QUESTION:

Dear Dr. Heller,

I don't have a question concerning your new book, but a comment on "Life at the Border" and see no other mailing address on the webpage. I take exception to your shilling of Prozac at every chance you get in your book. Yes, SSRI's are a great help and development, but not the be-all and end-all. I tried Prozac and after 3 days was a raging maniac ready to do violence to myself or someone else. You mention once in one line, I believe that it may not be for everyone. It's not for everyone. My father retired from Lilly's and you do more to sell the product than he ever did. I think you should modify your book. I felt like I was reading an infomercial.

ANSWER:

Thank you so much for this question. It’s so important, and the answer is so incredibly simple.

All the SSRI’s - Prozac, Paxil, Zoloft, and Celexa help. Everyone I’ve ever encountered with the BPD who was on the others felt Prozac was far superior. I actually did a study - funded by the Zoloft manufacturer, Pfizer, - and Prozac clearly won! It’s available on my Website in the BPD section at ../study.htm. The How I treat the BPD and Why section goes on to explain it much better. Everyone I switched from Prozac to another profoundly preferred Prozac. Prozac is the only one that really works for rejection sensitivity as well.

I have had many frustrating experiences regarding Eli Lilly and Prozac, and their profound refusal to cooperate regarding studies and the BPD. I had repeatedly looked forward with excitement when all the other SSRI’s came out with the hope they would be just as good and give me other options, but it has just not been the case. I am not on Eli Lilly’s payroll, I do not get paid by them, and I have no financial interest in the company - including having absolutely no stock in the company either directly or via a mutual fund. I spent a day years ago as an "advisor" in a ridiculous "think tank" session, and was paid a small amount for that - but that amount was less than I would have earned if I had stayed home and worked in the office.

The answer for you and your problem is easy to understand, and I see it every day. You most likely also have the generalized anxiety disorder (GAD) - particularly the cognitive component. This means an imbalance is present - some serotonin receptors (particularly S1 and S2) are too high, and others are too low. When you take Prozac or any other SSRI medication (or stimulants), those with both the GAD and BPD get more anxious. Having the BPD means the individual’s "trapped animal" or "cornered animal" response is overfunctioning. The increased anxiety triggers more dysphoria (anxiety, rage, depression and despair) and thus triggered your being a "raging maniac ready to do violence to myself or someone else."  BuSpar is a key medication here to lower the high levels, so Prozac can work on the low levels. As always, it’s the additional diagnoses - the "comorbidities" - that are so important. The two most classic symptoms of the GAD (which is genetic - and the gene has been discovered) are persistent thinking and worry. The screening test I use for my patients may be of use to you.

There are three keys to treating the BPD successfully:

a)    Controlling all the chronic symptoms of the BPD and everything else that’s wrong
b)    Having a formal plan for stress
c)    Retraining the brain

Prozac is only a part of (a). When a patient of mine read your question her answer was a simple one: "Because it works." I have a simple philosophy in treating my patients - I want them doing great in every area of life (../goals.htm). I also believe in recommending the best treatment, and what I’d want for me if I were in that situation. I see so many treatment failures from other regimens - such as extremely high Effexor doses, Remeron, lithium, etc., that I have a firm belief that Prozac is one of our modern day miracles.

I recently sent out a press release on the subject. Here are some excerpts:

I treat many of these individuals who get agitated from medications, and they all have a true "chemical imbalance." Some brain areas have high levels causing anxiety, others have low levels causing depression and other problems. When medications like Ritalin and some antidepressants are used to raise the low levels, the brain areas that are already high get even higher. This can cause a dramatic increase in anxiety, which may trigger problem behaviors - particularly in those with the borderline personality disorder who then experience increased dysphoria (anxiety, rage, depression and despair) and psychosis."

Dr. Heller says: "By treating both the high levels and the low levels with a combination of safe, non-addicting, non-sedating medications, this problem can be avoided and the individuals lead a happier, more productive life with a much lower risk of violent behavior.