Medical Literature

Please Answer Some BPD Questions:

QUESTION:

Dear Dr. Heller,

I was diagnosed with BPD this past March.  I have struggled with depression, anxiety, and suicidal ideation since age 21.  I am now 34.  I was at one point with very high functioning.  I made it through college and graduate school.  I am a physical therapist and have done very well in the field.  I became a manager of a rehab hospital but hated managing.  I left the field and went in to pharmaceutical sales and things started going down hill.  I had surgery and had many complications.  All along depression and anxiety were getting worse.  I became extremely suicidal and went in to the hospital.  I’ve been out of work for a year and half between all the physical and emotional problems.  Physically I’m OK to return to work, but not emotionally.  I have been consistently in therapy since 1991.  My first therapist retired and I left my second therapist after several years .  I’ve been with my current therapist for a year and a half.  I’ve also had 8 weeks of an intensive DBT training.  I have several questions. 1.  Does Celexa work as well as Prozac does for BPD?  I’ve been on it since March 40-60mg and it hasn’t changed my moods or suicidal ideation. ANSWER: I don’t believe Celexa is anywhere near as effective for the BPD.  I’m highly suspicious that what makes Prozac more effective is it’s ability to improve the functioning of glial cells – these are the cells that support the neurons.  90% of the cells in your brain are supportive glial cells, not neurons. 2.  What do you suggest for sleep?  I can fall off to sleep OK, I just can’t stay sleeping.  Klonopin makes me more depressed.  Ambien doesn’t work, and Ativan helps some.  However, I’m afraid about addiction.  I have a rare colon disorder where I don’t have any peristalsis, so I have to be careful about not taking things that cause constipation.  I have to take 5 dulcolax a night in order to move my bowels. ANSWER: Most BPD patients sleep very well on the Prozac/Tegretol combination.  Some with PTSD need Remeron, at least for a while.  Seroquel 100-600mg nightly will usually take care of the other sleep problems. 3.  I also take Neurontin 3x/day – 300mg a.m., noon, and in the p.m.  I take 900mg.  I also need the Neurontin because I have interstitial cystitis.  I take Elmiron as well. ANSWER: I’ve treated many interstitial cystitis (IC) patients with good results.  Every one also had the BPD, which needs to be treated aggressively.  I’m highly suspicious IC is a herpetic infection, like shingles that affects the bladder.  Drugs like Zovirax, Famvir and Valtrex have worked extremely well for my patients.  Neurontin generally does very little for the BPD. 4.  Is DBT therapy the only answer for BPD?  Or, is DBT the best treatment approach? ANSWER: DBT is an extraordinarily comprehensive and expensive therapy approach that has been shown without medication to lower suicide attempts and self-mutilation by half.  DBT is not the only answer.  There are many forms of therapy that help, particularly those that emphasize where we go from here.  Learning to recognize dysphoria (anxiety, rage, depression and despair) and treating it medically is extraordinarily important.  I don’t believe in rehashing the past, particularly when abuse was present. 5.  Could Wellbutrin be helpful in treating BPD? ANSWER: In and of itself Wellbutrin has very little positive effect on the BPD.  Some individuals on Prozac lose their zest for life {this is different from dysphoria (anxiety, rage, depression and despair)} due to an imbalance of serotonin with noradrenaline and dopamine.  Wellbutrin can help put this into balance. Any suggestions?

 

ANSWER:

I’d recommend you read over the BPD section and FAQ section (part of “Ask The Doctor”) on my website. P.S.  I thought you’d like this one.  After being in the hospital, I had three psychiatrists during an initial evaluation tell me they didn’t want to work with me because I had BPD.  Then I finally found one who enjoys working with BPD.  After several months of working with her, she decided that if I didn’t leave my current therapist and see just a DBT therapist that she wouldn’t work with me.  Now I found a psychiatrist that has a wonderful rep.  However, I’m not sure you can figure out appropriate medications in 15min.  My PCP has been amazing through all of this with me.  Without her I would have probably committed suicide.  She has been such a stable force in my life. Being a PCP has helped me enormously in treating the BPD because I’m used to seeing the entire patient, and making all their diagnoses and treating them comprehensively.  It usually takes me considerably less than 15 minutes to determine medication changes, although I don’t do the therapy.  I look for specific signs of medication need.  For example, a sign that a higher Prozac dose is necessary would be unprovoked mood swings, chronic anger, emptiness or boredom.

 

2001 August Questions

 

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Is there ever a case where psychotherapy is better than medications?

QUESTION:

Dear Dr. Heller,

Isn’t it true that some of these medications like antidepressants, antipsychotics, etc.  can actually make BPD worse?  In my case it did.  Psychotherapy worked best for me these medications, most of them, caused addictions and adverse side effects and very hostile and psychotic behavior I have never experienced before.  Is there ever a case where therapy is better than meds?

ANSWER:

Side effects of medications usually reveal additional diagnoses – particularly the generalized anxiety disorder which is usually aggravated by SSRI medications.

I’m a huge believer in counseling, and it can make a huge difference – particularly with the ability to change the way stressors are perceived.  Lowering the perception of stress markedly lowers the need for medication and can make for a much better life.

There are two medical symptom complexes that medications treat:

Unprovoked mood swings, chronic low level anger, emptiness, boredom and emotional pain are usually resolved by Prozac, although other SSRI’s help some patients.

Dysphoria (anxiety, rage, depression and despair) and dissociation need medical treatment, as these symptoms appear to be a seizure-like phenomenon (nerve cells firing inappropriately and out of control).  Neuroleptics like Haldol and epilepsy medications like Tegretol can make a huge difference here.

I believe the BPD is due to damage to the brain’s “trapped, cornered animal response.” Anything that makes this response kick in interferes with accurate reality perception.  The individual with BPD may believe he/she is interpreting reality correctly, but they’re not.  This problem destroys many areas of a borderline’s life – and is part of why I so strongly believe in medication.



 

2001 September Questions

 

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