(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
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