Medical Literature

Is BPD Misdiagnosed With Other Illnesses?

QUESTION:

Dear Dr. Heller, Hi, I was wondering if Borderline Personality Disorder is often misdiagnosed with other illnesses?  I have BPD and I have other diagnosis but I think that they are all a part of the BPD.  These include acute anxiety, psychotic episodes, dissociative episodes, OCD, and Anorexia.  Could these be a part of my BPD?

ANSWER:

The acute anxiety, psychotic episodes and dissociative episodes are part of stress-induced dysphoria (anxiety, rage, depression and despair).  OCD and anorexia are not. Most individuals with BPD have more than one diagnosis.  My screening test ( http://pks.947.myftpupload.com/screen.htm) may be helpful in this regard.



 

2001 November Questions

 

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Why Am I On Naltrexone?

QUESTION:

Dear Dr. Heller, I have just recently been diagnosed with major depression and BPD.  I am on many medications, one of which is naltrexone.  My psychiatrist told me this was to decrease my impulsivity and to prevent my body from producing endorphins when I cut myself. Well, I have been on it for a few months now, and it has done neither, yet my doctor wants me to stay on the medications.  I am not very familiar with this medicine.  The only other action I know that it has is an opioid antagonist.  Is there any other reason related to BPD for my doctor would want me to stay on naltrexone?

ANSWER:

Naltrexone (ReVia and Narcan) has been shown to stop flashbacks in some patients with BPD.  These flashbacks cause severe dysphoria (anxiety, rage, depression and despair) – which is often “treated” with cutting.  I have limited experience with it, but I have seen some dramatic positive effects.



 

2001 November Questions

 

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Do borderlines always have all the symptoms?

QUESTION:

Dear Dr. Heller,

Hello, I was looking at your website, and had a few questions that were not covered.  If someone has BPD, will they exhibit all of the symptoms, like cutting themselves, and suicide, or can the exhibit a milder form of this disorder?

I guess what I am getting at is I was involved in a relationship with a person, who had shown some of the signs of BPD, more so the milder symptoms, saying they love one day the not having anything to do with you the next day.  I understand that is a broad description of the events that take place with this disorder, but I guess I was wondering if there are a milder version of this disorder, and maybe a some places to collect more information about it.

ANSWER:

One only needs to have 5/9 criteria consistently, causing significant problems to have the diagnosis.  Most borderlines don’t self-mutilate.

I believe the BPD is due to damage in the brain’s “trapped, cornered, wounded animal” instinctual response, located primarily within the limbic system.  An instability in that area causes unprovoked mood swings, chronic low level anger, emptiness, boredom and emotional pain (like one’s best friend died) .  Under stress they experience an epileptic phenomenon (nerve cells firing inappropriately and out of control) called “dysphoria” (anxiety, rage, depression and despair).  If the seizure spreads to the temporal lobes dissociative symptoms such as deja vu and unreality can result.

Borderlines generally find some activities that temporarily stop the dysphoria, such as binge eating, binge spending, reckless driving, etc.  Some find cutting the skin in a linear manner also stops the horrible dysphoria (anxiety, rage, depression and despair), just like scratching insect bites stops the horrible itching.

Mild versus severe is difficult to define.  It really depends on how the symptoms are interfering with life and affecting others.  There is a considerable range of variability in how symptoms manifest.



 

2001 September Questions

 

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Am I a BPD Who Just Can’t Take Antidepressants?

QUESTION:

Hello Dr. Heller! Thank you for such a helpful Website.  My problem is that when I take the various antidepressants prescribed to cure BPD I feel myself wind up as tight as a drum and then am prone to almost blind rages and am intensely uncomfortable. Could this reaction mean that my serotonin level is adequate to begin with and does not need manipulation? Do all BPD people (I definitely am a textbook case) have a faulty serotonin level? Can you have BPD and not be helped by antidepressants? I was recently diagnosed with hypothyroidism.  I was encouraged that you said 1 out of 3 BPD’s have this.  The initial small dose of Synthroid is helping.  But again the entire pill caused a feeling of overstimulation that began to border on this “hypertensive reaction” to stimulant-like medications (if only as regarding my system’s perception of them). Lastly, could a very low thyroid cause inability to tolerate antidepressant medication or process it properly? My life depends on your answers as the borderline reactions to 12 step groups and “peopled” workplaces is causing me to live an increasingly restricted lifestyle, and I am losing my will to go on. Thank you for answering my letter.

ANSWER:

In my opinion, the BPD is damage to the brain’s glial cells.  In addition to its serotonin effects, Prozac improves glial cell function.  I’m highly suspicious borderlines are either low on serotonin or have a problem utilizing the serotonin they have. The usual reason for your problem is the cognitive generalized anxiety disorder, where the serotonin 1A receptor is overactive.  SSRI’s increase serotonin and make the anxiety worse.  BuSpar is the answer here.  It will lower the overactivity and make it possible to take Prozac.  I go into this at length in “ Biological Unhappiness.” Thyroid can stimulate the brain, increasing the GAD.



 

2001 November Questions

 

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Can You Answer Some Questions About My BPD Girlfriend?

QUESTION:

Dear Dr. Heller,

I’ve read through pretty much all of your archives – thank you.  I do, however, have a few more questions.  My girlfriend was diagnosed many years ago (maybe the late ’80’s?) with the BPD after many other diagnoses (including bipolar and some others).  She was a self-mutilator, mis-interpreted the world around her, and fit the profile in most other ways.  She was sexually abused as a child and was assaulted and raped once in her mid twenties, although I believe it was after the initial BPD diagnosis and treatment.  She went through some chemical treatment (Prozac, other meds) and a lot of counseling.

On the outside, she appears to be doing well, but seems to have some tendencies that worry me and bring up some questions.  1) Your books – I feel like I understand what she is going through, and would like useful tools to interact with her.  Would either of your books (or both) be helpful to me?  2) She’s not currently on any meds.  How long do people with the BPD normally take Prozac?  Do people ever completely recover?  3) Although she has not self-mutilated for years, she still has very strong urges to do so – she says it seems like it would be very relieving.  Is this indicative of a need for medication?  Does this urge ever completely go away?  4) She sometimes (maybe 4-6 times a month, usually for 1-2 hours, sometimes longer) has a “moody” bout during which she severely misinterprets the world and is very unhappy.  She usually realizes that she’s going through such a bout and tries not to act on any impulses she has during this time because she recognizes that she’s probably misinterpreting the situation and things will seem different later.  Helping her logically talk through the problem seems to work somewhat well to help her get out of it.  Are there other techniques?  Does Prozac/Tegretol help this?  5) She thinks of herself as a horrible person, although she can’t explain why and normally hides this from the outside world.  She is in fact a wonderful person, very intelligent, nice, helps others for a living, and is incredibly capable.  Do you have suggestions of ways that I can interact with her so that she will feel better about herself?  I may order Ziglar’s tapes, but I would like all the tools I can to help her learn to love herself.  6) Finally, can you point me to any information about serotonin levels in people with the BPD?  Is this why Prozac helps?  Do serotonin precursors like 5-HTP ever help?  Are things that could depress serotonin levels, dangerous?

I really love this woman – she’s absolutely wonderful and it seems like everyone in the world sees this but her.  I’d like to help her get to the point of loving herself, seeing the world as it is, and not feeling like she should hurt herself.

Any help you can give is GREATLY appreciated.

 

ANSWER:

1)    My books are written for borderlines and their loved ones, and have lots of information for both of you.  “Life at the Border” is on the recommended reading list at the National Institute of Mental Health. 2)    BPD patients generally need some medication the rest of their lives, although that may be stretched where only as needed medication is needed.  Some patients recover enough to have a normal and successful life, but again will still need medication at times. 3)    Self mutilation urges generally get better over time, but when the individual experiences dysphoria (anxiety, rage, depression and despair) they will do whatever works to make it go away. 4)    See http://pks.947.myftpupload.com/dysphori.htm and http://pks.947.myftpupload.com/20a.htm. 5)    Ziglar’s tapes are remarkably effective, as are affirmations.  I go over this at length in both books.  Brain retraining is most effective when the medications are working. 6)    Not much is known about serotonin levels, and the exact levels are probably not the problem.  More important is brain dysfunction, and in what areas, and how various medications improve the situation.  Serotonin receptors, and combinations of neurotransmitters are equally important, and I believe the function of support cells called “glial cells” is also important.  I’m much more in favor of Prozac than 5-HTP.

 

2001 March Questions

 

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What Can I Do When I Feel Vulnerable?

QUESTION:

Dear Dr. Heller,

When a BPD feels vulnerable, a normal conversation is impossible because we are on”automatic”, and can’t say what we want.  Instead, we defend our sanity anyway we can.  If I try to mess with my defense mechanism (fight it), I slip into psychosis instantly.

My question is: Can one feel psychosis and stay in the middle of it without automatically responding to it?

 

ANSWER:

Medication is the most important thing.  When an individual with the BPD feels vulnerable, the trapped wounded animal instinct will kick in.  Haldol 2mg / Tegretol 200mg / Risperdal 3mg as needed for dysphoria (anxiety, rage, depression and despair) is particularly useful. Counseling and brain retraining will help you to see things in a less scary state and make you feel less vulnerable over time.

 

2000 October Questions

 

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