My goal in treating borderlines is not just a reduction in anger or moodiness, but a great life with success in every important area of life. To me this means 1) diagnosing and treating all their problems, 2) have a formal plan for dysphoria, and 3) retraining the brain. Controlling the self-destruction/dysphoria cycle is crucial, as patients just can’t recover when they continue to participate in self destructive behaviors.

It has been my experience that Prozac is the most effective SSRI, but that others can work well. The study I did comparing Prozac (fluoxetine) with Zoloft (sertraline) and Prozac was more effective (available in this section).

Effexor:

Effexor in very high doses of 450mg daily has shown efficacy in treating the BPD, but in my experience side effects limits their use at these doses. Sedation, weakness, agitation, and blood pressure elevation are the biggest problems. At these high doses Effexor blocks dopamine receptors, and I’m concerned that long term tardive dyskinesia will develop as it has with other drugs affecting the dopamine system including neuroleptics and the gastroesophageal reflux medication Reglan (metoclopramide).

Tegretol:

When I first started treating borderlines in 1988, Prozac was clearly the first medication that had a big impact for borderlines. Shortly thereafter, I had some patients tell me "Prozac stopped working." All the psychiatrists I referred my patients to refused to take care of my BPD patients, so I did some literature searches to see what I could do for them. When I came upon Dr. Cowdry’s article (available in the Medline section) I decided to give these patients a try with Tegretol and miracles happened. Every single patient with dysphoria who was already taking Prozac had a "miracle" three hours later - the dysphoria went away.

I found something both surprising and amazing: if the patient was on Tegretol alone there wasn’t much benefit and if the patient was started on Prozac and Tegretol at the same time, it took a month for the benefit to develop. If they were on Prozac for a week and then the Tegretol was added, the miracles occurred. This finding is remarkably consistent for those with chronic dysphoria, dissociative symptoms, and self-mutilators. Persistent success generally requires blood levels in the upper half of therapeutic if they need to take Tegretol on a consistent basis.

I do the recommended blood work (CBC & 14 initially, CBC after one week, one month and every 3 months, with a 14 after 3 months and annually), and it’s extremely unusual to have problems except for sedation. The sedation affects 75% of patients, usually goes away eventually, and can be easily controlled with nighttime dosing. Nighttime, and as needed dosing, works for at least 90% of my patients. The melancholia Dr. Cowdry subsequently described appears to be due to Tegretol induced thyroid dysfunction, which is easily manageable with Synthroid. Studies in the 1980's at NIMH on borderlines show 1/3-1/2 have an impaired TSH response to TRH infusion anyway, and many have non primary hypothyroidism based on symptoms that respond to treatment - with or without Tegretol. This resolves with treating the thyroid problem, just like treating the temporary low thyroid problem that occurs in post partum depression (depression after childbirth). I go into this in more detail in Biological Unhappiness.

In 1992 a New England Journal of Medicine Article from the VA comparing Tegretol to Depakote for regular and complex partial seizures found comparable efficacy, but Tegretol was superior for complex partial seizures - which I suspect BPD dysphoria is. More significantly the authors stated that Tegretol was SAFER than Depakote long term (this article is available in this section). I’ve often heard the statement "Tegretol is out of favor," which doesn’t make sense to me., and there is no literature confirmation of this myth.

Due to occasional Tegretol allergy or intolerance, along with the literature showing efficacy of newer agents I have tried them with the following results:

When Depakote was discovered to be efficacious for bipolar and BPD, I of course tried it. While it helped some - with or without an SSRI - it just wasn’t as effective as Tegretol. Many patients still required temporary extra doses of Tegretol with the Depakote, and got extraordinary relief. They did not get this relief with the addition of more Depakote. Chronically dysphoric patients on Prozac and Depakote often need the temporary addition of Tegretol. There is literature documentation on the safe use of both medications together.

Felbatol worked very well, with an efficacy similar to Tegretol. Unfortunately it turned out to be very toxic and was essentially withdrawn. I still have patients lamenting that they cannot take Felbatol any more.

Lamictil has had some successes, but in general patients hate it. I’ve had many patients refuse to take it after using it in the past. It really can’t be used as needed because of the way it needs to be prescribed and it has the significant rash risk that can be fatal. Additionally, like Depakote, I’ve had many new patients come to me with severe chronic dysphoria taking Lamictil and Prozac, who got relief 3 hours later by adding Tegretol.

Neurontin works for some, and has the huge advantage of not needing blood levels performed. It’s extremely expensive, and in my experience it’s much more effective for neuropathic pain than the BPD. It also can cause a "hyperactive" side effect that mimics ADHD.

Neuroleptics:

For long term use I couldn’t agree more with the use of the atypical antipsychotics. I perceive Risperdal to be the best, and the one with the longest track record. Expense and side effects are the biggest problems. Grogginess is the biggest problem, some have weight gain, some get dystonic reactions, and rarely a patient will lactate. 3mg of Risperdal is usually required to stop a dysphoria spell in a borderline patient.

Zyprexa hasn’t been as effective, and can cause massive weight gain - in the 30-100 pound per year area. This has been discussed regularly in schizophrenia management. My experience has been that if you want a BPD patient to absolutely hate you, prescribe a medication that makes them obese. Weight gain takes an enormous toll on physical health, particularly regarding diabetes, arthritis, HTN, back pain, and heart disease. Patients also frequently complain that Zyprexa causes them to feel emotionally numb. Head to head comparisons for acute use during severe dysphoria crises has shown me that Risperdal is far superior in efficacy compared to Zyprexa.

My experience with Seroquel is limited, but I have had many patients come to me on it requesting something that "actually works." It’s very effective in the elderly with fewer side effects than Risperdal, especially for those with parkinsonism.

I know Clozaril can work based on the literature, but I can’t justify using it based on my successes with Risperdal and Zyprexa second line. The warning in the PDR is flat out scary, and I could never justify in court using it instead of the other ones first. The PDR states: ""Because of the significant risk of agranulocytosis, a potentially life-threatening event, Clozaril should be reserved for use in the treatment of severely ill schizophrenic patients who fail to show an acceptable response to adequate courses of standard antipsychotic drug treatment, either because of insufficient effectiveness or the inability to achieve an effective dose due to the intolerable adverse effects from those drugs. Consequently, before initiating treatment with Clozaril, it is strongly recommended that a patient be given at least 2 trials, each with a different standard antipsychotic drug product, at an adequate dose, and for an adequate duration.." Weekly blood tests for 6 months are required.

If a BPD patient needs continuous use of an antipsychotic, Risperdal is my first choice. I never choose long term use of a non atypical antipsychotic like Haldol for continuous use.

Borderlines do their self destructive behaviors, including self-mutilation, for one reason: it works to stop their dysphoria. That’s their goal. Occasionally some have so much self hatred that they want to see themselves injured, but in my experience that’s usually in a self-defeating person who wants to get even with someone by self-injuring. For most, it’s pain relief plain and simple.

The beauty of occasional use of low dose Haldol is extremely rapid efficacy and lack of side effects. When brand name Haldol was available and I could use 0.25-0.5mg I only saw one or two dystonic reactions per year, usually easily manageable with Benadryl. Generic appears to be equivalent at 2mg, and dystonic reactions are more common, probably 6-10 patients per year. Cogentin often has a lot of side effects, so I give those patients the choice of Cogentin or Benadryl after trying low doses. The efficacy is usually within 10 minutes--5 minutes if chewed and allowed to be absorbed through the oral mucosa (patients discovered this trick and told me of it). Since Tegretol takes 3 hours to work, Risperdal and Zyprexa 1.5-3 hours to work, and Haldol 5-10 minutes to work, the choice seems obvious. Dysphoria is about as painful as it gets, and borderlines need to have confidence they can stop their dysphoria without having to resort to self destructive behaviors. Haldol is so effective, that I know if two doses don’t work, they need Tegretol. Risperdal is usually only needed for severe crises, and patients generally hate how they feel on it.

The atypicals are very, very expensive - particularly for a group who’s financial situation is rarely good. $200 or more per month for an atypical psychotic, particularly combined with weekly labs for Clozaril, is enormously expensive and out of reach for most people. The average income for borderlines is not that high. Additionally, Haldol doesn’t cause sedation or impair driving - which the others do. Haldol is not that expensive, neither is generic Tegretol.

The long term risk of tardive dyskinesia is ever present, although the atypical antipsychotics can do that also, hopefully at a lower long term rate. The PDR warning is the same for the atypicals as it is for the older ones, and we don’t yet have long term data on what the atypicals will do. I recommend Haldol for as needed use only, and if daily use is needed for a while, they clearly need the addition of Tegretol and also Risperdal if needed. I don’t advocate the daily use of Haldol for more than a short period of time.

Additionally in medicine it’s risks v benefits. With a 10% suicide rate, substance abuse, raging on the highway, domestic violence, and financial destruction due to dysphoria the tiny risk of long term tardive dyskinesia (or even the rare short term one) is worth the benefit of stopping dysphoria in 10 minutes.

I know what I’m doing works. I see many, many borderlines, and they come from all over the country because what they’re being prescribed doesn’t work. Many physicians have tried the medication regimen I recommend with the same results, because patients insisted upon it based on what they have read.