Q. Dr. Heller:
It concerns me that you are so absolute in recommending Prozac and Tegretol almost exclusively for BPD. Prozac's ineffectiveness landed me in the hospital. I had been told I suffered from Depression and PTSD prior to hospitalization, but the BPD was added by the hospital doctor. I have been through a crash course on DBT and it all made sense, but I was unable to continue the follow-up sessions. I am now on 300 mg Effexor and 900 mg Lithium and do fine as long as I take the medicine and go to weekly therapy. How can you say Effexor doesn't work, when it seems to be helping me? People with BPD have so many different experiences, it seems sensible they could respond differently to medications as well.
A. First of all I'm thrilled for you that your combination is working for you.
What I've stated is that I've never encountered anyone in my practice with the BPD who did well with either Effexor or lithium - in fact there's usually enormous hostility towards lithium.
Prozac works well for what it works for: inappropriate mood swings, chronic anger, emptiness, boredom, emotional pain, depression, and rejection sensitivity.
One study by Markovitz showed that at 80mg all borderlines had improvement.
The key issues regarding Prozac and the BPD to me are the comorbidities and the presence or absence of chronic dysphoria (anxiety, rage, depression, despair). For example, if an individual has the generalized anxiety disorder, the BPD may seem worsened by Prozac as the high serotonin #2 level triggers increased anxiety, causing a worsening dysphoria. Many patients, particularly those who also needed Tegretol, noticed no change on Prozac until everything was successfully treated.
In treating over 3000 individuals with the BPD, I have yet to encounter one patient who didn't respond well to Prozac PROVIDING the other diagnoses were correctly made and treated, and the addition of therapeutic doses of Tegretol were included...AND the individual used a neuroleptic on an as needed basis for dysphoric spells.
Although I try to avoid lithium in my patients due to side effects - particularly weight gain - I am curious how the Effexor/lithium combination has worked for your inappropriate mood swings (not the triggered ones, but the inappropriate ones), the chronic anger (not to be confused with rage), the emptiness, boredom, feeling like your best friend died all the time, the rejection sensitivity and the frequency of your dysphoric spells compared to pre-treatment.