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Dysphoria & PMS

    Dysphoria & PMS

    QUESTION:

    Dear Dr. Heller,

    I am a 41 year-old woman who has been diagnosed with BPD for over three years now. My current drug regimen is 60 mg a day of Prozac and one 150 ml Wellbutrin per day. Complications: I have been diabetic (using glipizide) for over 10 years, do not control my diet well, don’t exercise much, am about 90-100 lbs over my ideal weight. At some point I realized that in the week before my period, I often had one day of terrible rage or sadness. As I’m getting older, I find that there seems to be more and more a correlation between dysphoria levels and the time after ovulation and before my next period. The durations and intensity vary, but it seems to me my worst dysphoria is at that time, usually in the week before my period. Last week for example, I cut myself twice (more than in a long time), then suddenly felt sane again Tuesday, and my period started Wednesday. The difference is remarkable… it feels like I push through a glass wall and find sanity again, though I don’t realize while dysphoric how dysphoric I am. Do you see in your practice ties between BPD and the menstrual cycle, and particularly changes with premenopause? Is there anything I can do to lessen the dysphoria in the premenstrual period? I see you recommend Tegretol a lot… do you think it would be better for me than the Wellbutrin? I think I feel more stable on the Wellbutrin, but it has not stopped the dysphoria from being particularly bad lately, triggered by a change in a relationship. Many thanks..

     

    ANSWER:

    There is a direct correlation between PMS and BPD dysphoria. My patients no longer have a problem with this due to a safe and effective treatment for the underlying problem in PMS – fluid retention causing brain swelling. I explain PMS, particularly in those with the BPD, in my new book “Biological Unhappiness” (http://pks.947.myftpupload.com/order.htm) and there is a true story in that section which will describe you perfectly.

    Mid-cycle dysphoria usually means either cyclothymic disorder is also present or the temporary drop in hormones is triggering the same phenomenon as PMS. In my practice, I recommend trying the same treatment for this mid-cycle problem as for PMS. A very reasonable option at your age is continuous hormones to prevent these terrible mood swings. The above 40 age group has the most abortions, and whether you are “pro choice” or “pro life” – all agree preventing unwanted pregnancies is the best option. Early menopause causes severe irritability which can be deadly for borderlines, and it’s clear treating menopausal and post menopausal women with estrogen replacement has an incredible benefit, particularly for those prone to depression.

    Smashing your fist through glass and injuring it is very much like scratching a severe itch – it temporarily relieves the horrible sensation, but injures the body. There are safer and more effective ways for you to “restore my sanity.” http://pks.947.myftpupload.com/dysphori.htm

    I have enormous respect for what Tegretol can do for BPD individuals with dysphoria, both in treatment and prevention. An option I would give my patients in this regard is to take Tegretol at night only, a few days before mid cycle and before the PMS time.

    I rarely prescribe Wellbutrin anymore since, to me, better options are available. It’s also being used to help folks quit smoking under the brand name “Zyban.” Since recent data seems to indicate Wellbutrin is not significantly better at not causing mania, I don’t perceive a real good reason to use it in my practice. It’s used in combination with SSRI’s for sexual dysfunction, but in my experience is rarely successful. Ginkgo is usually more successful, and you can read about it at ../Ginkgo.htm.

    My “How I Treat the BPD and Why” may be useful to you as well. It’s located at: ../HowBPD-Y.htm.

Should Tegretol use be as needed only?

QUESTION:

Dear Dr Heller,

I have read your first book and am very grateful for all your research and work that you have done in regards to this debilitating illness.

My son now in his early 20’s has had problems with anger management from a young age and after seeing numerous psychologists and psychiatrists through the years has been diagnosed BPD.  He has been on Prozac at various strengths 20mg up to 60mg only for the last 6 years and even with psych visits lost it completely a couple of years ago, starting a trend of self destructive behavior involving gambling/alcohol addiction that led to lying stealing and bizarre rages.

After reading your book 2 years ago I tried and failed to get the treatment you recommend until now.  I have returned to my former physician who thinks your treatment plan is sensible and safe and is willing to give it a try.  Yay!  He is very interested in your procedure and has prescribed Prozac, Haloperidol, Tegretol and Risperdal as per your patients’ dysphoria instruction sheet.

My question is in reference to your good results with Tegretol.  Should he start using it on a regular basis or just according to the instruction sheet?

Also in regards to Haloperidol when is it a good idea to use this as a preventative?  His dramatic mood change comes soon after a personal upset and there’s no predicting them.

ANSWER:

Thank you for your kind words.  Chronic Tegretol use depends on the patient and the symptoms.  Based on what you wrote he probably would benefit from it – the goal is to get the level in the upper third of normal.

It’s an excellent idea to use Haldol as a preventive treatment.

What’s causing my memory and mood problems?

    What’s causing my memory and mood problems?

    QUESTION:

    Dear Doctor,

    I am not asking for a diagnosis, but I would like to understand.  I do not seem to have long-term or short-term memory.  I don’t remember my childhood (this could be from things that were bad, so I wanted to forget), or last week.  I don’t seem to retain information.  I read a lot and such, but I can’t remember enough to bother reading.  It seems to take me a lot longer to recall information than others.  It takes me normally 1 hour to 3 days to recall something.

    I do not finish tasks, nor do I seem motivated.  I don’t seem to care about anything.  I am not happy the majority of the time.  I also get mad a lot and have fits of rage.  I can plan fun stuff for my kids, but after 10 minutes, I don’t want to.  I yell a lot.

    I was told in high school that I was dyslexic, because I have trouble spelling, I was told that I did not have a speech problem.  I think I do.

    Can you give me some idea of what is wrong.  Also, I seem to switch from happy to mad at the drop of a hat.

    ANSWER:

    The memory problems are likely related to ADHD (http://pks.947.myftpupload.com/AD-H-Dcr.htm) and the BPD (http://pks.947.myftpupload.com/bpd.htm)

    It’s very common to have both ADHD and the BPD.  Memory problems are common in both.  Sometimes B12 deficiency can contribute to the memory problems.

    A lot of my dyslexia patients have ADHD with the generalized anxiety disorder.  I’d recommend you look into all of these diagnoses.  The screening test might be of help, and can be found at http://pks.947.myftpupload.com/screen.htm

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Why Has Zoloft Stopped Working And What Can Be Done About It?

QUESTION:

Dear Dr. Heller,

Great relief of chronic depression from Zoloft for 3 years, then effectiveness decreased by 75%. Have any other drugs been shown to pick up the slack in this situation?

Thank You

ANSWER:

The two most common causes for this are:

  1. BPD (Borderline personality disorder) with chronic dysphoria (anxiety, rage, depression and despair). The depression of dysphoria is neurologically different than regular depression.
  2. An imbalance of serotonin with noradrenaline and dopamine. SSRI’s like Zoloft raise serotonin and a relative imbalance can occur. Adding Wellbutrin usually solves the problem.

Is This the Right Combination for my Daughter?

QUESTION:

Hi Dr. Heller,

My daughter is 20 and currently in the state mental hospital. She has recently been diagnosed with depression with psychotic features and borderline personality disorder. They have her on 1000mg. Depakote and 30 mg. Paxil.

She is like a zombie and they just keep telling her to “relearn new skills”. She can’t function and sleeps most of the day. She then misses out on her groups and then loses her privileges. She has had many different diagnoses throughout her life, from ADHD to Bi-Polar. Do you think this med. combo is the wrong one and how long should the Dr. wait before changing it?

Thank You.

 

ANSWER:

If she is “like a zombie” and not doing well, the medication regimen isn’t a good one. Blood levels of medications are far more important than the actual dose. I consider Depakote and Paxil secondary medications for the BPD.  They can be effective, but they’re not the best for most patients.

The most important issue here is what exactly her diagnoses are. I doubt if only one diagnosis is present. There are a number of diagnoses that need to be addressed. BPD, bipolar, and ADHD are just a few. The screening test, official criteria, and “Is it bipolar, BPD or ADHD” will undoubtedly be useful to you.

I can’t understate the importance of making all the diagnoses. The generalized anxiety disorder is particularly important. I have a few adolescents who are extraordinarily difficult to manage, and my heart goes out to you, the child, and the dedicated people trying desperately to succeed with her. I encourage you to get as much information as you can.

Can a Psychiatrist Have the BPD?

    Can a Psychiatrist Have the BPD?

    QUESTION:

    Dr. Heller,

    Have you ever heard of a Psychiatrist being borderline?? I have had a 7 year relationship with this man. I am 52, he is 61 and both have had previous marriages. I have done extensive reading and am convinced that he is afflicted with this problem.

    When our relationship is on track, everyone we know envies us and considers us to be the perfect couple- true soul mates. About 7 times, perhaps a few more- he would rage at me for the most ridiculous reasons (actually no reason) and become so verbally abusive that once he even called the local police to have me removed from his clinic while I was trying to talk some sense into him about his accusations. Unlike a normal relationship where the two parties can have a dialogue, his rages are strictly a monologue.

    Two weeks prior to the final rage, we were out of town at a family wedding (his side of the family) and he sang my praises – telling of how I was the most important person in the world to him – to his family and telling me in private that he was afraid that I was going to leave him for a younger man. A couple of days after Xmas, I found out through other means that he was lying to me about who we were spending New Year’s Eve with and because I am by nature a pacifist and because I am afraid to put him into a rage – I very gingerly approached the subject – like – is there something that you are uncomfortable about that perhaps we should talk about?? He screamed that he never wanted to see me again and he was tired of my “splitting.” From that moment on, I figured that he must know that he is borderline.

    Under the circumstances of his being a health professional, do you think that he knows what is going on here?? Do borderlines ever have remorse or fond memories of their significant other?? Do they ever try to make amends? He is incapable of saying that he is sorry. I did get a CD of love songs placed in my mailbox which I know came from him. I ignored it.

    Also, Dr., I have one more question. Do borderlines have a particularly difficult time with control and their children. The man in question has two adult adopted children whom he will not let out of his control. The boy and his wife even live with him – for no apparent reason – especially not financial. We are both attending the wedding of a friend’s daughter and I am really fearful about what to expect. To this point, he has come into my business and will not acknowledge that I am alive. I don’t know if I should ignore him, be civil. I don’t know what to do.

    Thanks so much for listening.

     

    ANSWER:

    1) There is no reason an individual with the BPD can’t be found in any profession. I have treated many in the mental health professions for the BPD. Whether it’s appropriate for the individual to be functioning in a profession depends upon the individual’s perception of stress and therefore their ability to handle it. Studies show that untreated borderlines tend to do well in employment situations over time – particularly if they are smart and have financial resources.

    2) He may or may not be aware of what’s happening. If he perceives the BPD is a death sentence, that it only fits self-mutilators, and that it can’t afflict doctors or other mental health professionals then it’s unlikely he’d recognize the disorder in himself. They can try to make amends, and it appears the love song CD was an example, although many people are extremely afraid of admitting a mistake or of being wrong.

    3) Borderlines often have remorse and fond memories, but it depends upon what psychotic interpretations developed. If he/she believes someone truly behaved terribly, he/she will treat that individual with contempt subsequently whether that person is “guilty” or not.

    4) The usual situation is problems with children. Control issues are common, and misinterpretation issues are extremely common. It’s rarely due to lack of good intentions. There’s a high likelihood that behaviors begun when they were small children will continue as adults, although it’s highly variable.

    5) I can’t make any specific recommendations about what you should do, but there is a question I often ask my patients: “If your child was in your exact position, what would you recommend?” It’s usually smart to take your own advice.

 

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