How I Treat the BPD and Why

Written by Dr. Leland Heller

(This was initially written as a correspondence to another physician)

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, and 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:

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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.

In 1992 a New England Journal of Medicine Article from the VA comparing Tegretol to Depakote for regular and complex partial seizures found comparable efficacy, but Tegretol was superior for complex partial seizures - which I suspect BPD dysphoria is. More significantly the authors stated that Tegretol was SAFER than Depakote long term (this article is available in this section). I've often heard the statement "Tegretol is out of favor," which doesn't make sense to me., and there is no literature confirmation of this myth.

Due to occasional Tegretol allergy or intolerance, along with the literature showing efficacy of newer agents I have tried them with the following results:

When Depakote was discovered to be efficacious for bipolar and BPD, I of course tried it. While it helped some - with or without an SSRI - it just wasn't as effective as Tegretol. Many patients still required temporary extra doses of Tegretol with the Depakote, and got extraordinary relief. They did not get this relief with the addition of more Depakote. Chronically dysphoric patients on Prozac and Depakote often need the temporary addition of Tegretol. There is literature documentation on the safe use of both medications together.

Felbatol worked very well, with an efficacy similar to Tegretol. Unfortunately it turned out to be very toxic and was essentially withdrawn. I still have patients lamenting that they cannot take Felbatol any more.

Lamictil has had some successes, but in general patients hate it. I've had many patients refuse to take it after using it in the past. It really can't be used as needed because of the way it needs to be prescribed and it has the significant rash risk that can be fatal. Additionally, like Depakote, I've had many new patients come to me with severe chronic dysphoria taking Lamictil and Prozac, who got relief 3 hours later by adding Tegretol.

Neurontin works for some, and has the huge advantage of not needing blood levels performed. It's extremely expensive, and in my experience it's much more effective for neuropathic pain than the BPD. It also can cause a "hyperactive" side effect that mimics ADHD.