BPD and Generalized Anxiety Disorder Medications

Written by Dr. Leland Heller

QUESTION:

I suffer from both BPD and PTSD. I also have extremely poor psychosocial skills, making it difficult to protect myself from others. This combination attracts manipulative and exploitative people and I sometimes lash out at them in fear and anger. Prozac exaggerated this fear and anger response. My nerves were so raw and my reactions so pronounced that I effectively destroyed what was left of my life during the time I was on Prozac.

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My GP added Buspar in an attempt to control the problems I was having on Prozac. I almost immediately got much worse. In desperation, we tried Stelazine to control the reaction. No result. I went off all meds, seemed to suffer a withdrawal syndrome and lapsed into suicidal depression.

The depression passed and I tried to tough it out without any meds, but I now suffer from chronic dysphoria. Even minor stressors will set off hellish bouts. However, I am terrified of the SSRI's, suspecting that I may be one of the few who simply cannot take them.

While I know that I must have all my diagnoses made and treated this is no easy feat. It was exhausting, depressing and financially difficult to even get one diagnosis made much less both. (PTSD was made by Memorial Sloan Kettering and BPD by Columbia Presbyterian). Treatment for one or the other will be disastrous. I keep getting Paxil as a standard answer, with the insistence that my reaction will be controlled solely by the addition of Depakote. I know from your site that this is not true.

I am aware that you pretreat patients such as myself with Buspar to reduce the serotonin levels at receptor site 2. However, I suspect that I cannot tolerate any drug which affects serotonin levels. Do you think that I could be treated with Depakote alone? Or as a last resort, Buspar and Depakote? I can tolerate the depression, emptiness etc. but cannot survive the anger, fear and behavioral dyscontrol.

DR. HELLER'S ANSWER:

I wouldn't be surprised if you also had panic disorder and craved sweets. This appears to be a subset of the BPD.

There are two options I've been using with people like you and I'm finally having some success. It's a tough, tough combination.

1. Very, very low doses of Buspar moving up very slowly. I've had some patients take a hammer and smash it, taking a pinch daily for a few weeks and slowly move up. This is the best approach in my experience. Once the individual is up to 10mg twice daily without side effects then Prozac can be added without side effects, although very low doses are necessary first. The phrase is "slow and steady" - and I consider the side effects you experienced to be unacceptable. Paxil usually makes things worse with this combination, although usually it's the best Rx for panic in my practice. In patients like this, Buspar and all SSRI's must be taken on a totally full stomach - or else the person will understand misery due to rapid absorption! Kind of like sipping Vs chugging alcohol.
2. Low doses of multiple medications is another option I've had success with. Effexor is now approved for the GAD, but only seems to work in my experience with the combination above. What I'm now doing is using 37.5mg of the XR at bedtime for a week, then 75mg in the evening. In a few weeks I'll usually add Remeron 15-30mg daily (low doses are sedating, higher doses feel more stimulating). After two weeks of this Prozac can be added. I usually use 10mg daily for a week, then 20mg daily for a week. Then Tegretol can be added and the chronic dysphoria stops, along with the panic and GAD. The key appears to be low doses of multiple meds, and some individuals can't go over 37.5mg of Effexor due to the profound fatigue that can develop.

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