Category: Articles

QUESTION:

Dr. Heller,

I found your article for Primary Care Physicians and intend to pass it on to the practitioners who are treating my Borderline Personality Disorder significant others. However, I noted the article is dated Nov 2, 1991. A great deal has happened in 7 years. I wonder if there are updated thoughts, research and information out on managing BPD…..

ANSWER:

There’s not a lot of scientific literature on the subject, particularly biologically based, which has been frustrating. A few medical studies have shown that SSRI’s, particularly Prozac, do indeed work for the BPD, although except for my small study on Prozac vs. Zoloft, the exact target symptoms haven’t been addressed.

There has been a study showing Depakote reduced hostility in BPD victims, however a study in 1991 showed that Tegretol was better and safer than Depakote for complex partial seizures, which many of us believe are part of the BPD.

Since I believe the BPD is correlated with glial cell malfunction, the discovery in the last two years that Prozac improves glial cell function is very exciting, and may partially explain why Prozac is so superior for BPD symptoms.

The “comorbidity” of panic disorder with the BPD and the ability of Paxil to work for the panic disorder has been a great find. Paxil, to me, works best for borderlines also experiencing panic – and the combination untreated has a 25% suicide rate. Many of my combined panic and BPD patients take both Paxil for the panic and Prozac for rejection sensitivity and the SSRI BPD target symptoms – moodiness, chronic anger, emptiness and boredom.

The most frustrating change has been the loss of brand name Haldol. Haloperidol is now only available generically, and it doesn’t work as well. It does work as well when the dose is high enough, but that makes it expensive and less predictable. In general where the brand name used to work at 0.5mg, the generic usually required 1-2mg to get the same effect.

To me the most exciting changes in the past 8 years has been the recognition of ADD as strongly associated with the BPD and the release of Risperdal. I believe as many as half of BPD victims had and continue to have ADD with their BPD. Risperdal is a powerful antipsychotic that works on more than the dopamine system, and can stop virtually all borderline dysphoria, suicidality and psychosis, although usually Prozac and Tegretol have to be in the system at the same time to get an excellent result. High doses are generally needed to accomplish this, and side effects are a problem at these high doses. Sedation (sleepiness) can be impressive, and can render some individuals nonfunctional for a few days. When in a crisis, however, grogginess is not as important as preventing a disaster. Zyprexa is a fair alternative.

In my work I’ve discovered the incredible importance of diagnosing and treating the other disorders commonly associated with the BPD – particularly panic, GAD, OCPD, OCD, ADD, and dysthymia. Very exciting for me as well is my observation that in the last 2 years every patient who felt hyper on Prozac also had the cognitive GAD – generalized anxiety disorder. The GAD appears to be due to an abnormally high serotonin at serotonin receptor site #2, which is aggravated by the SSRI class, particularly Prozac. Buspar works effectively for almost everyone who needs it to bring this down and make it possible for higher doses of Prozac to be used when necessary, and/or to add psychostimulants like Ritalin for ADD. Everything wrong has to be effectively treated for a borderline to successfully recover.

Permission by Leland M. Heller, M.D.

 

The borderline disorder is usually associated with other neuropsychiatric problems. Attention deficit disorder is probably the most common one. Most of these “disorders” are really not illnesses at all, but traits that had advantages in a different time and environment – but they are a serious problem for patients in today’s society and it’s pressures. Successful BPD treatment requires successful treatment of all neuropsych problems:

1) Generalized Anxiety Disorder (GAD):

the body’s “flight or fight” system seems to be on all the time, causing fear related symptoms. One can experience mostly a “thinking” anxiety problem, called the “cognitive component” of the GAD, where the person is unable to sit peacefully with a quiet mind. This diagnoses is almost always the case when medications like Paxil, Prozac and Ritalin cause increased anxiety. Treating this disorder first is often necessary before successfully treating the other diagnoses.

2) Obsessive Compulsive Personality Disorder (OCPD):

like the BPD, it’s a medical problem, not a “character disorder.” In my opinion it is a condition people are born with. The body’s automatic switch that takes over when facing a life and death situation stay’s on all the time, constantly experiencing “life and death” sensations. Symptoms include inappropriate perfectionism, difficulty making decisions, inability to prioritize, and being a pack rat – all because the person feels literally like he/she will die if an error is made.

3) Obsessive Compulsive Disorder (OCD):

an anxiety disorder (and/or symptom) characterized by excessive and intrusive thoughts and ritual behaviors that help the person cope, such as washing hands excessively, repeatedly checking the door, etc. The B vitamin inositol in high doses can be as effective as standard medications.

4) Attention Deficit (Hyperactive) Disorder:

a reduced flow of blood to the brain areas responsible for staying focused on an activity or thought, and/or to think and consider before acting or speaking. Some patients have hyperactivity as well. It appears that the “disorder” does not go away at adulthood. I suspect a high percentage, if not a majority, of untreated or undertreated ADD individuals go on to get the BPD.

5) Rejection sensitivity:

along with dysthymia (rarely depressed, rarely happy – sort of in between) and irritability they compromise a syndrome I call “fractured enjoyment” (not a true medical diagnosis!). These symptoms collectively so far are only treatable with Prozac, and are the main reason Prozac has been so successful.

6) Panic Disorder:

results when the brain incorrectly assumes the individual is being choked to death. This is a true medical problem with a high suicide risk. Experiencing the body’s last ditch effort to avoid being “choked to death” is a terrible sensation, and the victim may live in terror that he/she will experience it again (preanticipatory anxiety).

7) Phobias:

irrational fears that limit the person’s ability to function, even though he/she knows they’re irrational. They are usually treatable medically, and include claustrophobia.

8) Cyclothymia:

is a relatively common mood swing disorder, similar to bipolar but with “mini highs” and “mini lows.”

(Dr. Heller’s book “Biological Unhappiness” explains the biology and treatment of these and other conditions).

Permission by Leland M. Heller, M.D.

(article for Primary Care Physicians)

by Leland M. Heller, M.D.

November 2, 1991

 

INTRODUCTION

The Borderline Personality Disorder (BPD), a psychoneurological disorder affecting tens of millions [1,2] is now treatable with a combination of medication and other therapies. Fortunately fluoxetine (Prozac) [3] and low dose intermittent neuroleptics [4] can stop most of the mood swings, and many of the irrational behaviors. Untreated, these patients suffer from very painful, difficult lives – and a caring health care professional can make a profound difference.

GENERAL DESCRIPTION

According to Dr. Rex Cowdry of the NIMH the “BPD is characterized by tumultuous interpersonal relationships, labile mood states, and behavioral dyscontrol set against the background of a relatively stale character structure. While the syndrome can be identified with reasonable reliability, the fundamental nature of the disorder remains unclear…” [ 5] See Table 1 for the DSM-III-R criteria. It is a worldwide phenomenon, being described in the U. S., England, Scotland, Switzerland, Germany, France, Norway, and Japan. [6] It likely affects approximately 2-3% of men and 5-10% of women. [1]

Prior to effective medical therapy, managing borderlines was a difficult struggle. Articles in Family Physician [7] and Nursing [8] journals describe them as demanding, manipulative, disruptive, frustrating, non-compliant, and hostile – especially when not medicated properly.

WHAT BORDERLINES EXPERIENCE

Untreated, a borderline lives an emotional vertigo – experiencing totally unstable moods. These mood swings and most any stress cause a horribly progressive dysphoria. They intensely feel almost every painful emotion at once.

Borderlines desperately search for relief, usually by endorphin releasing behaviors that are ultimately self-destructive – such as binge eating, binge spending, aberrant sexual behavior, substance abuse, and reckless driving. When a severe borderline is extremely dysphoric, cutting the skin causes no physical pain and actually relieves the dysphoria.

Because untreated borderlines live with constant mood swings and frequent dysphoria, normal psychological functioning is crippled. Understanding this enables the Family Physician to help. Borderlines need to understand their illness, and to be treated properly.

MAJOR SYMPTOMS

Mood Swings: Mood swings are a fundamental devastating symptom of borderline. Moods can shift inappropriately from hour to hour, even minute to minute. Without appropriate environmental of though-provoked justification. [9]

Dysphoria: A combination of depression, rage, anxiety, and despair – often complicated by shame, humiliation, embarrassment, excitement, terror, jealousy, and self-hate. It can be triggered by mood swings, stress, and emotional pain. Once dysphoria begins, it tens to steadily intensify – possibly due to limbic system malfunction. [5] The sensation is so painful that borderlines will desperately search for a way out – often relying on drugs, alcohol, self-destructive and impulsive behaviors, self-mutilation, and suicide. [9.10]

Psychosis: Psychotic thinking often develops when the dysphoria becomes severe. Because of the psychotic episodes, borderlines are said to live at the “border” between reality and psychosis. The main psychotic symptoms are moods, physical sensations and perceptual distortions.

The dominant psychotic moods center around worthlessness, badness, rage, and self-destruction. The physical sensations are remarkably similar to temporal lobe epilepsy and include unreality, derealization (familiar things become unreal). Deja-vu, out-of-body experiences, depersonalization (as though no longer yourself), unawareness spells, and feeling like body parts are numb and no longer part of oneself. [9]

Psychotic perceptual distortions primarily include transference (incorrectly perceiving a present day person to be like someone hurtful from the past), inappropriate interpretation of motives, and hallucinations. Psychosis can also be brought on by drugs, especially alcohol and marijuana. [1]

Splitting: Small children see everything in life as being all good or all bad. This immature psychological defense persists in borderlines, resulting in “black and white thinking.” When life events are perceived as bad, dysphoria usually results. When things are good, the borderline frequently feels vulnerable, and fears the black returning – often leading again to dysphoria.

Other symptoms: A borderline’s life is defined by inconsistency – mood, identity, trust, behavior, attitudes, values and thoughts. While intelligence is not impaired, [11] organization and structure are [12] – borderlines have trouble following through and completing tasks. Access to memory is frequently impaired. Chronic anger, fear of abandonment (often resulting in manipulative behavior), lack of trust, impulsivity, feelings of emptiness and/or boredom, jumping to incorrect conclusions, and severe PMS are commonly experienced.

Comorbidity: Borderlines frequently suffer from other psychiatric illnesses. The most common include depression, [1] anxiety, [13] substance abuse, alcohol abuse, [14] other personality disorders, and eating disorder (approximately 40% of eating disorder inpatients suffer from the borderline). [15] There is no association with schizophrenia. [16]

ETIOLOGY

Psychological theories alone cannot explain the BPD. Borderlines have significant biological abnormalities – see Table 2. CNS serotonin malfunction is likely involved. Temporal lobe dysfunction is often associated with stress. The BPD is probably a medical predisposition combined with environment insult.

There are many psychological theories and concepts, with considerable disagreement among experts in the field. Both overprotective and underprotective parents have been “blamed” as the cause. [16] Most theories center around traumatic childhood experiences, arrested psychological development (especially at the separation/individuation phase), and reliance on maladaptive coping and survival mechanisms. [23,28]

Adoption, early parental loss, and incest are often associated with the BPD. [14] The most severe borderline patients suffered from both sexual and physical abuse, usually while very young [6] – chronic dysphoria and derealization are the best predictors. [29] In one study, 81% reported major childhood trauma, 71% physical abuse, 68% sexual abuse, and 62% witnessed serious domestic violence. [30]

Genetics: The BPD tends to run in families, six times more likely in first degree relatives. There is an increased family history of alcoholism, substance abuse, other personality disorders, and depression, but not schizophrenia. [16]

DIAGNOSIS

Psychological tests, such as the MMPI and NIMH Diagnostic Interview Schedule, are only accurate between 85 and 89%. [31,32] Most knowledgeable psychologists can easily arrange for an MMPI. The NIMH test may be more difficult to obtain.

If I encounter a patient who has multiple complaints, especially fatigue, headaches, stress, depression, etc. I will often review and discuss the DSM-III-R Borderline criteria to determine if he/she feels 5 or more symptoms are present. If yes, I will usually initiate treatment with fluoxetine (Prozac), evaluating the patient and diagnosis 1 week later.

TREATMENT

Medications:

Prozac (fluoxetine): Prozac appears to increase serotonin. It is a breakthrough medication for borderlines – eliminating most mood swings, chronic anger, chronic emotional pain, emptiness and boredom within 3 days. A daily a.m. 20 mg. dose is usually effective. For most side effects (nausea, jitteriness, agitation), reduce the frequency to every 2 or 3 days. If fatigue develops, switch to an evening dose. While for a few patients the serotonin deficiency symptoms resolve permanently in 6-12 months, most need to take the medication long term. In my experience, clomipramine (Anafranil) and sertraline (Zoloft) have shown similar efficacy.

Neuroleptics: Can be effectively used on a prn basis during stress or dysphoria, or prophylactically for stressful situations. I prefer Haldol 0.5 – 1 mg every 4-6 hours as needed (side effects are rarely a problem at this low dose). Navane (thiothixene) [3] and Mellaril (thioridazine) [4] have been proven effective. High doses, especially in hospitalized patients, are also effective. [4]

Tegretol (carbamazepine): Can markedly reduce episodes of behavioral dyscontrol. [5] Extremely effective for unreality, chronic dysphoria, incest crisis, relationship dissolution, extreme anger, dissociative symptoms, and when neuroleptics are ineffective. Dosing and blood levels are comparable to treating temporal lobe epilepsy.

Thyroid: Many borderlines have symptoms of hypothyroidism, with “low normal” thyroid blood tests. Approximately 1/3 of borderlines have an impaired TSH response to TRH. [33,34]

Vitamin B12 deficiency: Approximately 20% of borderlines have low vitamin B12 levels, with symptoms of fatigue, leg stiffness, and dysesthesias.

Medications to Avoid: Xanax (alprazolam) can markedly worsen behavioral dyscontrol. [5] Elavil (amitriptyline) increases suicide threats, demanding and assaultive behavior, and paranoid ideation. [35] MAO inhibitors have helped borderline symptoms, but may be dangerous due to the impulsivity and behavioral dyscontrol borderlines can experience.

Psychological Counseling: Borderlines need a multidisciplinary approach. A good therapist is necessary, and borderlines should be strongly encouraged to get into counseling. For some, a psychologist/family physician team is very effective. Referral to a psychiatrist may be necessary. Psychiatric hospitalization is occasionally required, especially for strong suicidal ideation.

Stress Reduction: Borderlines need to keep their stress level down, and to use neuroleptics when under stress. Physical exercise, relaxation techniques, and TM (Transcendental Meditation) can be very helpful.

Spiritual Healing: Making peace with God and one’s spiritual self is very important. The AA (Alcoholics Anonymous) approach can help, especially with destructive behavior patterns. Borderlines generally hate themselves. I try to get them to understand that they have a “good” soul that has been “stuck” in a broken biological computer.

Self-esteem: Since most borderlines experience self-hate, strong efforts must be made to build a strong and secure self-esteem.

Retraining the Brain: Borderlines must learn to think differently. Cassette tapes, books, and affirmations can teach them how. I strongly encourage borderlines to purchase and listen to the “How to Stay Motivated” tape series (or at least “Success and the Self-Image”) by Zig Ziglar. (1-800-527-0306).

Borderlines need to listen to positive/motivational tapes frequently and persistently. Brian Tracy’s “The Psychology of Achievement,” and others (Earl Nightingale, Denis Waitley, Robert Schuller) from Nightingale /Conant (1-800-323-5552) are excellent subsequent tapes.

Borderlines must be convinced to read positive/inspirational books. I recommend How to Win Friends and Influence People by Dale Carnegie, The Power of Positive Thinking by Norman Vincent Peale, Seeds of Greatness by Denis Waitley, Unlimited Power by Anthony Robbins, Your Erroneous Zones by Wayne Dyer, and books by Leo Buscalia and Norman Cousins.

Affirmations: Saying a meaningful phrase in a repetitive, broken record like manner – are very effective. The borderline needs to say these affirmations dozens of times daily, and within a few weeks they will subconsciously accept new and much needed positive concepts. I recommend phrases like “I like myself and feel terrific,” “I am lovable,” and “I’m a success.” This technique is very powerful.

FINAL COMMENTS

The borderline personality disorder is common and now treatable with a combination of medications, psychological counseling, and self-help approaches. Untreated borderlines suffer painful, destructive lives. They are victims of an illness they don’t want and didn’t cause. They deserve to be helped, and the primary care physician is in the best position to initiate treatment.

TABLE 1 – DSM – III-R CRITERIA

“A pervasive pattern of instability of mood, interpersonal relationships, and self-image, beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following:

1) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of overidealization and devaluation.

2) impulsiveness in at least two areas that are potentially self-damaging, for example, spending, sex, substance abuse, shoplifting, reckless driving, binge eating, (do not include suicidal or self-mutilating behavior covered in No. 5)

3) affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days

4) inappropriate, intense anger or lack of control of anger, for example, frequent displays of temper, constant anger, recurrent physical fights

5) recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior

6) marked and persistent identity disturbance manifested by uncertainty about at least two of the following: self-image, sexual orientation, long-term goals or career choice, type of friends desired, preferred values

7) chronic feelings of emptiness or boredom

8) frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-mutilating behavior covered in No. 5)”

Those who suffer from the Borderline Personality Disorder have at least 5 of the 8 criteria.

TABLE 2 – BIOLOGICAL ABNORMALITIES

1) Abnormal neurological soft signs (such as awkward gait, left-right confusion, and difficulty with pronation/supination and finger-thumb opposition). [17]

2) Abnormal REM sleep. [18,19]

3) IV procaine, normally sedating, causes dysphoria in BPD. [20]

4) Abnormal auditory P300 on EEG – sharing a dysfunction of auditory neurointegration with schizophrenia. [21]

5) EEG abnormalities in 1/3 – ½, not usually correlating with symptoms. [22,23]

6) Altered platelet alpha 2-adrenergic receptor bind sites. [24]

7) Low platelet monoamine oxidase activity. [25]

8) Low circadian melatonin profile. [18]

9) Abnormal lithium transport. [26]

10) Normal head CT’s. [22,27]

11) Cases of BPD have been described from CNS trauma and infection. [27]

TABLE 3 – SUMMARY OF TREATMENT

1. Prozac 20 mg daily (clomipramine) Anafranil and other SSRI’s may prove to be just as effective

2. Haldol 0.5 mg q 4-6h prn (thioridazine, 10 mg and thiothixene 1 mg can be equally effective)

3. check for hypothyroidism, treat if suspicious

4. check for vitamin B12 deficiency

5. psychological counseling

6. stress reduction

7. help with spiritual issues

8. develop self-esteem

9. retrain the brain with books, tapes and affirmations

REFERENCES

1. Gunderson, John G., MD Borderline Personality Disorder American Psychiatric Press, Washington, D.C. 1984 p.11

2. Kreisman, Jerold J., MD, Straus, Hal: I Hate You, Don’t Leave Me. Price Stern Sloan, Inc., Los Angeles, CA 1989

3. Norden, MJ “Fluoxetine in BPD.” Prog Neuropsychopharmacol Biol Psychiatry 1989;13(6): 885-93

4. Soloff, P: “Progress in Pharmacotherapy of Borderline Disorders – A Double Blind Study of Amitriptyline, Haloperidol and Placebo.” Arch Gen Psychiatry Vol 43 July 86

5. Cowdry, R; Gardner, D: “Pharmacotherapy of Borderline Personality Disorder.” Arch Gen Psychiatry, Vol 45, Feb 1988

6. Links, P; Steiner, M: “Characteristics of Borderline Personality Disorder: A Canadian Study.” Can J Psychiatry Vol 33, June 1988

7. Nowlis, DP: “Borderline Personality Disorder in Primary Care.” J Fam Pract 1990 Mar;30(3):329-335

8. Runyon, N; Allen, C; Ilnick, S: “The Borderline Patient on the Med-Surg Unit.” American Journal of Nursing, Dec 1988

9. Cowdry, R: “Psychopharmacology of Borderline Personality Disorder – A Review.” J Clin Psychiatry 48:8 (suppl) August 1987

10. Lucas, P: Gardner, D; Wolkowitz, O; Cowdry, R: “Dysphoria Associated with Methylphenidate Infusion in Borderline Personality Disorder.” Am J Psychiatry 144:12 December 1987

11. Wallace, J; Martin, S: “Can Psychological Assessment Address Borderline Phenomena?” Can J Psychiatry Vol 33 June 1988

12. Edell, W: “Role of Structure in Disordered Thinking in Borderline and Schizophrenic Disorder.” Journal of Personality Assessment, 1987 51(1), 23-41

13. Weiler, M; Altman, E: “Associated Diagnoses (Comorbidity) in Patient With Borderline Personality Disorder.” Psychiatr J Univ Ott 1990 Mar;15(1):22-7

14. McGlashan, Thomas H., MD The Borderline: Current Empirical Research American Psychiatric Press, Washington, D.C. 1985

15. Johnson, C; Tobin, D; Enright, A: “Prevalence and Clinical Characteristics of Borderline Patients in an Eating-Disordered Population.” J Clin Psychiatry 1989 Jan;50(1):9-15

16. Pfohl, B: Medical Basis of Psychiatry W.B. Saunders Company, Philadelphia, PA 1986 Ch. 28

17. Gardner, D; Lucas, P; Cowdry, R: “Soft Sign Neurological Abnormalities in Borderline Personality Disorder and Normal Control Subjects.” Journal of Nervous and Mental Disease Vol 175 No3 1987

18. Steiner, M; Links, P; Korzekwa, M: “Biological Markers in Borderline Personality Disorders: An Overview.” Can J Psychiatry Vol 33 June 1988

19. McNamara, E; Reynolds, C III, Soloff P: “EEG Sleep Evaluation of Depression in Borderline Patients.” Am J Psychiatry 141:2 February 1984

20. Kellner, C; Post, R; Putnam, F; Cowdry, R; Gardner, D: “Intravenous Procaine as a Probe of Limbic System Activity in Psychiatric Patients and Normal Controls.” Biological Psychiatry 1987;22:1107-1126

21. Kutcher, S; Blackwood, D: “Auditory P300 in Borderline Personality Disorder and Schizophrenia.” Arch Gen Psychiatry Vol 44 July 1987

22. Cornelius, J; Brenner, R; Soloff, P: “EEG Abnormalities in BPD: Specific or nonspecific.” Biol Psychiatry 1986;21:974-977

23. Cowdry, R; Pickar, D; Davies, R: “Symptoms and EEG Findings in the Borderline Syndrome.” Int’s J Psychiatry in Medicine Vol 15(3) 1985-86

24. Southwick, SM; Yehuda, R, Giller, EL Jr; Perry, BD: “Altered Platelet Alpha 2-/Adrenerigic Receptor Binding Sites in the Borderline Personality Disorder.” Am J Psychiatry 1990 Aug;147(8):1014-7

25. Yehuda, R; Southwick, SM; Edell, WS; Giller, EL Jr: “Low Platelet Monoamine Oxidase Activity in the Borderline Personality Disorder.” Psychiatry Res 1989 Dec;30(3):265-73

26. Lahmeyer, HW; Val, E; Gaviria, FM; Prasad, RB; Pandey, GN: EEG Sleep, Lithium Transport, Dexamethasone Suppression, and Monoamine Oxidase Activity in the Borderline Personality Disorder.” Psychiatry Res 1988 Jul;25(1):19-30

27. Lucas, P; Gardner, D; Cowdry R; Pickar, D: “Cerebral Structure in Borderline Personality Disorder.” Psychiatry Res 1989 Feb;27(2):111-5

28. Pine, F: “On the Development of the “Borderline-Child-To-Be.” Amer J. Orthopsychiat 56(3) July 1986

29. Ogata, SN; Silk, KR; Goodrich, S; Lohr, NE; Westen, D; Hill, EM: “Childhood Sexual and Physical Abuse in Adult Patients With Borderline Personality Disorder.” Am J Psychiatry 1990 Aug;147(8):1008-13

30. Herman, JL; Perry, JC; van der Kolk, BA: “Childhood Trauma in Borderline Personality Disorder.” Am J Psychiatry 1990 Aug;147(8):1008-13

31. Swartz, M; Blazer, D; George, L: “Identification of Borderline Personality Disorder With the NIMH Diagnostic Interview Schedule.” Am J Psychiatry 146:2 February 1989

32. Resnick, R; Goldberg, S; Schulz, C: “Borderline Personality Disorder: Replication of MMPI Profiles.” Journal of Clinical Psychology. Vol 44 No 3 May 1988

33. Sternbach, H; Fleming, J; Extein, I; Pottash, ALC; Gold, M: “Short Communication The Dexamethasone Suppression and Thyrotropin-Releasing Hormone Tests in Depressed Borderline Patients.” Psychoneuroendocrinology, Vol 8, No 4 pp459-463, 1983

34. Garbutt, J; George, A: “Paradoxical Effects of Amitriptyline on Borderline Patients.” Am J Psychiatry 143:12 December 1986

 

Copyright 1991; Permission granted by Leland M. Heller, M.D.