Question:

My sixteen-year-old daughter has been tentatively diagnosed with bpd. She is currently hospitalized for the second time in less than a year. She nose-dived last fall when her boyfriend *dumped* her; she had invested all she had into the relationship, and could not recover unaided. This is why she was hospitalized (October '98 to January '99) in the first place (self-mutilation/depression) She has also been formally diagnosed with ADD and there seems to be an OCD component, too. 

Addictions and depression run in our families on both sides. She has never been exposed to active addiction; all of us (mom, step-dad, biological father) are in the second decade of AA/NA recovery. Her biological father is now in prison for aggravated sexual assault of two of her best friends; she will not acknowledge/has not experienced abuse at his or anyone else's hand, but therapists have expressed concern that she has in fact been abused. She is not sexually active, but is definitely (normally!) attracted to boys. She has been in special education for emotional instability since second semester of first grade or so, and *hates* her special Ed classes school (socially inept, contextually clueless). Did not do well in mainstream classes, either, due to extremely poor study habits (No one would give her homework until now!!) Two (out of four) siblings, both male, have experienced substance abuse problems and have been hospitalized for depression/drug abuse/parasuicidal behavior.

Current Medication History and Brief Comments: A regimen of Tegretol 600mg AM and Tegretol 800 mg plus Remeron 30 mg plus Zyprexa 7.5 mg at around 8:00PM was instituted after some trial and error and a four-month period of hospitalization. She *seemed* to be doing well, and got to the discharge level (Hospital. used a pretty standard level system) in January of this year. She began to *degenerate* immediately, and failed to pass her sophomore year in high school. Her teachers and counselors remarked that the medication she was taking *did not seem to be doing any good at all.* In April I (mother) made the unilateral decision to take her off all medication, and am/was trying to find some kind of *natural* regimen (including nutrition, exercise, affirmations, and some kind of herbal/homeopathic remedies). I was not successful, and of course realize (now that she has been hospitalized again for parasuicidal behavior/self-medication attempt with 7, 7.5mg Zyprexa she *found* after I thought I had thrown them all away!!) that my decision was irresponsible. Actually, I knew all along I shouldn't have done this; I was just desperate! The doctors at the hospital are now trying--again--to find a medication regimen that will work for her. They are not having much success.

Concluding Comments/Errata: The doctors wanted to have her take some kind of neurological test (sounds like *beam*), but the insurance company won't pay for it. I am pursuing this today, and will find out how much this test costs, why the doctors want it done, and exactly who at the insurance company to talk to. Wish me luck!

Have you any medication (or any other) suggestions? She is really a neat kid--creative to the max, compassionate, intuitive, and has ALWAYS been highly reactive to other peoples' emotions (highly empathetic--must build walls to protect self from overload?).

Answer:

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In my experience I've rarely found a patient who succeeded without an SSRI, and without a doubt Prozac is the best. Zyprexa is not as good as Risperdal and can cause enormous weight gain. Adding Prozac to Tegretol may require a month or so to work, although if Tegretol is added to Prozac after a week, the Tegretol will work in 3 hours.

Without treating the attention deficit disorder there is little chance of success. The individual can't stay focused, can't think before acting, and is extraordinarily impulsive - including impulsive anger which leads to rage. Ritalin is the best medication, but "robust" doses are needed. If Ritalin and/or Prozac causes an increase in anxiety, the generalized anxiety disorder should be investigated and Buspar added.

Remeron with Effexor offers some hope, but side effects can be a problem.

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