ETIOLOGY

Psychological theories alone cannot explain the BPD. Borderlines have significant biological abnormalities - see Table 2. CNS serotonin malfunction is likely involved. Temporal lobe dysfunction is often associated with stress. The BPD is probably a medical predisposition combined with environment insult.

There are many psychological theories and concepts, with considerable disagreement among experts in the field. Both overprotective and underprotective parents have been "blamed" as the cause. [16] Most theories center around traumatic childhood experiences, arrested psychological development (especially at the separation/individuation phase), and reliance on maladaptive coping and survival mechanisms. [23,28]

Adoption, early parental loss, and incest are often associated with the BPD. [14] The most severe borderline patients suffered from both sexual and physical abuse, usually while very young [6] - chronic dysphoria and derealization are the best predictors. [29] In one study, 81% reported major childhood trauma, 71% physical abuse, 68% sexual abuse, and 62% witnessed serious domestic violence. [30]

Genetics: The BPD tends to run in families, six times more likely in first degree relatives. There is an increased family history of alcoholism, substance abuse, other personality disorders, and depression, but not schizophrenia. [16]

DIAGNOSIS

Psychological tests, such as the MMPI and NIMH Diagnostic Interview Schedule, are only accurate between 85 and 89%. [31,32] Most knowledgeable psychologists can easily arrange for an MMPI. The NIMH test may be more difficult to obtain.

If I encounter a patient who has multiple complaints, especially fatigue, headaches, stress, depression, etc. I will often review and discuss the DSM-III-R Borderline criteria to determine if he/she feels 5 or more symptoms are present. If yes, I will usually initiate treatment with fluoxetine (Prozac), evaluating the patient and diagnosis 1 week later.

TREATMENT

Medications:

Prozac (fluoxetine): Prozac appears to increase serotonin. It is a breakthrough medication for borderlines - eliminating most mood swings, chronic anger, chronic emotional pain, emptiness and boredom within 3 days. A daily a.m. 20 mg. dose is usually effective. For most side effects (nausea, jitteriness, agitation), reduce the frequency to every 2 or 3 days. If fatigue develops, switch to an evening dose. While for a few patients the serotonin deficiency symptoms resolve permanently in 6-12 months, most need to take the medication long term. In my experience, clomipramine (Anafranil) and sertraline (Zoloft) have shown similar efficacy.

Neuroleptics: Can be effectively used on a prn basis during stress or dysphoria, or prophylactically for stressful situations. I prefer Haldol 0.5 - 1 mg every 4-6 hours as needed (side effects are rarely a problem at this low dose). Navane (thiothixene) [3] and Mellaril (thioridazine) [4] have been proven effective. High doses, especially in hospitalized patients, are also effective. [4]

Tegretol (carbamazepine): Can markedly reduce episodes of behavioral dyscontrol. [5] Extremely effective for unreality, chronic dysphoria, incest crisis, relationship dissolution, extreme anger, dissociative symptoms, and when neuroleptics are ineffective. Dosing and blood levels are comparable to treating temporal lobe epilepsy.

Thyroid: Many borderlines have symptoms of hypothyroidism, with "low normal" thyroid blood tests. Approximately 1/3 of borderlines have an impaired TSH response to TRH. [33,34]

Vitamin B12 deficiency: Approximately 20% of borderlines have low vitamin B12 levels, with symptoms of fatigue, leg stiffness, and dysesthesias.

Medications to Avoid: Xanax (alprazolam) can markedly worsen behavioral dyscontrol. [5] Elavil (amitriptyline) increases suicide threats, demanding and assaultive behavior, and paranoid ideation. [35] MAO inhibitors have helped borderline symptoms, but may be dangerous due to the impulsivity and behavioral dyscontrol borderlines can experience.

Psychological Counseling: Borderlines need a multidisciplinary approach. A good therapist is necessary, and borderlines should be strongly encouraged to get into counseling. For some, a psychologist/family physician team is very effective. Referral to a psychiatrist may be necessary. Psychiatric hospitalization is occasionally required, especially for strong suicidal ideation.

Stress Reduction: Borderlines need to keep their stress level down, and to use neuroleptics when under stress. Physical exercise, relaxation techniques, and TM (Transcendental Meditation) can be very helpful.

Spiritual Healing: Making peace with God and one's spiritual self is very important. The AA (Alcoholics Anonymous) approach can help, especially with destructive behavior patterns. Borderlines generally hate themselves. I try to get them to understand that they have a "good" soul that has been "stuck" in a broken biological computer.

Self-esteem: Since most borderlines experience self-hate, strong efforts must be made to build a strong and secure self-esteem.