Diagnosing Borderline Personality Disorder And Finding Treatment That Works - Borderline Personality Diagnosis and Treatment

Written by HealthyPlace.com Staff Writer

David: One of the other troubling aspects that audience members mentioned was what I would call "severe depression". The sense of hopelessness that things won't get any better and despair.

Dr Heller: Once the medications are even partially stabilized, that dysphoria based depression is usually gone in 3 hours, at most 24 hours. The sequencing of medications can be as important as the actual medications.

An interesting but true story. I have a patient who was sexually molested from age 4-16. She was finally doing well. On a Monday morning, she came into the office in the fetal position saying she wanted to die - because her ex-husband had just been arrested for sexually molesting their four year old daughter. I gave her 3mg of Risperdal and 400mg of Tegretol and asked her boyfriend to stay with her until she falls asleep - likely within three hours. When she woke up the next morning she came into the office and said "Gosh Doc, I can't believe how much better I feel." She was better able to cope with the bad news which I believe speaks to the benefits and effectiveness of some medications. I see cases like this every day. Some patients need higher doses, but these are the results I expect.

Some recent scientific studies confirm that the depression in BPD dysphoria is a different phenomenon than regular depression.

David: I want to make sure I ask this next question clearly. Some doctors have told BPD patients that BPD is incurable. That, yes, some "symptoms" can be dealt with, but a complete recovery is impossible. Is that true? And is that your experience in treating over 3,000 BPD patients?

Dr Heller: I think that expectation is the problem. The comorbidities are the key. Unless they also have character problems, borderlines can do extremely well.

Two former self-mutilators work for me. They have to learn to like and love themselves, to gain self-confidence, social skills, and how to succeed in relationships. It's a learnable skill.

If the individual wants to be successful more than they want what they're doing to be declared "correct," they can have success in every important area of life.

My goals are very high - I want success in every important area of life. When not treated in this way, the literature shows that some will have moderate work success and no success in relationships - and that success depends upon being brilliant, obsessive, rich and good looking!

I don't believe that success and happiness are reserved for the rich and gorgeous. I believe in mastering the principles of success - because by mastering them you'll have learned the principles of being successful in everything important - including relationships.

Three things are necessary for success: 1) diagnosing and comprehensively treating everything that's wrong; 2) have a formal plan for stress and dysphoria; and 3) retraining the brain.

David: Here are some audience questions:

BarbNY: Do you believe in giving mega doses of SSRI's?

Dr Heller: Not in general. Most borderlines do well on 20-40mg of Prozac - which I believe strongly is the best one. Some individuals do well with high doses, and sometimes they're clearly needed, but high doses are expensive and potentially risky. Inappropriate moodiness, chronic anger, lack of energy, and emptiness are to me the most significant signs that a higher dose should be tried. The change is often dramatic by the next day.

Luci: As prozac at 40mg a day did very little for me I have been switched to Venlafaxine. Is there any evidence that Venlafaxine can be used successfully in aiding treatment of BPD?

Dr Heller: Yes. Effexor - the brand name - has been shown to work. I've never seen anyone do great on it. The studies are with very high doses - in the 450-600mg dose range. Side-effects are usually a huge problem at these doses. Effexor has effects on different neurotransmitters as the dose is increased. High doses have anti-psychotic effects, and the long term safety has clearly not been established.

I greatly fear the chronic daily use of medications that block dopamine - as neuroleptics and the GI medication Reglan have caused tardive dyskinesia. The newer agents are better and safer, but still have risks.

David: Here are some audience comments about what's being said tonight, then more questions:

donna2: I don't want to be on medications. I have such a small reality base as it is I'm afraid I'll lose it altogether. I was on various medications for years and nothing helped anyway.

cypress: I've been on medications for 3 months and I still feel suicidal.

donna2: I agree about depression in BPD being different. I don't want to kill myself, I want to kill the bad things that are bothering me. I don't lie around.

mazey: I am in recovery in all different areas including self-injury. I'm very afraid that one day I will snap and the borderline stuff will consume me again.

Dr Heller: It's not just medications, but which medications, the doses, and the sequence. That penicillin didn't work for moodiness doesn't mean another medication won't work. The long-term data is so profound that the choice to avoid medications is a very dangerous and painful one. It's not a tragedy that one needs medication, it's a miracle that such safe and effective medications are available.