Diagnosing
Borderline Personality Disorder
And Finding Treatment That Works
online conference transcript

Leland Heller, M.D. is a family practice doctor who specializes in psychiatric illnesses.  He is a Borderline Personality Disorder treatment expert and author of the books, "Life on the Border: Understanding and Recovering from the Borderline Personality Disorder" and "Biological Unhappiness". 

David Roberts is the HealthyPlace.com moderator.

The people in green are audience members.

BEGINNING

David: Good Evening.  I'm David Roberts.  I'm the moderator for tonight's conference.  I want to welcome everyone to HealthyPlace.com.  I hope everyone's day has gone well.  Our conference tonight is on "Diagnosing Borderline Personality Disorder (BPD) and Finding a Treatment That Works".  Our guest is Leland Heller, M.D. His "Biological Unhappiness" site is located here at HealthyPlace.com.   Dr. Heller is a family practice doctor.  His office is in Florida. 

Although he is a family practice doctor, during his residency Dr. Heller specialized in psychiatric illnesses and later became very interested in Borderline Personality Disorder.  He has treated over 3,000 patients with BPD and has run a BPD support group for nearly 4 years.  Dr. Heller has also authored two books: "Life on the Border: Understanding and Recovering from the Borderline Personality Disorder" and "Biological Unhappiness".

Good Evening Dr. Heller and welcome to HealthyPlace.com. Thank you for agreeing to be our guest.  Because people in the audience may have different levels of understanding, please define Borderline Personality Disorder and it's affects on those who suffer from it.

Dr Heller: Good evening, It's great to be here. I have a way of explaining the Borderline Personality Disorder in layman's terms that might be useful.  It's how I explain it to patients and their families.

Imagine you had a pet dog and it runs into the street and by accident it's hit by a car.  The dog's leg is broken and it limps off into an alley to lick it's wounds.  A friend of yours sees the dog and comes over to help.  The dog is now feeling trapped and cornered - a "wounded animal" - and misinterprets the friend's attempts to help.  The dog snaps at the friend's hand who is trying to help.  The BPD (Borderline Personality Disorder) is a malfunction in the brain's trapped or "cornered" animal area.  Under stress, a seizure develops in that area.  That's why under stress, while raging, a borderline will say to him or herself:  "Why am I doing this" - yet be unable to stop it.  It's a seizure - nerve cells firing inappropriately and out of control.

David: And the cause of Borderline Personality Disorder?

Dr Heller: The BPD has many causes including head trauma and brain infections, but it appears that emotional hurts literally damage the brain.  Most likely the brain's support cells - the 90% of brain cells called "glial cells" - are damaged by traumas, causing the person to overreact to stress once puberty strikes.  During puberty the brain's limbic system goes into "overdrive" and adolescents are at their highest risk of seizures in their lifetime.  "Sticks and stones may break my bones...but names cause brain damage."  So does incest, abuse, severe trauma, head injuries, attention deficit disorder, and other causes.

David: From my understanding, one of the biggest difficulties facing individuals who have BPD is maintaining stable relationships.  This is a great cause of consternation for those people who are on the other side of the relationship.  What causes this?

Dr Heller: There are a number of problems.  The three most significant are 1) inappropriate mood swings; 2) misinterpretation of motives; and 3) remembering those misinterpreted motives as real.  Oftentimes self-fulfilling prophecies occur, and self-hate eventually leads to a significant other coming to the same conclusion - that the individual isn't worth being with.

David: I have received a few requests for the official criteria -- the DSM criteria for Borderline Personality Disorder.  Here they are:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistent unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress related paranoia or severe dissociative symptoms

When a person comes into your office, Dr. Heller, are there any tests you do to determine if the person is BPD?

Dr Heller: I go over the DSM criteria. There are no blood tests, physical examination findings, or imaging studies that can give the information.

David: Here's an audience question:

CrossEyed Rottweiler: Are there neurological examinations that can support your theory of BPD?

Dr Heller: This is something I emphasize - no one "is" BPD, they have BPD.  No more than someone is a bad gallbladder.

There are neurological soft signs. There can be short term memory impairment, visual findings - but these are specialized and are not specific to the BPD.  In other words, it won't make a difference.  The BPD is a potentially life destroying illness that must be treated even without "proof."   This is no different than someone going to the emergency room with crushing chest pain, shortness of breath, left arm numb, breaking out in a sweat and vomiting. It's presumed to be a heart attack first, and we go from there.

BarbNY: Why are some people affected by these "emotional hurts" and others are not.

Dr Heller: It's an excellent question.  Virtually all of us are affected by the hurts.  Some of us have more severe hurts, or less of a support system, or a genetic predisposition.  It does depend upon the individual.

savanah: DSM is a way of labeling and is not a diagnosis.  What can a person do to get proper diagnosis?

Dr Heller: While any diagnosis can be used as a way of labeling or hurting someone, the BPD is a very real disorder that affects many, many people.  I've not been a part of the diagnosis establishing, but my experience has made it clear it's very, very real.

David: To follow-up on Savanah's question though, people go to their doctor or psychiatrist hoping they are doing the right thing.  How do you find the right doctor to treat BPD and secondly what should a good doctor be doing to determine the BPD diagnosis?

Dr Heller: A very difficult problem.  I got involved as a family physician because the psychiatrists refused to take care of my suicidal borderlines.  I literally had patients get on their hands and knees begging me to write my first book.  That's how I got involved.  I found medications that were working, I looked at the literature - and it confirmed these medication choices.  There are no hard and fast rules.  There are many, many physicians who really believe in what they do and in helping people as their highest priority.  Sometimes they literally have to be interviewed by the patient.  Finding someone who is open-minded and willing to look at the literature is crucial. 

The information is there.  Prejudice, misinformation, old information, and blaming patients for their problems get in the way.  I get calls and correspondence from physicians all over the world who have used these medication combinations and retraining methods and also found them successful. The data is there, but with 1600 articles published daily it's hard for physicians to keep up on everything.  The person responsible for your health is you, and sometimes you have to ask questions.

janet: Would you please tell us more about the self-hate characteristic and how that damages the BPD or his/her relationships?

Dr Heller: Much of it comes from self-destructive behaviors that are used to stop the horrible pain of dysphoria; anxiety, rage, depression and despair.  When an individual behaves out-of-control, in a manner that's inconsistent with their beliefs or normal choices, terrible self-hate develops.  Additionally many individuals had low self-esteem and related problems since childhood and are in an environment that causes self-hate to flourish.

crazy32810: How is self-injury related to BPD?

Dr Heller: We all injure ourselves to stop noxious neurological sensations. Interestingly we do it in a linear manner, ripping the skin.  A common noxious neurological sensation is the toxins released with an insect bite.  BPD dysphoria is about as bad as it gets.  The pain is horrible.  Many individuals have broken major bones and declared the pain of the fracture was nowhere as severe as dysphoria.  When an individual with the BPD discovers that self-mutilation, or other techniques of self injury, work to temporarily stop the pain of dysphoria - they'll do what it takes to stop it.  This is no different than the individual with a fracture wants pain medication.  I broke my shoulder last December and I tried to deal with it without taking narcotics.  I was foolish and wrong.  The pain was so bad it needed to be treated medically.  Once individuals with the BPD have their chronic symptoms stabilized, and have safe medication options that work for dysphoria, the self-destructive patterns are no longer needed to stop their pain.

 David: I want to move onto treatment of Borderline Personality Disorder.  How are the treatments selected and what is available today?

Dr Heller: There are a number of treatment approaches.  I agree completely with Dr. Karousi from 1991 where the use of seritongergic medications like Prozac, mood stabilizers like Tegretol, and low-dose neuroleptics like Haldol for transient psychosis can work.

My technique is to use the "screening test" that's available at my website here at HealthyPlace.com and look for the most common diagnoses.  I also do the "Zung" depression index to see how depressed they are.  I also do the DSM IV criteria for the Borderline Personality Disorder.

Once the diagnosis is established, I generally begin an SSRI - usually Prozac, adding Tegretol a week later.  For some reason, it takes a week on Prozac for Tegretol to really work well.  Some patients need Tegretol for awhile, others just as needed.

I'll then treat the other diagnoses - the most common being the generalized anxiety disorder, attention deficit disorder, obsessive-compulsive problems, etc.  It's extremely unusual for the BPD to exist by itself.

David: Dr. Heller, what role does therapy play in the treatment of the Borderline Personality Disorder, and is it necessary?

Dr Heller: There are articles in the BPD section on the medications, the dysphoria instruction sheet I use for my patients, the literature and lots of other useful information sources.  Therapy is extremely important for treating the BPD.  However, it rarely works well until the medications are correct.  Borderlines have lots to learn regarding social skills, trying to determine which memories are real and which were incorrectly interpreted during psychosis, learning self-esteem, etc.

David: Here are some audience questions regarding treatment:

TheDreamer: Why is Tegretol used most out of all the mood stabilizers for BPD?  Is seeing images and hearing commanding voices a part of BPD?  Is 2mg of Risperdal high enough dose to rid these symptoms?

Dr Heller: Tegretol works the best.  It's been around a long time, so we know a lot about it.  Dr. Cowdry at NIMH did studies published in 1986 and 1988 in the Green Journal that showed tegretol worked to reduce behavioral dyscontrol.  This was in a double-blinded cross over study.  I use it the most for one simple reason - it works! ...and it works well!

Hallucinations can be a part of the BPD psychosis experience, but it's very uncommon.  Temporal lobe seizure symptoms such as deja vu, unreality and seeing things through someone else's eyes are more common.

When Risperdal is needed, 3mg is the usual dose in my experience.  It doesn't work well when used every day - it's better as a "control/alt/delete" medication to reboot the limbic system when it's stressed out.

summertime: My doctor won't push Prozac dose over 60mg/day because it is max in Britain.  What else could I try?  I'm also on Tegretol 200mg twice daily and Haloperidol as required.

Dr Heller: About 10% of patients need 80mg, and a few need higher.  Dr. Markovitz and others are prescribing very high doses of it and other SSRI's.  Prozac will be generic shortly, which should simplify the process.  The dose of Tegretol doesn't matter - what does matter is the blood level. That needs to be in the upper half to third of normal. Haloperidol as needed is sensational, as my "dysphoria instruction sheet" recommends.  Just as crucial for treating the BPD is the other diagnosis, such as the General Anxiety Disorder, ADD (Attention Deficit Disorder), etc.  Treating the Borderline Personality Disorder) alone rarely does the whole job.

Irene: How do you get help for a teenager who ABSOLUTELY refuses to get help and will NOT cooperate with a therapist?

Dr Heller: Another tough problem.  After age 18, there's nothing you can do.  Before 18, you're still the boss, even though the adolescent may believe otherwise.  Worst case, the teen may need hospitalization.  Once hospitalized, medications will be administered.  Almost every teenager I've dealt with is willing to try if you present the disorder to them in a clinical and easy to diagnose manner.  It's crucial to make sure they understand they neither caused their disorder nor chose it.  Optimism about it's treatment is important as well.  No matter how angry the individual with BPD is, they are still in pain and want the pain to stop.  That "wounded" animal response is simply kicking in, and likely having a seizure.  These seizures can be chronic as well.  I tell my patients that I don't want them to believe me based on my words, because talk is cheap.  I hope what I have said makes enough sense that they'll try the medication and see if I told the truth or not.  I want results to speak for themselves.

David: For the audience, I'd be interested in knowing what treatments have worked for you.

If you would like some additional insight into what living with a personality disorder is like, here's the link to our journalers in the Personality Disorders Community who keep online diaries of their experiences.  You can read them and post your comments on their bulletin boards.

Here are some audience comments on what has worked treatment-wise for you:

Marci: I was on Tegratol for several years which helped, and I was even able to wean off of it until a robbery recently which precipitated BPD rearing its ugly head again, and now nothing seems to help.

savanah: After my therapist dumped me, I got educated and began recovery on my own.  I believe that you are accountable for how you feel.

ssue32: I have been on Depakote for many years and it has helped a lot plus I have begun therapy on abuse issues I never wanted to explore

David: I'm also interested in knowing from those of you with Borderline Personality Disorder; what is the most difficult aspect of having it?

Ona1: I find that my extreme mood shifts and behavior are the worst for me.  That, and the self-injury aspect.

Silent: Not knowing what is wrong with you, but the constant feeling of being alone, the thought of wanting to die, is so depressing.

ssue32: For me, it is the self-injury and also believing at any minute I will be abandoned.

savanah: the most difficult aspect is trying to get loved ones to understand what it feels like to be BPD.  It's like explaining to someone who has never had cancer what it feels like.  Not easy!

Marci: I think for me the most difficult aspect is the stigma attached to Borderline Personality Disorder, and the difficulty of finding a professional to help you.

Rednebsaf: Trying to believe I don't have it every time I hurt myself

Ona1: I have recently been diagnosed with BPD and the most difficult thing has been the extremes of my behavior. I fight with it constantly.

donna2: The most difficult aspect of having BPD is not having a passion for anything.  I see people with hobbies and collections and I have no interest in anything.  All I do is survive from day-to-day.

cypress: I have also been recently diagnosed. Its hard to know whether or not the diagnosis is correct.

susie: Have been diagnosed with DID but many don't believe it.  They say that I may have BPD.

David: One of the things that some have trouble dealing with are the extremes in behavior.  What is your suggestion for dealing with that?

Dr Heller: The extremes in behavior are medical problems.  The individual misinterprets reality, and acts reasonably based on that misinterpretation.  The most important aspect here is medication, particularly as needed.  The therapist I work with the most - and ran 3 treatment programs with - became interested when she attended some family support groups I ran.  The therapist was amazed at how, as needed, Haldol worked.  The family members saw the results.

David: One of the other troubling aspects that audience members mentioned was what I would call "severe depression".  The sense of hopelessness that things won't get any better and despair.

Dr Heller: Once the medications are even partially stabilized, that dysphoria based depression is usually gone in 3 hours, at most 24 hours.  The sequencing of medications can be as important as the actual medications.

An interesting but true story.  I have a patient who was sexually molested from age 4-16.  She was finally doing well.  On a Monday morning, she came into the office in the fetal position saying she wanted to die - because her ex-husband had just been arrested for sexually molesting their four year old daughter.  I gave her 3mg of Risperdal and 400mg of Tegretol and asked her boyfriend to stay with her until she falls asleep - likely within three hours.  When she woke up the next morning she came into the office and said "Gosh Doc, I can't believe how much better I feel."  She was better able to cope with the bad news which I believe speaks to the benefits and effectiveness of some medications. I see cases like this every day.  Some patients need higher doses, but these are the results I expect.

Some recent scientific studies confirm that the depression in BPD dysphoria is a different phenomenon than regular depression.

David: I want to make sure I ask this next question clearly.  Some doctors have told BPD patients that BPD is incurable.  That, yes, some "symptoms" can be dealt with, but a complete recovery is impossible.  Is that true?  And is that your experience in treating over 3,000 BPD patients?

Dr Heller: I think that expectation is the problem.  The comorbidities are the key.  Unless they also have character problems, borderlines can do extremely well.

Two former self-mutilators work for me.  They have to learn to like and love themselves, to gain self-confidence, social skills, and how to succeed in relationships.  It's a learnable skill.

If the individual wants to be successful more than they want what they're doing to be declared "correct," they can have success in every important area of life.

My goals are very high - I want success in every important area of life.  When not treated in this way, the literature shows that some will have moderate work success and no success in relationships - and that success depends upon being brilliant, obsessive, rich and good looking!

I don't believe that success and happiness are reserved for the rich and gorgeous.  I believe in mastering the principles of success - because by mastering them you'll have learned the principles of being successful in everything important - including relationships.

Three things are necessary for success: 1) diagnosing and comprehensively treating everything that's wrong; 2) have a formal plan for stress and dysphoria; and 3) retraining the brain.

David: Here are some audience questions:

BarbNY: Do you believe in giving mega doses of SSRI's?

Dr Heller: Not in general.  Most borderlines do well on 20-40mg of Prozac - which I believe strongly is the best one. Some individuals do well with high doses, and sometimes they're clearly needed, but high doses are expensive and potentially risky.  Inappropriate moodiness, chronic anger, lack of energy, and emptiness are to me the most significant signs that a higher dose should be tried.  The change is often dramatic by the next day.

Luci: As prozac at 40mg a day did very little for me I have been switched to Venlafaxine.  Is there any evidence that Venlafaxine can be used successfully in aiding treatment of BPD?

Dr Heller: Yes.  Effexor - the brand name - has been shown to work.  I've never seen anyone do great on it.  The studies are with very high doses - in the 450-600mg dose range.  Side-effects are usually a huge problem at these doses.  Effexor has effects on different neurotransmitters as the dose is increased.  High doses have anti-psychotic effects, and the long term safety has clearly not been established.

I greatly fear the chronic daily use of medications that block dopamine - as neuroleptics and the GI medication Reglan have caused tardive dyskinesia.  The newer agents are better and safer, but still have risks.

David: Here are some audience comments about what's being said tonight, then more questions:

donna2: I don't want to be on medications.  I have such a small reality base as it is I'm afraid I'll lose it altogether.  I was on various medications for years and nothing helped anyway.

cypress: I've been on medications for 3 months and I still feel suicidal.

donna2: I agree about depression in BPD being different.  I don't want to kill myself, I want to kill the bad things that are bothering me.  I don't lie around.

mazey: I am in recovery in all different areas including self-injury.  I'm very afraid that one day I will snap and the borderline stuff will consume me again.

Dr Heller: It's not just medications, but which medications, the doses, and the sequence.  That penicillin didn't work for moodiness doesn't mean another medication won't work. The long-term data is so profound that the choice to avoid medications is a very dangerous and painful one.  It's not a tragedy that one needs medication, it's a miracle that such safe and effective medications are available.

Rednebsaf: How do you feel about Dielectical Behavioral Therapy?

Dr Heller: How do I feel about Dialectical Behavioral Therapy in treating Borderline Personality Disorder?  DBT is an excellent program, and I give Marsha Linehan tons of credit for developing a counseling approach that reduced suicide and self-mutilation attempts by half.  It's difficult to replicate in the "real world" of managed care, limited funds, etc.  Actually, Dr. Linehan's approach and mine are quite similar in a lot of ways.  This is particularly true regarding validating what the individual is feeling, talking straight with them, making them aware of consequences even though the brain is leading them towards places they don't really want to go.

cypress: I was on Prozac 80, but have been cut back to 40, do you consider 80 a "mega dose"?

Dr Heller: No - it's within the FDA approved dose range. Mega doses would be above the FDA approved levels for dosing.  But "mega" is an arbitrary term.  I want success for my patients, and sometimes the economics and politics behind FDA recommendations must be bypassed.

David: A few more audience comments:

cypress: It's hard to deal with the stigma of having a mental illness.

Jocasta: Your focus is much on medication Dr. Heller, and true that must be treating for the biological disorder that lives along with BPD.  But is it not true that once medications are even somewhat effective, intensive therapy dealing with interpersonal skills, and ways of dealing with BPD by practicing working at relationships, working on improving self-esteem, and getting to the nitty gritty part that being abused is not one's fault; this is all in the post medication treatment, which has helped me equally.

Dr Heller: Jocasta: absolutely - which is what I've written about at length in my books, my website, and in tonight's chat.  It's the combination of medication, as needed medication, and retraining the brain that's needed.

Zppt2da: I have had unhealthy relationships that I feel they are all related to an issue back from childhood with father.  I have opened up a wound of self mutilating form 8 years, I have read titles of cutting and self mutilating and why this happens (overwhelming), and I am finding it hard to find a therapist who will take me on.  You are threatened with a contract of no self injury, I have taken Dielectical Behavioral Therapy (DBT), but I don't know where else to turn too for help.

David: Dr. Heller, Zppt2da makes a good point, and it follows on something you said tonight.

Dr Heller: To Zppt2da: The trauma may have been a trigger for your condition, but it doesn't have to rule your life.  I don't use self-mutilation as a cause to punish someone.  That individual is in pain and needs help.

David: You mentioned that many therapists and psychiatrists don't want to take on patients who are suicidal. Where does one go then to get the help they need?

Dr Heller: Why you are who you are now and how you got here is of minimal importance, compared with who you want to be and how you get there.  And that also includes patients who self-injure.   You literally have to search, you have to have the information in hand, and you have to ask questions. There's lots of material on line - particularly on my site - that can be of enormous help to patients - including those who self-injure.  Be educated, and bring concise information in for the physician.  Physicians who are open minded - including open minded skeptics - welcome the opportunity to know more and to help patients.  This is particularly true when non-addicting medications aren't used.  Family physicians prescribe most mental health medications in the US - and that's a good place to start.  There is a suicide attempt per minute in the US - it's not just a topic for psychiatrists.

ssue32: I am on Depakote, Wellbutrin and Celexa in high doses.  Are these good for treatment of BPD, and are there any risks in the higher doses?

Dr Heller: Depakote is the more dangerous of the group. High doses of SSRI's can cause "serotonin syndrome" - although usually only when combined with other medications such as tricyclic antidepressants.  Depakote often works as well as Tegretol, just not as consistently.  Wellbutrin is commonly used also - particularly as it's other brand name "Zyban" to help patients quit smoking.  I don't prescribe it very often.  I have some patients on Celexa, but most prefer Prozac in head to head combination.

Silent: When in treatment, how long should it take for a person to find relief, or some relief, or does it never happen?

Dr Heller: I haven't had an individual fail to have a significant response in years - particularly when all the diagnoses are made.  An individual with the BPD should be dramatically better within 7 days or something else significant is going on.

David: It is getting late.  I want to thank Dr. Heller for being our guest tonight and sharing his knowledge and expertise with us.  I also want to thank everyone in the audience for coming and participating.  I especially like getting the audience involved because we can learn from each other too.

Dr Heller: It's been my pleasure, and I hope I've been of help to you.

David: Here's the link to the HealthyPlace.com Personality Disorders Community.  I encourage to you sign up for the mail list so you can keep up with community events.

Don't forget to visit Dr. Heller's site Biological Unhappiness, and check his books "Life on the Border: Understanding and Recovering from the Borderline Personality Disorder" and "Biological Unhappiness". 

Thank you, Dr. Heller.

Good night everyone.

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