QUESTION:
Dear Dr. Heller,
My daughter has been diagnosed with BPD. After perusal of your site and the one on which Dr. Markovitz answers questions (Mental Health Sanctuary), I pushed her to ask her psychiatrist to put her on 80mg of Prozac and on an antipsychotic on an as needed basis. (She asked for haloperidol but she insisted on a different one - however, it works to bring down the rages).
I have three questions.
One: Is there a risk of Serotonin Syndrome with 80mg Prozac? (The psychiatrist is very anxious about this - an anxiety that is not helped by the fact that she is taking herbal 5HTP tablets -- she is doing so because she is a vegetarian and also restricts her diet, and I understand that a tryptophan restricted diet can render SSRI's inefficacious as is the case with anorexics).
My second question is about Tegretol: You recommend it strongly starting about a week after the Prozac, Dr Markovitz, however, suggests that "Tegretol will make your Prozac concentration break down quicker and probably not help much with your illness. The Tegretol decreases mood swings when it works, but usually causes depression. You may wish to be taken off Tegretol and go to 80mg of Prozac." This disagreement between two experts leaves me confused as to what to suggest to my daughter to inquire of her psychiatrist (assuming that such enquiry will achieve anything. She is very anti-med and insistent that only therapy will work, whereas we want both medication and therapy - preferably DBT).
My third set of questions relate to social phobia which my daughter has always had throughout her childhood and still now. Is this a cause/effect or in some way related to BPD, e.g through a common cause? Would you recommend Wellbutrin or Ritalin as an augmentation to the Prozac, given that she has this condition? Also, given the impulsivity she displays, would either of these be advisable to enable her to 'think before she acts' (I am thinking about your comments about adult ADHD).
I would be grateful for an answer to these questions though I must apologize for their length.
From a Professor at the University of Birmingham, Great Britain
ANSWER:
1) The risk of serotonin syndrome is grossly overrated. It's
extremely unusual for any physician to report actually seeing a case. Dr. Markovitz wrote
to me in the past that as long as an MAO inhibitor or TCA (tricyclic antidepressant) are
not used with the SSRI, there is virtually no risk of serotonin syndrome from high SSRI
doses. Some researchers are using doses many times the maximum dose of SSRI medications.
Prozac is approved for 80mg daily, and I have a few patients taking 100 and 120mg daily.
At a mental health conference, I had a chance to discuss the subject of 5HTP with
SSRI's with the Chairman of Psychiatry at Harvard University - who told me there was
no data available yet on this interaction. I've had no problem with Prozac's
effectiveness in vegetarians.
2) Studies at the US National Institute of Mental Health (NIMH) in the
mid 1980's showed Tegretol (carbamazepine) was effective for treating the BPD (American
Journal of Psychiatry April 1986 - "In a double-blind crossover trial, carbamazepine,
an anticonvulsant with primary effects on subcortical limbic structures, decreased the
severity of behavioral dyscontrol ...significantly more than placebo." Drs. Cowdry
and Gardner.) A subsequent report by the same authors published in the Journal of Clinical
Psychopharmacology August 1986 showed that 18% developed melancholia while taking
carbamazepine. Studies in the early 1980's showed that the TSH response to TRH was blunted
in those with the BPD
(http://www.BiologicalUnhappiness.com/abstract.htm
- references 33 and 34). Those with the BPD commonly have non-primary hypothyroidism
(hypothyroidism without an elevated TSH). In my experience every patient who developed
melancholia on Tegretol had a significant drop in thyroid blood levels and responded to
thyroid augmentation. There is some debate in endocrinology whether the drop in thyroid
levels from Tegretol is clinically significant or not - my experience has shown that it is
indeed very significant.
(My patient Newsletter on thyroid
problems). I have never seen a significant problem with reduced Prozac effectiveness
from thyroid. In fact the drug interaction means lower doses of Tegretol are needed. The
symptoms I treat with Prozac are unprovoked mood swings, chronic anger, emptiness,
boredom, and emotional pain. Rejection sensitivity and chronic, non dysphoric depression
respond well also.
3) Social phobia is an additional condition that needs to be dealt with.
Any emotional trauma as a child can cause the BPD, where the brain's "trapped
animal" response is broken. Before giving additional drugs, I'd want to know
what all her diagnoses are and comprehensively treat them. The
screening
test
I use for my patients will be of great help.
(The
official criteria for ADHD).
4) One of the major areas of difference between my approach and Dr.
Markovitz is the difference between family physicians and psychiatrists. Psychiatrists
practice the concept of "parsimony of diagnoses" - meaning make as few diagnoses
as possible. Family physicians use problem lists - making all the diagnoses and then
comprehensively treating them. It's a major difference. Another difference is trying
to control all the diagnoses with one medication (often in very high doses) at the price
of significant residual symptoms as opposed to treating all the diagnoses with medication
combinations. The price of this approach is multiple medications.
5) Without medication her prognosis is dismal. DBT's success in the
literature was to significantly reduce self-harm episodes and suicide attempts. Treating
the target symptoms is extremely important. I explain my medication approach at
http://www.BiologicalUnhappiness.com/20a.htm
and
http://www.BiologicalUnhappiness.com/dysphori.htm.
