2010 Annual Updates
Borderline Personality Disorder (BPD):
1) Severe situational crises respond best to
the temporary use of night time Zyprexa
(olanzapine). The patient can still use the
Haldol (haloperidol) and get relief. A study
showed Haldol (haloperidol) and Zyprexa
(olanzapine) for chronic use were equal. Haldol
(haloperidol) works more quickly and Zyprexa
(olanzapine) is more effective initially in
treatment and for severe stressors. Both have
possible serious long term risks.
2) The literature continues to prove that there
is no "borderline drug" or a "mental health
pill". The medications are great for specific
symptoms, but usually need to be used in
combination, even if only for as needed use.
Additionally, treating the comorbidities (other
diagnoses) is vital, and that's not measured
with single-drug regimens.
3) Looking for the genetic cognitive
generalized anxiety disorder as a comorbidity
continues to be crucial as SSRI's like Prozac
(fluoxetine) and SNRI's like Effexor
(venlafaxine) and Cymbalta will increase the
anxiety--worsening BPD dysphoria (anxiety, rage,
depression and despair). BuSpar usually turns
off this gene, making it possible to take these
medications without making the BPD worse.
4) There were many studies in 2010 about the
medical basis of the borderline personality
disorder. They can be found at
http://www.BiologicalUnhappiness.com/hippocampus _BPD.htm.
5) Doing functional MRI or equivalent studies
on individual patients does not help with the
diagnosis or management of the BPD or other
disorders causing biological unhappiness.
6) For the first time a study was done looking
for statistics of comorbid ADHD and BPD. The
article stated that 38% of those with BPD also
have ADHD. I suspect the actual number is
closer to 50%. There was also a study showing
that there are specific neurological changes in
those with both diagnoses.
7) Most patients I've seen who carry the
diagnosis of bipolar disorder have never had a
manic or hypomanic episode in their life and
actually have the borderline personality
disorder. Some BPD patients also have bipolar -
and they can be successfully treated with the
same medications except that Tegretol
(carbamazepine) is mandatory instead of
optional. There was a study in 2010 that
confirmed my observation that bipolar is often a
misdiagnosis and the BPD was the correct
diagnosis.
ADHD (attention deficit hyperactive disorder):
1) I check all my adolescents and adults with
ADHD for comorbid borderline personality
disorder.
2) A recommendation was made to try amantadine
to improve executive function for those with
ADHD. I had one patient who got better for a
few weeks, then the benefits went away. The
other three patients I treated saw no benefits.
2009 Annual Updates
Borderline Personality Disorder (BPD):
1. For chronic antipsychotic use I’ve found
Abilify (aripiprazole) to be the extremely
effective with minimal weight gain.
2. Taking folic acid or folate 800mcg - 1000mcg
daily can prevent bone marrow suppression
from Tegretol (carbamazepine).
3. When Haldol (haloperidol) causes dystonic
reactions, I’ve successfully been able to
prescribe Navane (thiothixene) instead
without the reaction or other side effects.
4. I believe that everyone with the BPD should
be evaluated for ADHD as well, as approximately
50% of those with BPD also have ADHD, and
vice-versa.
http://www.BiologicalUnhappiness.com/AD-H-Dcr.htm
5. A study by Dr. Links and his group from Canada
showed that good psychotherapy by psychiatrists
familiar with treating the BPD is as effective as
DBT.
2008 Annual Updates
Borderline Personality Disorder (BPD)
1. The prevalence of BPD has been debated over the years, with
most estimates ranging between 1-2%. Those of us who
treat the BPD know that estimate is too low. A
population telephone study in Iowa during the 1990's found
7% of the population had the BPD. A large study
(34,653 adults) showed the
prevalence was ~ 6% (5.9%
actually), with men equal to women. This study was
published in the April 2008 edition of the Journal of
Clinical Psychiatry.
2. Seroquel (quetiapine) has not been shown to be of
significant benefit for BPD symptoms. I use it primarily
for sleep, especially the most difficult cases of insomnia.
3. Dysphoria (anxiety, rage, depression and despair)
treatment has been updated at:
http://www.BiologicalUnhappiness.com/dysphori.htm
4. I have found most patients get significant symptom
relief by adding a dose of Zyprexa (olanzapine) to Risperdal
(risperidone). It makes the 24 hours less unpleasant
and Zyprexa (olanzapine) seems to reduce
the side effects of the Risperdal (risperidone) dose.
2007
Borderline Personality Disorder (BPD):
1) More than any other year in history, more medically and
scientifically based studies were published. It's
great to see all this research proving the medical basis
for the BPD. (See the bottom of
http://www.BiologicalUnhappiness.com/medline.htm
for these updates.)
2) Topamax (topiramate) has shown benefit. In my
experience the best mood stabilizer is Tegretol
(carbamazepine), especially in combination with
Prozac (fluoxetine) with as needed dysphoria
(anxiety, rage, depression and despair) medical
treatment
(http://www.BiologicalUnhappiness.com/dysphori.htm).
Tegretol (carbamazepine) costs ~$4.00 for 30
pills, so it's very affordable. Unless there's a
problem with Tegretol (carbamazepine) (rash, severe
low sodium, bone marrow suppression), it's the best
mood stabilizer, and the only one proven to reduce
behavioral dyscontrol (losing control of behavior).
If one of those problems exists there are other
options:
a) Depakote (valproic acid or valproate): This
has been shown to reduce anger. It's expensive
(despite being generic), can cause weight gain, and
liver function needs to be monitored. The price is
usually costing $100-$300 per month.
b) Lamictal (lamotrigine): The dose has to be
slowly increased to get effect. It doesn't require
blood tests and can cause a very severe rash that
can be fatal and possibly cause disfigurement.
It's very expensive and costs hundreds of dollars
per month.
c) Topamax (topiramate): It helps some
individuals, but in my experience makes as many
worse - with increased hostility and irritability.
It's very expensive and costs hundreds of dollars
per month. Topamax (topiramate) can greatly reduce
migraines and for that reason it's a useful
alternative for individuals with migraines (which
are more common in the BPD).
3) Using Zyprexa (olanzapine) for the first week
of therapy can be enormously useful when initiating
treatment with Prozac (fluoxetine). It prevents
worsening of anxiety and dysphoria (anxiety, rage,
depression and despair) while the medication is
started. It's also great for stressful episodes
when the mind is constantly racing. It's extremely
expensive and causes weight gain.
4) If I need to prescribe a continuous
antipsychotic medication, I choose Abilify
(aripiprazole). It works well without causing
weight gain. It's also extremely expensive.
ADHD (Attention Deficit Hyperactivity Disorder):
5) A new form of Adderall -- Vyvanse -- is an
excellent choice for ADHD. Its blood levels are
much smoother and it usually lasts 10-12 hours. It
rarely has the "jolt" that regular Adderall &
Adderall XR can cause. It's a "pro-drug" - meaning
that the medication is inactive until "activated"
by the liver (it removes the lysine molecule).
Abusing Vyvanse rarely works since snorting or
using it IV doesn't give a rapid onset of Adderall
(dexedrine). 70mg of Vyvanse is equivalent to
Adderall XR 30mg.
Depression:
6) A new antidepressant "Cymbalta" (duloxetine) is
available, and can help with chronic pain (even in
the absence of depression). It's expensive and has
had little benefit for my BPD patients, although it
can be a useful "add-on" medication.
2006
Borderline Personality Disorder (BPD):
1) Many individuals have restless legs
syndrome. While iron deficiency is often
the problem, and the most likely problem in
menstruating females, it's not always the
case. Sometimes antidepressants - including
SSRI's - can be the cause, although usually it's
a dopamine phenomenon in the muscle control part
of the brain. The medication Requip
(ropinirole) works for most individuals, but can
make many borderlines worse - likely by raising
dopamine in the trapped, cornered, wounded animal
part of the limbic system. These
individuals need to be treated with iron, and if
unsuccessful with nighttime benzodiazepines like
lorazepam or clonazepam. My experience has
been approximately 60% of borderlines treated
with Requip (ropinirole) get agitated and have to
stop the medication.
2) There has been some renewed interest in the
scientific community regarding the biological
basis for BPD symptoms. The "G protein
beta 3" has different types called
"alleles." The "T allele"
has been associated with self-mutilation in
individuals with childhood abuse and BPD.
Some work is being done on dopamine receptors as
well, which is particularly exciting because of
the success borderlines have using Haldol
(haloperidol) on an as needed basis and the
likelihood of dopamine dysfunction as a part of
psychosis and dysphoria (anxiety, rage,
depression and despair).
3) As mentioned in previous updates, Topamax
(topiramate) can make borderlines worse. It
can be so profoundly effective in reducing or
eliminating migraine headaches that it's often
worth a trial, sometimes taking it at the same
time as Tegretol to reduce the risk of behavioral
and anger/rage problems. Approximately 70%
can't take it.
4) Something I emphasize to new BPD patients is
the neurological basis of their disease. I
tell them that there are times when they are
sweet, loving and kind - that's who they really
are. The rest is a neurological disease
than can be treated medically.
2005
Borderline Personality Disorder:
1) While anti-epilepsy medications like Lamictal (lamotrigine),
Trileptal (oxcarbazepine) and Topamax (topiramate) show some
benefit in small studies, in my experience they still aren't
as effective or as consistent as Tegretol (carbamazepine).
Topamax (topiramate) is a double edged sword - while it works
for some, it makes others very hostile and self destructive.
Its advantage is the weight loss and reduction or elimination
of migraine headaches. I have used it successfully in
combination with Tegretol.
2) Zyprexa (olanzapine), particularly in combination with Prozac
(fluoxetine), is very effective. It's extraordinarily
expensive and many patients complain that they "don't have
feelings." The problem is that it can cause
massive weight gain (25 to 100 pounds) and diabetes.
3) My dysphoria (anxiety, rage, depression and despair)
instruction sheet is still available at
http://www.BiologicalUnhappiness.com/dysphori.htm.
Sometimes SSRI antidepressants like Prozac (fluoxetine) can
cause a neurotransmitter imbalance that causes low energy,
a lack of pleasure and the "blahs." This
is not the same as dysphoria. It is not associated with
suicidal thoughts and it persists. Wellbutrin
(buproprion) usually makes this go away in 1-2 weeks and I
usually only prescribe it for a month or so.
4) I very rarely prescribe antipsychotic medication for chronic
use, but if I do Abilify (aripiprazole) is the one usually
prescribed primarily because of its low side effect profile (it
doesn't cause weight gain).
5) A number of studies showed that the BPD has a biological basis
(or at least significant biological abnormalities). They
can be found at
http://www.BiologicalUnhappiness.com/hippocampus_BPD.htm.
6) I have found over and over again that it's the comorbid
conditions (what else is wrong) that defines how well an individual
with the BPD will do. Prozac (fluoxetine) will stop the
unprovoked mood swings, chronic anger, emptiness and boredom.
Tegretol (carbamazepine) can stop chronic dysphoria (anxiety, rage,
depression and despair) and dissociation. Intermittent
dysphoria can easily be treated. For most individuals with
the BPD the actual taking of pills is the easy part, it's
convincing oneself that he/she should be treated that's the hard
part. That's why character issues and spiritual issues are so
important and can't be left out of any BPD evaluation or treatment plan.
7) Two books I'm recommending a lot lately are
"Looking Out for Number One"
by Robert Ringer (available very inexpensively at
Amazon.com)
and
"Are You As Happy As Your Dog?"
By Alan Cohen. I've found that many individuals find it easier to
learn from their pets than from people. The latter book is
hysterical, poignant, inexpensive and worth having at home.
8) There's been a dramatic change in the way academic
psychiatrists interpret borderlines over the 18 years I've
been working with individuals who are afflicted with the BPD.
In the 1980's and 1990's there was a tendency to blame
borderlines for having their illness - a view many still have
today. In a 2005 article from Harvard, published in the
American Journal of Psychiatry, the authors (Zittel and Westen) while
advocating a continuation of the diagnosis in the DSM V described
the borderline experience as one of "intense psychological
pain". It's a long overdue acknowledgment of the
suffering this dreadful disorder causes, and on behalf of the
thousands of BPD patients I've treated I want to say thank you
for writing that.
2004
Borderline Personality Disorder:
1) There is a growing consensus that the BPD is due to brain
problems caused by trauma and/or genetic factors that can respond
to medication. The extent of medication response and which
medications to use remains controversial. In 2001 the American
Psychiatric Association recommended the use of medications for BPD
treatment.
2) A number of studies came out in 2004 showing a biological
basis in the brain for BPD. They can be found at
http://www.BiologicalUnhappiness.com/hippocampus_BPD.htm
3) Not much new about treatment was discovered in 2004. I
continue to see Prozac (fluoxetine) as the best pharmacological
BPD treatment. At the right dose, Prozac (fluoxetine) stops the
unprovoked mood swings, chronic anger, emptiness and boredom. I
still strongly believe the reason Prozac is better than other SSRI
medications is its effect on glial cells (the brain’s support
cells - much more numerous than nerve cells). SSRI’s like Lexapro
and Zoloft do help many individuals, but switching to Prozac
achieves much better symptom improvement. Tegretol
(carbamazepine) remains the best anti-epilepsy medication for the
BPD.
ADHD & ADD:
1) I continue to see that Adderall is far more effective in
adults and adolescents than methylphenidate (Ritalin, Concerta and
others). I generally follow dosing guidelines advised by Dr.
Biederman (0.5-1mg per day of Adderall XR), although some patients
need higher or lower doses. Many need a late afternoon and/or
evening dose of a short acting stimulant.
Dr. Biederman, Professor of Psychiatry at Harvard advises higher
doses of stimulants when needed for successful ADHD treatment in
adolescents and adults. In "Today’s Therapeutic Trends"
20(4):311-328, 2002 Dr. Biederman wrote: "It should be reiterated
that stimulant medications are considered to be very safe, and,
and that dosage titration should continue until an adequate dose
is reached, if tolerated. The large therapeutic window associated
with these agents indicates that there is a wide dosage range for
their safe use... under-dosing in older adolescents and adults is
a significant problem...." - page 324.
2) Strattera works for many individuals, but overall has been a
disappointment. Some individuals experience an increase in
hostility when taking Strattera.
Panic Disorder:
1) Medications that don’t require water are now available
including Klonopin wafers and Nirivam (A form a Xanax
{alprazolam}) that dissolves on the tongue.
2003
Borderline Personality Disorder:
1) Omega 3 fish oils 1000mg daily can improve many BPD
symptoms. This was based on one very small study and was
not done in comparison to prescription medications.
2) The new epilepsy medication "Topamax" can help with
headache, bipolar and some forms of epilepsy. Weight loss
can be a side effect. Unfortunately, in my experience,
most individuals with the BPD see their condition worsen
when they take Topamax.
3) The use of chronic antipsychotic medication is a
problem. The newer "atypical antipsychotics" can cause or
worsen diabetes and can cause massive weight gain.
Interestingly, in my experience, taking Risperdal daily
usually doesn’t work - it seems to work best when it leaves
the system, not while it’s in the body. If I need to
prescribe an anti-psychotic medication on a regular basis,
I usually prescribe Abilify.
ADD & ADHD:
1) Strattera is a non stimulant approved by the FDA for
children, adolescents and adults with ADHD. It has the
huge advantages of not being addicting, it can be phoned
in, and it works 24 hours a day. It can work as
effectively as the stimulants, but takes some time to work
- usually weeks. Side effects primarily relate to
grogginess and stomach upset, and urinary retention. The
heart rate and pulse may go up by a small amount. Dose
adjustments may be needed frequently. It’s not uncommon
for Strattera to be combined with a stimulant.
2) I am finding that for most adults Adderall gives the
greatest benefit compared to Strattera and methylphenidate
(Ritalin, Concerta and others).
Major Depression:
1) A study showed that antidepressants cause more brain
cells and glial cells to grow.
2) If Prozac is not needed, I’m prescribing Lexapro in
addition to Remeron, Effexor and Wellbutrin. It seems to
be tolerated better than other SSRI medications.
Panic and Anxiety:
1) The epilepsy medication Neurontin (gabapentin) can be
just as effective as benzodiazepines such as Xanax
(alprazolam), Klonopin (clonazepam) and Ativan (lorazepam)
for treating and preventing panic attacks. The dose range
is wide - ranging from 100mg daily to 1800mg three times
daily. Most patients need to start with a low dose and
move up to a more effective dose. It’s an expensive
option, but it can be very useful - especially in
alcoholics, those with the BPD, and substance abusers where
benzodiazepines can be dangerous.
2002
Borderline Personality Disorder:
1) Abilify (aripiprazole), a new
antipsychotic, can replace Risperdal (risperidone) for
many borderlines experiencing severe dysphoria (anxiety,
rage, depression and despair). 60% have no side effects,
and when it works it generally works within 3 hours. Many
get just as sedated as they do with Risperdal. In that
case I prefer Risperdal because Risperdal always works,
and Abilify (aripiprazole) doesn’t always work.
2) In his wonderful new book "Where God Lives," Dr.
Melvin Morse reports that many researchers, particularly
at the University of California, San Diego, have
discovered the part of the brain that is attached to God
and the Universe. It’s above the right temporal lobe in
the Sylvian Fissure. When an individual with the BPD has
a dysphoric spell, it’s a seizure that temporarily cuts
the person off from God and spirit. This is why the
borderline can act antisocially when dysphoric and feel so
much remorse afterwards.
3) The medical research has shown additional evidence of
the medical nature of the BPD.
4) Prozac (fluoxetine) has been shown to improve the
function of glial cells. 90% of the cells in your brain
are support cells called glial cells, not neurons. I
strongly suspect the BPD is largely due to glial cell
malfunction. This may explain why Prozac is so much more
effective than the other SSRI’s in treating the BPD, such
as Zoloft (sertraline) Paxil (paroxetine), Luvox, Celexa
or Lexapro.
5) Effexor (venlavaxine) in high doses (450-600mg daily)
can be helpful with the BPD, but I’ve never seen a patient
who did better with Effexor than the Prozac/Tegretol
(carbamazepine) combination.
ADD & ADHD:
1) The major change has been the addition of many long
acting formulations that mean individuals don’t have to
take a mid-day dose.
2) Focalin, a "stereoisomer" of methylphenidate, is
particularly useful for early evening stimulant use
without causing insomnia.
3) While substance abuse has gone up enormously in our
society, treating ADHD lowers substance use. The use of
psychostimulants in children has gone up 800% in 10 years,
but substance use is down 50%.
4) The combination of the antidepressant Remeron
(mirtazapine) with a stimulant can counteract the appetite
loss and insomnia.
5) Many strides have been accomplished proving the
biological, and mostly genetic cause of ADHD. The study
showing smaller frontal lobes in some ADHD individuals
does NOT mean they are less intelligent. I have routinely
found that those with ADHD are brilliant, clever and
creative.
Major Depression and Prozac:
Prozac (fluoxetine) is an amazing medication for the
genetic depression I described as "Fractured Enjoyment" in
Biological Unhappiness. It’s also phenomenal for the BPD.
Other than those two diagnoses, I am prescribing more
Remeron, Effexor and Wellbutrin (buproprion) for
depression due to the sexual dysfunction SSRI’s can cause.
Antidepressant induced sexual dysfunction:
The major treatments for difficulty getting erections I
prescribe are ginkgo in high doses (180-240mg daily) and
Wellbutrin. In males, if there is a lack of sexual
interest or inability to get or maintain erections, the
total or free testosterone should be measured and treated
if low.
Panic Disorder:
It turns out that Prozac and the other SSRI
antidepressants work about as well as Paxil does for panic
disorder.
Insomnia:
1) The new medications Sonata and Ambien have a much
lower risk of addiction and dependence than the older
benzodiazepine medications like Xanax (alprazolam) or
Ativan (lorazepam). The sedation is usually completely
gone by the next morning.
2) Remeron (mirtazapine) can be very helpful for sleep,
especially with those who have been traumatized and are
having trouble sleeping due to "Hypervigilance."
3) The antipsychotic Seroquel (quetiapine) has been
extremely useful for difficult to treat cases of insomnia.
4) Insomnia causes many, many problems including work
and auto accidents and impairment of the immune system.
It’s not a minor problem and for most insomniacs it’s not
a short term problem either.
5) The FDA has expressed concern regarding melatonin.
Lack of zest for life:
This can occur with all SSRI antidepressants, including
Prozac. The development of the persistent blah’s or lack
of interest in life can be due to an imbalance of
serotonin with low dopamine and noradrenaline. The
addition of Wellbutrin, usually temporary, can solve this
problem.
Spiritual Healing:
I believe strongly that we have to heal mind, body and
spirit. While some have a strong and successful spiritual
base, most don’t - particularly with the BPD.
Spirituality is about how you see yourself, God, the
Universe and your role in it. No one, including me, has
the right to tell you that you are wrong and they are
right. It’s a journey you have to make for yourself. I’m
sharing with you some of my teachers:
The book "The Other Side and Back" by Sylvia Browne has
been very helpful to many individuals, especially in
determining their purpose for coming to Earth. She is the
psychic the FBI uses. I usually recommend avoiding the
predictions at the end. While psychics may be right about
their prediction, the time is usually wrong. Individuals
may lose sight of her message by focusing on what
predictions came true, etc.
Also in "Where God Lives," Dr. Morse describes a 20 year
reunion of children who had a near death experience. They
were not involved with drugs, not pregnant, had no
problems with authority figures, and had a purpose in
life.
In "The Dancing Wu Li Masters," Gary Zukov describes
quantum physics, which can be very useful in understanding
the universe and your spirituality.
"Soul Stories," also by Gary Zukov, describes a happy and
spiritual life, including a clear and loving description
of a true spiritual partnership.
"Journey of Souls" by Michael Newton describes "life
between lives" - based on reports of individuals who have
undergone hypnosis.
"The Dragon Doesn’t Live Here Anymore" by Alan Cohen
describes the beautiful journey he has taken towards
enlightenment and is extremely helpful towards an
understanding of spirituality and healthy thinking.
Dr. Wayne Dyer has a number of terrific spiritual books
and tapes out in the past few years, especially "The
Wisdom of the Ages," "There’s a Spiritual Solution to
Every Problem," and "Manifesting Your Destiny." The tape
"101 Ways to Transform Your life" has been extremely
helpful to me and many of my patients and friends.
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