Question:
Dear Dr. Heller:
I was impressed with your interview about treatment
of BPD on healthyplace.com. My daughter has been
diagnosed with BPD and my purpose in writing is to
solicit advice with her treatment. I was
particularly impressed with the success of Prozac
and Tegretol in treating BPD. I was unsure of the
date of your interview and wanted to know if you
currently recommend Prozac and Tegretol as a 1st
line of treatment.
Alex is a 26 year old who is presently living at
home with us in the Boston area. She is unable to
work and has great difficulty functioning at this
point in time. She has been in regular treatment
since September 2005 but has not made any real
progress despite several different medications and
psychotherapy 2x per week. I understand some of the
difficulties involved with BPD and do not envision a
miracle pill but am looking for some progress.
Alex had symptoms of depression and mood disorder in
high school but did not begin any real treatment
until college and graduate school. She had had
trichotillomania since the 1st grade plucking out
her eye brow and lashes and this is still a big
problem for her. She graduated from Washington
University in St. Louis in 2002 and began an MSW at
the UChicago in September 2003. During the fall of
2003 she "crashed" at the beginning of her MSW
program in the context of a deteriorating
relationship with her boyfriend. Since that time she
had worse social anxiety, panic attacks, worsening
trichotillomania, and an abuse of pain medicines
during late 2004 into 2005. She began treatment in
Chicago, and managed to graduate but could not look for a
job and had to move home in July 2005 where she has
been in treatment.
Her medications most recently have been on Cymbalta
120 mg from May 05 thru current although she is
being taken off to try another anti-depressant. She
is also on Lithium 1200 mg since January 2006 along
with the Cymbalta. She seems to have some elements
of bipolar also. Her 3rd med is Risperdal .5 mg
since September 2005. Previously Tegretol 600mg was
used in conjunction with the Cymbalta from October
2005 to January 2006.
Before going on the Cymbalta she was on Effexor300
mg. while in Chicago along with Lamictal 100 mg. In
high school she was on Paxil and earlier in Chicago
was on Zoloft before her "crash".
Alex seems to need some type of stimulant in
addition to her anti depressant in order to focus,
energize and motivate her. However, the stimulant
seems to aggravate her anxiety condition and
interferes with her sleep at night and increases her
urges to pull out her lashes and brows. She has had
some periods when she would not sleep for 72 hours
when on the stimulant.
I know there is additional information I can provide
but I have probably gone on too long already. If you
can provide any information (including whether the
Prozac, which she has never tried, in conjunction with
the Tegretol may be a useful approach), advice or
know of anyone in the greater Boston area or in the
Northeast that you could recommend we would be most
appreciative. If you think coming to Fla. would be
helpful or know of any residential programs we would
consider any proposals which may offer help.
Thank you for your anticipated assistance.
Dr. Heller's Answer:
There is no better combination than Prozac
(fluoxetine) and Tegretol (carbamazepine). Prozac
and Zyprexa is also effective (but Zyprexa usually
causes massive weight gain and I use it primarily
for extremely short periods of time).
The medications she's been on are unlikely to be of
much benefit. I use Lamictal occasionally when drug
allergies to Tegretol are a problem and it works for
a small number of people.
Tegretol alone helps to reduce the severity of
behavioral dyscontrol (Arch Gen Psychiatry Feb 1988)
and improves stress tolerance, but without the Prozac
the improvement is disappointing overall for most
patients.
She probably has at least the generalized anxiety
disorder which will also need to be treated. ADHD
is 50/50 with the BPD and if present will need to be
treated. The sequence of treating the diagnoses is
often as important as the medication itself.
Treating all the diagnoses is crucial - everything
you have wrong with you makes everything else you
have wrong with you worse.
I would love to set up a residential and/or
outpatient treatment program for the BPD, but I
don't have the financial resources to do this yet.
The three 6 week programs we did in the 90's had
spectacular MMPI test results. It's badly needed
and I get requests all the time. It would emphasize
recognizing dysphoria episodes so they can be
treated, learning to think and interpret better, and
would deal aggressively with self-esteem and
spiritual issues (spirituality would be
individualized based on the person's beliefs or lack
of them, it would not be focused on any one religion
or religious basis). Hopefully some investor or
philanthropist who wants to fill this need will be
interested some day.
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