QUESTION:
Dear Dr. Heller,
My son has had emotional problems most of his life. He’s 19 years old. His father is an alcoholic, and could go into a rage from time to time, but manages to hold onto a very good job. My son’s problems seem to be that he can’t get along with people and will do things to get them angry at him.
He went to live with his father for two years and during that time got into so much trouble. He started stealing from his father and then from a friend’s father and got caught. He was charged with three felonies for check forgery. When he came back to me he was so out of control. Cutting himself, stealing, lying. Doing really strange things to get back at me if I disciplined him. He couldn’t sleep. Would steal my car and drive all night long. I took him to a psychiatrist and he said he has BPD. He started him on Risperdal. Then I took him to another doctor who put him on Depakote. Now he’s on Depakote 500 mg in a.m. and 500 in p.m., 4 mg Risperdal, and 20 mg Paxil. He’s groggy most of the time and has gained about 100 pounds. It’s so sad. So the doctor suggested Neurontin instead of the Depakote to lose weight. He just started that the other day and last night he said he was feeling suicidal and felt like cutting himself again. The doctor said give it two more days and then if no better would put him back on the Depakote. But the weight gain is horrible! Does this sound like BPD? I would like to try him on your plan of Prozac and then Tegretol. Does Tegretol have the weight gain associated with it like Depakote, or is the Risperdal causing the massive weight gain?
ANSWER:
The BPD sounds like a likely diagnosis, although Im highly suspicious AD(H)D may be present as well. I strongly recommend doing the screening test that I use for my patients – and for both you and the boys father to do the test to see what diagnoses you have in common. Genetics plays a very powerful role. Treating all the diagnoses comprehensively is crucial. Ive never been impressed with Depakote. It just doesnt work that well for most patients in my experience. Tegretol is generally far superior. Unlike Depakote, Tegretol doesnt cause weight gain unless it also causes low thyroid (which can of itself cause weight gain but is easily treatable). Risperdal and Zyprexa can cause profound weight gain. I prefer to use Risperdal only during the most severe crises, suicidal spells, and during severe dysphoria (anxiety, rage, depression and despair). Neurontin can be a fair second or third choice for a mood stabilizer, but it rarely works. I also havent found Paxil to be as effective in treating the BPD as Prozac is, but it is a reasonable second choice. Paxil can profoundly worsen irritable bowel syndrome in some patients.