QUESTION:

Dear Dr. Heller,

What do you think of Perceptual Distortion as an aspect of how BPD people react to the world around them with extreme hurt and anger? What is your opinion of a neuroleptic agent to control this? What would be your recommendation in terms of one?

Gratefully,...

DR. HELLER'S ANSWER:

Perceptual distortion is a major part of the BPD. The scariest part is that they remember these distortions as reality.

When a borderline is stressed or threatened, the trapped animal part of the brain takes over - and is on "survival mode." "Shoot first and ask questions later" describes it well. Since most of the time they are not really trapped and cornered this perception is untrue, and is called psychosis. Borderlines act very rationally from that incorrect perception.

I teach my BPD patients that dysphoria (anxiety, rage, depression and despair) must be treated. It is while experiencing dysphoria that psychosis occurs. My usual approach is to have Haldol 2mg available for these episodes. If Haldol doesn't work, Tegretol is usually necessary. Occasionally Risperdal 3mg is needed.

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