Question:
How does Luvox (fluvoxamine) compare to Prozac
(fluoxetine) and does it affect the HPA axis?
Dear Doctor Heller,
Thank you for your website which has given me some
hope.
I have been caring for a young woman since she was 5
years (now 17). She has definite signs of borderline,
as have two other members of her natural family.
A few years ago we visited a pediatric psychiatrist who
reported to our GP that BPD was most likely. He gave
a grim assessment of any possible help. She is on
25 mg Fluvoxamine daily but that's all. I have been
using homeopathic treatments to try to help.
I have
recently come across a study that fluvoxamine 150mg daily
for six weeks reduces the responsiveness in the HPA axis
of BPD patients. What is your opinion of this?
Do you think the fluvoxamine 25 mg that she is on is a
helpful option, or should I discuss the treatment
program that you have outlined on the website with the GP?
She tries so hard, and I feel so sad when I can see that
things are building up for failure. Whenever she tries
to lead a 'normal' type of life (part time work, etc.), the
pattern is the same: extreme anxiety (she seems hyperalert
to how others are going to accept her), then manic type
behavior, then she becomes angry whenever she interprets
something (even a look on someone else's face) as rejection
or disapproval. She can't hold the anger in,
but it all 'blows up', and she is left feeling low again.
She is constantly seeking approval through attention seeking
behavior ('If I am not getting attention I feel as though I am
nothing'), but she keeps trying to fit in etc., and I
desperately want to help her.
I would be grateful for your opinion on the trial, and
whether the Prozac treatment you outline would be
a good option for her to try.
Thanks for the website
Dr. Heller's Answer:
The hypothalamic pituitary axis (HPA) is impaired in
many individuals with the BPD, with or
without medications. I’m not aware of any SSRI
effects (drugs like Luvox (fluvoxamine) or
Prozac (fluoxetine)) although Tegretol
(carbamazepine) can affect the system--particularly
thyroid. I don’t prescribe Fluvoxamine, and I
haven’t seen any effects with thyroid, sex
hormone, or cortisol function with Prozac
(fluoxetine).
Individuals with the BPD who are unstable cannot be
controlled alone with an SSRI. A mood
stabilizer and/or antipsychotic is necessary. Prozac
(fluoxetine) is by far the most effective SSRI--likely
because of its effects on glial cell
function.
Tegretol (carbamazepine) is much more
effective than any other mood stabilizer. Chronic
antipsychotic use is a problem. Zyprexa
(olanzapine) is the best but tends to cause
significant weight gain. I generally use Abilify
(aripiprazole) if I need to prescribe an
antipsychotic chronically. Haldol (haloperidol) is
great
for as needed use.
Risperdal one 3mg dose for severe
dysphoria works in 24 hours. As always,
making all the medically treatable diagnoses and
comprehensively treating them is crucial.
The BPD itself doesn’t have a grim prognosis. It all
depends on the comorbidities (the other
diagnoses). Character disorders, the passive
aggressive personality and antisocial personality
disorders combined with the BPD are huge problems,
and substance abuse that doesn’t
respond to treating the mental health problems also
has a grim prognosis.
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