How I Treat the Borderline Personality Disorder (BPD) and Why

My goal in treating borderlines is not just a reduction in anger or moodiness, but a great life with success in every important area of life. To me this means:

1. Diagnosing and treating all their problems.
2. Have a formal plan for dysphoria.
3. Retraining the brain. Controlling the self-destruction/dysphoria cycle is crucial, as patients just can’t recover when they continue to participate in self destructive behaviors.

It has been my experience that Prozac is the most effective SSRI, but that others can work well. The study I did comparing Prozac (fluoxetine) with Zoloft (sertraline) and Prozac was more effective (available in this section).

Effexor:

Effexor in very high doses of 450mg daily has shown efficacy in treating the BPD, but in my experience side effects limits their use at these doses. Sedation, weakness, agitation, and blood pressure elevation are the biggest problems. At these high doses Effexor blocks dopamine receptors, and I’m concerned that long term tardive dyskinesia will develop as it has with other drugs affecting the dopamine system including neuroleptics and the gastroesophageal reflux medication Reglan (metoclopramide).

Tegretol:

When I first started treating borderlines in 1988, Prozac was clearly the first medication that had a big impact for borderlines. Shortly thereafter, I had some patients tell me "Prozac stopped working." All the psychiatrists I referred my patients to refused to take care of my BPD patients, so I did some literature searches to see what I could do for them. When I came upon Dr. Cowdry’s article (available in the Medline section) I decided to give these patients a try with Tegretol and miracles happened. Every single patient with dysphoria who was already taking Prozac had a "miracle" three hours later - the dysphoria went away.

I found something both surprising and amazing: if the patient was on Tegretol alone there wasn’t much benefit and if the patient was started on Prozac and Tegretol at the same time, it took a month for the benefit to develop. If they were on Prozac for a week and then the Tegretol was added, the miracles occurred. This finding is remarkably consistent for those with chronic dysphoria, dissociative symptoms, and self-mutilators. Persistent success generally requires blood levels in the upper half of therapeutic if they need to take Tegretol on a consistent basis.

I do the recommended blood work (CBC & 14 initially, CBC after one week, one month and every 3 months, with a 14 after 3 months and annually), and it’s extremely unusual to have problems except for sedation. The sedation affects 75% of patients, usually goes away eventually, and can be easily controlled with nighttime dosing. Nighttime, and as needed dosing, works for at least 90% of my patients. The melancholia Dr. Cowdry subsequently described appears to be due to Tegretol induced thyroid dysfunction, which is easily manageable with Synthroid. Studies in the 1980's at NIMH on borderlines show 1/3-1/2 have an impaired TSH response to TRH infusion anyway, and many have non primary hypothyroidism based on symptoms that respond to treatment - with or without Tegretol. This resolves with treating the thyroid problem, just like treating the temporary low thyroid problem that occurs in post partum depression (depression after childbirth). I go into this in more detail in Biological Unhappiness.

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