is mothering me.  My main question: Is there a possible diagnosis OTHER than BPD to explain this fantasy?  I was not abused as a child and I do not engage in suicidal behaviors other than thinking about killing myself, and, saying that I will after I am abandoned.  At other times, I think about it only in the abstract.  I don’t mutilate myself (cut, burn, etc.)  – unless you call being diabetic, weighing over 250 lbs.  and eating large amounts of sugar daily a form of mutilation.  I don’t, because I have never had any side effects or been hospitalized.  It doesn’t hurt.  Finally, my other big issue is spending money compulsively.

 

ANSWER:

You could easily have the BPD, although you didn’t give enough information to prove or disprove the diagnosis.  The official criteria can be found at: http://pks.947.myftpupload.com/DSM.htm. There are lots of psychiatric explanations for feeling like a child – that are best addressed by a therapist. Since self-mutilation is simply an effort to stop dysphoria (anxiety, rage, depression and despair), if an individual eats excessively to treat dysphoria, then it is a similar problem.  They are classified differently however, self-mutilation is criteria 5, whereas overeating as you do fits criteria 4.  Eating like you do can be a sign of many diagnoses, including OCD.  Celexa is a good medication for the BPD.  It’s similar to Prozac and works for unprovoked mood swings, chronic anger, emptiness and boredom.  In my experience patients who take Celexa who are switched to Prozac do much better on Prozac.  I explain my medical management of the BPD in http://pks.947.myftpupload.com/20a.htm and http://pks.947.myftpupload.com/HowBPD-Y.htm. All your diagnoses need to be treated comprehensively.

Are There Tools To Predict BPD Decompensation?

    Are There Tools To Predict BPD Decompensation?

    QUESTION:

    Dear Dr. Heller,

    My husband is in recovery from the BPD.  Our journey has made me very aware recently that “psychotic” is a “dirty” word, and even people who know better still react very defensively to the idea that someone in their family might be “psychotic” – no matter how much they’ve had to adapt to accommodate their family member’s obvious illness.  The “unhappiness” still means something closer to “shameful” than “biological”.

    As you know, people with BPD can decompensate.  This poses a serious problem for the whole family.  Our homes are not psychiatric facilities and we can’t do what a doctor can do to help stabilize our family member.  Often, we can’t even risk transporting them ourselves.  (As I write this, my husband is recovering from a decompensation due to a medication adjustment.  Hopefully, he will be able to make it in to see a doctor tomorrow.  It’s been more than a week now.)  So, I’m trying to come up with a tool to help myself spot changes in behavior that could help me predict such a crisis.  I help facilitate a support group for family members, and I’ve asked the group to look over my (very rough) draft.

    We go into this endeavor knowing that we are living with very delicate, sometimes nearly ephemeral phenomena and that we are *not* doctors; that the stakes can be very very high.  But, between the invisible and the chaos that can overtake our households, we can (and do) observe so many “predictors”, if you will.  My reasoning is, the better observer and communicator I become, the more I contribute to the treatment team.  And because most clinicians no longer make house calls – indeed, it’s extremely difficult to find a clinician expert in BPD in a hospital – it is up to me to stay active and to use whatever tools at my disposal to support my husband’s recovery and to ensure the quality of my life at home.

    Having said all this, I attach the “checklist” I’m developing.  Again, the aim to give family members a tool to help them assess the behavior they are living with and hopefully avoid needless crises at home.  It is not meant as a substitute for a medical consultation; rather, it is meant to help a family member assess a potential crisis and also to help them verbalize what they are seeing in their home to the professionals they rely upon.  If you can offer any feedback, I’d appreciate hearing from you.

    Best regards.

     

    ANSWER:

    Psychotic means misinterpreting reality.  Individuals with the BPD, when dysphoric, perceive the world the way a trapped, cornered, wounded animal does.  From that perspective their behavior makes sense.  Self-destructive behaviors are simply techniques that work to stop dysphoria.  Dissociative symptoms are psychotic as well.  I don’t shy away from using the word psychotic because individuals with the BPD need to fully understand the risks of untreated dysphoria (anxiety, rage, depression and despair).  Dysphoria is a horribly painful sensation. The most effective tool I’ve ever encountered is doing mood checks hourly.  Because borderlines have felt so bad for so long, feeling bad isn’t something “new” or “abnormal” to them.  By checking the mood hourly (1 = the worst they’ve every felt, 10 = the best), they can treat their dysphoria with a low neuroleptic dose (I prefer Haldol 2mg).  The dysphoria instruction sheet I use for my patients is available here. The therapist I work with, Mary Sales, helps patients and their loved ones recognize dysphoric spells and the particular “red flags” that warn the BPD patient that they are “crashing.” Decompensating, psychosis, or crashing mean the same thing – there is a seizure like phenomenon occurring in the limbic system (and the temporal lobes when dissociation is present).  Treating it as a medical problem with medication is a crucial aspect of recovering from the BPD.

Separator (Biological Unhappiness)

 

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Do Borderlines Belong In Jail?

QUESTION:

Dear Dr. Heller,

I have been treated for years for BPD, and I keep having relapses.  My last relapse got me fired from my job as a security officer in a mental health facility.  Some of the staff there made comments that borderlines belong in jail and not in the hospital.  How do you feel about this comment.

ANSWER:

It was an offensive, uneducated and judgmental remark that gives insight into the staff, not into those with the BPD.  I have many, many individuals with the BPD as patients who are upstanding citizens with outstanding character.  Two work for me in positions of responsibility.  The BPD is a medical problem!  Those with character problems and the BPD are a huge problem, and often end up in jail.