ANNUAL UPDATES – BIOLOGICALUNHAPPINESS.COM Annual Updates - BiologicalUnhappiness.com Biological Unhappiness Dr. Leland Heller Annual Updates - BiologicalUnhappiness.com Annual Updates - BiologicalUnhappiness.com ANNUAL UPDATES – BIOLOGICALUNHAPPINESS.COM Annual Updates - BiologicalUnhappiness.com 2010 Annual Updates Borderline Personality Disorder (BPD): 1)  Severe situational crises respond best to the temporary use of night time Zyprexa (olanzapine).  The patient can still use the Haldol (haloperidol) and get relief.  A study showed Haldol (haloperidol) and Zyprexa (olanzapine) for chronic use were equal.  Haldol (haloperidol) works more quickly and Zyprexa (olanzapine) is more effective initially in treatment and for severe stressors.  Both have possible serious long term risks. 2)  The literature continues to prove that there is no “borderline drug” or a “mental health pill”.  The medications are great for specific symptoms, but usually need to be used in combination, even if only for as needed use.  Additionally, treating the comorbidities (other diagnoses) is vital, and that’s not measured with single-drug regimens. 3)  Looking for the genetic cognitive generalized anxiety disorder as a comorbidity continues to be crucial as SSRI’s like Prozac (fluoxetine) and SNRI’s like Effexor (venlafaxine) and Cymbalta will increase the anxiety–worsening BPD dysphoria (anxiety, rage, depression and despair).  BuSpar usually turns off this gene, making it possible to take these medications without making the BPD worse. 4)  There were many studies in 2010 about the medical basis of the borderline personality disorder.  They can be found at http://www.BiologicalUnhappiness.com/hippocampus _BPD.htm. 5)  Doing functional MRI or equivalent studies on individual patients does not help with the diagnosis or management of the BPD or other disorders causing biological unhappiness. 6)  For the first time a study was done looking for statistics of comorbid ADHD and BPD. The article stated that 38% of those with BPD also have ADHD.  I suspect the actual number is closer to 50%.  There was also a study showing that there are specific neurological changes in those with both diagnoses. 7)  Most patients I’ve seen who carry the diagnosis of bipolar disorder have never had a manic or hypomanic episode in their life and actually have the borderline personality disorder.  Some BPD patients also have bipolar – and they can be successfully treated with the same medications except that Tegretol (carbamazepine) is mandatory instead of optional.  There was a study in 2010 that confirmed my observation that bipolar is often a misdiagnosis and the BPD was the correct diagnosis. ADHD (attention deficit hyperactive disorder): 1)  I check all my adolescents and adults with ADHD for comorbid borderline personality disorder. 2)  A recommendation was made to try amantadine to improve executive function for those with ADHD.  I had one patient who got better for a few weeks, then the benefits went away.  The other three patients I treated saw no benefits.2009 Annual Updates Borderline Personality Disorder (BPD): 1.  For chronic antipsychotic use I’ve found Abilify (aripiprazole) to be the extremely effective with minimal weight gain. 2.  Taking folic acid or folate 800mcg – 1000mcg daily can prevent bone marrow suppression from Tegretol (carbamazepine). 3.  When Haldol (haloperidol) causes dystonic reactions, I’ve successfully been able to prescribe Navane (thiothixene) instead without the reaction or other side effects. 4.  I believe that everyone with the BPD should be evaluated for ADHD as well, as approximately 50% of those with BPD also have ADHD, and vice-versa.    http://www.BiologicalUnhappiness.com/AD-H-Dcr.htm 5.  A study by Dr. Links and his group from Canada showed that good psychotherapy by psychiatrists familiar with treating the BPD is as effective as DBT.2008 Annual Updates Borderline Personality Disorder (BPD) 1.  The prevalence of BPD has been debated over the years, with most estimates ranging between 1-2%.  Those of us who treat the BPD know that estimate is too low.  A population telephone study in Iowa during the 1990′s found 7% of the population had the BPD.  A large study (34,653 adults) showed the prevalence was ~ 6% (5.9% actually), with men equal to women.  This study was published in the April 2008 edition of the Journal of Clinical Psychiatry. 2.  Seroquel (quetiapine) has not been shown to be of significant benefit for BPD symptoms.  I use it primarily for sleep, especially the most difficult cases of insomnia. 3.  Dysphoria (anxiety, rage, depression and despair) treatment has been updated at:    http://www.BiologicalUnhappiness.com/dysphori.htm 4.  I have found most patients get significant symptom relief by adding a dose of Zyprexa (olanzapine) to Risperdal (risperidone).  It makes the 24 hours less unpleasant and Zyprexa (olanzapine) seems to reduce the side effects of the Risperdal (risperidone) dose.2007 Borderline Personality Disorder (BPD): 1) More than any other year in history, more medically and scientifically based studies were published.  It’s great to see all this research proving the medical basis for the BPD.  (See the bottom of http://www.BiologicalUnhappiness.com/medline.htm for these updates.) 2) Topamax (topiramate) has shown benefit.  In my experience the best mood stabilizer is Tegretol (carbamazepine), especially in combination with Prozac (fluoxetine) with as needed dysphoria (anxiety, rage, depression and despair) medical treatment (http://www.BiologicalUnhappiness.com/dysphori.htm).  Tegretol (carbamazepine) costs ~$4.00 for 30 pills, so it’s very affordable.  Unless there’s a problem with Tegretol (carbamazepine) (rash, severe low sodium, bone marrow suppression), it’s the best mood stabilizer, and the only one proven to reduce behavioral dyscontrol (losing control of behavior).  If one of those problems exists there are other options:

a) Depakote (valproic acid or valproate):  This has been shown to reduce anger.  It’s expensive (despite being generic), can cause weight gain, and liver function needs to be monitored.  The price is usually costing $100-$300 per month. b) Lamictal (lamotrigine):  The dose has to be slowly increased to get effect.  It doesn’t require blood tests and can cause a very severe rash that can be fatal and possibly cause disfigurement.  It’s very expensive and costs hundreds of dollars per month. c) Topamax (topiramate):  It helps some individuals, but in my experience makes as many worse – with increased hostility and irritability.  It’s very expensive and costs hundreds of dollars per month.  Topamax (topiramate) can greatly reduce migraines and for that reason it’s a useful alternative for individuals with migraines (which are more common in the BPD).

3) Using Zyprexa (olanzapine) for the first week of therapy can be enormously useful when initiating treatment with Prozac (fluoxetine).  It prevents worsening of anxiety and dysphoria (anxiety, rage, depression and despair) while the medication is started.  It’s also great for stressful episodes when the mind is constantly racing.  It’s extremely expensive and causes weight gain. 4) If I need to prescribe a continuous antipsychotic medication, I choose Abilify (aripiprazole).  It works well without causing weight gain.  It’s also extremely expensive.ADHD (Attention Deficit Hyperactivity Disorder): 5) A new form of Adderall — Vyvanse — is an excellent choice for ADHD.  Its blood levels are much smoother and it usually lasts 10-12 hours.  It rarely has the “jolt” that regular Adderall & Adderall XR can cause.  It’s a “pro-drug” – meaning that the medication is inactive until “activated” by the liver (it removes the lysine molecule).  Abusing Vyvanse rarely works since snorting or using it IV doesn’t give a rapid onset of Adderall (dexedrine).  70mg of Vyvanse is equivalent to Adderall XR 30mg.Depression: 6) A new antidepressant “Cymbalta” (duloxetine) is available, and can help with chronic pain (even in the absence of depression).  It’s expensive and has had little benefit for my BPD patients, although it can be a useful “add-on” medication.2006 Borderline Personality Disorder (BPD): 1) Many individuals have restless legs syndrome.  While iron deficiency is often the problem, and the most likely problem in menstruating females, it’s not always the case.  Sometimes antidepressants – including SSRI’s – can be the cause, although usually it’s a dopamine phenomenon in the muscle control part of the brain.  The medication Requip (ropinirole) works for most individuals, but can make many borderlines worse – likely by raising dopamine in the trapped, cornered, wounded animal part of the limbic system.  These individuals need to be treated with iron, and if unsuccessful with nighttime benzodiazepines like lorazepam or clonazepam.  My experience has been approximately 60% of borderlines treated with Requip (ropinirole) get agitated and have to stop the medication. 2) There has been some renewed interest in the scientific community regarding the biological basis for BPD symptoms.  The “G protein beta 3″ has different types called “alleles.”  The “T allele” has been associated with self-mutilation in individuals with childhood abuse and BPD.  Some work is being done on dopamine receptors as well, which is particularly exciting because of the success borderlines have using Haldol (haloperidol) on an as needed basis and the likelihood of dopamine dysfunction as a part of psychosis and dysphoria (anxiety, rage, depression and despair). 3) As mentioned in previous updates, Topamax (topiramate) can make borderlines worse.  It can be so profoundly effective in reducing or eliminating migraine headaches that it’s often worth a trial, sometimes taking it at the same time as Tegretol to reduce the risk of behavioral and anger/rage problems.  Approximately 70% can’t take it. 4) Something I emphasize to new BPD patients is the neurological basis of their disease.  I tell them that there are times when they are sweet, loving and kind – that’s who they really are.  The rest is a neurological disease than can be treated medically.2005 Borderline Personality Disorder: 1) While anti-epilepsy medications like Lamictal (lamotrigine), Trileptal (oxcarbazepine) and Topamax (topiramate) show some benefit in small studies, in my experience they still aren’t as effective or as consistent as Tegretol (carbamazepine).  Topamax (topiramate) is a double edged sword – while it works for some, it makes others very hostile and self destructive.  Its advantage is the weight loss and reduction or elimination of migraine headaches.  I have used it successfully in combination with Tegretol. 2) Zyprexa (olanzapine), particularly in combination with Prozac (fluoxetine), is very effective.  It’s extraordinarily expensive and many patients complain that they “don’t have feelings.”  The problem is that it can cause massive weight gain (25 to 100 pounds) and diabetes. 3) My dysphoria (anxiety, rage, depression and despair) instruction sheet is still available at http://www.BiologicalUnhappiness.com/dysphori.htm.  Sometimes SSRI antidepressants like Prozac (fluoxetine) can cause a neurotransmitter imbalance that causes low energy, a lack of pleasure and the “blahs.”  This is not the same as dysphoria.  It is not associated with suicidal thoughts and it persists.  Wellbutrin (buproprion) usually makes this go away in 1-2 weeks and I usually only prescribe it for a month or so. 4) I very rarely prescribe antipsychotic medication for chronic use, but if I do Abilify (aripiprazole) is the one usually prescribed primarily because of its low side effect profile (it doesn’t cause weight gain). 5) A number of studies showed that the BPD has a biological basis (or at least significant biological abnormalities).  They can be found at http://www.BiologicalUnhappiness.com/hippocampus_BPD.htm. 6) I have found over and over again that it’s the comorbid conditions (what else is wrong) that defines how well an individual with the BPD will do.  Prozac (fluoxetine) will stop the unprovoked mood swings, chronic anger, emptiness and boredom.  Tegretol (carbamazepine) can stop chronic dysphoria (anxiety, rage, depression and despair) and dissociation.  Intermittent dysphoria can easily be treated.  For most individuals with the BPD the actual taking of pills is the easy part, it’s convincing oneself that he/she should be treated that’s the hard part.  That’s why character issues and spiritual issues are so important and can’t be left out of any BPD evaluation or treatment plan. 7) Two books I’m recommending a lot lately are “Looking Out for Number One” by Robert Ringer (available very inexpensively at Amazon.com) and “Are You As Happy As Your Dog?” By Alan Cohen.  I’ve found that many individuals find it easier to learn from their pets than from people.  The latter book is hysterical, poignant, inexpensive and worth having at home. 8) There’s been a dramatic change in the way academic psychiatrists interpret borderlines over the 18 years I’ve been working with individuals who are afflicted with the BPD.  In the 1980′s and 1990′s there was a tendency to blame borderlines for having their illness – a view many still have today.  In a 2005 article from Harvard, published in the American Journal of Psychiatry, the authors (Zittel and Westen) while advocating a continuation of the diagnosis in the DSM V described the borderline experience as one of “intense psychological pain”.  It’s a long overdue acknowledgment of the suffering this dreadful disorder causes, and on behalf of the thousands of BPD patients I’ve treated I want to say thank you for writing that.2004 Borderline Personality Disorder: 1)  There is a growing consensus that the BPD is due to brain problems caused by trauma and/or genetic factors that can respond to medication.  The extent of medication response and which medications to use remains controversial.  In 2001 the American Psychiatric Association recommended the use of medications for BPD treatment. 2)  A number of studies came out in 2004 showing a biological basis in the brain for BPD.  They can be found at http://www.BiologicalUnhappiness.com/hippocampus_BPD.htm 3)  Not much new about treatment was discovered in 2004.  I continue to see Prozac (fluoxetine) as the best pharmacological BPD treatment.  At the right dose, Prozac (fluoxetine) stops the unprovoked mood swings, chronic anger, emptiness and boredom.  I still strongly believe the reason Prozac is better than other SSRI medications is its effect on glial cells (the brain’s support cells – much more numerous than nerve cells).  SSRI’s like Lexapro and Zoloft do help many individuals, but switching to Prozac achieves much better symptom improvement.  Tegretol (carbamazepine) remains the best anti-epilepsy medication for the BPD.ADHD & ADD: 1)  I continue to see that Adderall is far more effective in adults and adolescents than methylphenidate (Ritalin, Concerta and others).  I generally follow dosing guidelines advised by Dr. Biederman (0.5-1mg per day of Adderall XR), although some patients need higher or lower doses.  Many need a late afternoon and/or evening dose of a short acting stimulant. Dr. Biederman, Professor of Psychiatry at Harvard advises higher doses of stimulants when needed for successful ADHD treatment in adolescents and adults.  In “Today’s Therapeutic Trends” 20(4):311-328, 2002 Dr. Biederman wrote: “It should be reiterated that stimulant medications are considered to be very safe, and, and that dosage titration should continue until an adequate dose is reached, if tolerated.  The large therapeutic window associated with these agents indicates that there is a wide dosage range for their safe use… under-dosing in older adolescents and adults is a significant problem….” – page 324. 2)  Strattera works for many individuals, but overall has been a disappointment.  Some individuals experience an increase in hostility when taking Strattera.Panic Disorder: 1)  Medications that don’t require water are now available including Klonopin wafers and Nirivam (A form a Xanax {alprazolam}) that dissolves on the tongue. 2003 Borderline Personality Disorder: 1)  Omega 3 fish oils 1000mg daily can improve many BPD symptoms.  This was based on one very small study and was not done in comparison to prescription medications. 2)  The new epilepsy medication “Topamax” can help with headache, bipolar and some forms of epilepsy.  Weight loss can be a side effect.  Unfortunately, in my experience, most individuals with the BPD see their condition worsen when they take Topamax. 3)  The use of chronic antipsychotic medication is a problem.  The newer “atypical antipsychotics” can cause or worsen diabetes and can cause massive weight gain.  Interestingly, in my experience, taking Risperdal daily usually doesn’t work – it seems to work best when it leaves the system, not while it’s in the body.  If I need to prescribe an anti-psychotic medication on a regular basis, I usually prescribe Abilify.ADD & ADHD: 1)  Strattera is a non stimulant approved by the FDA for children, adolescents and adults with ADHD.  It has the huge advantages of not being addicting, it can be phoned in, and it works 24 hours a day.  It can work as effectively as the stimulants, but takes some time to work – usually weeks.  Side effects primarily relate to grogginess and stomach upset, and urinary retention.  The heart rate and pulse may go up by a small amount.  Dose adjustments may be needed frequently.  It’s not uncommon for Strattera to be combined with a stimulant. 2)  I am finding that for most adults Adderall gives the greatest benefit compared to Strattera and methylphenidate (Ritalin, Concerta and others).Major Depression: 1)  A study showed that antidepressants cause more brain cells and glial cells to grow. 2)  If Prozac is not needed, I’m prescribing Lexapro in addition to Remeron, Effexor and Wellbutrin.  It seems to be tolerated better than other SSRI medications. Panic and Anxiety: 1)  The epilepsy medication Neurontin (gabapentin) can be just as effective as benzodiazepines such as Xanax (alprazolam), Klonopin (clonazepam) and Ativan (lorazepam) for treating and preventing panic attacks.  The dose range is wide – ranging from 100mg daily to 1800mg three times daily.  Most patients need to start with a low dose and move up to a more effective dose.  It’s an expensive option, but it can be very useful – especially in alcoholics, those with the BPD, and substance abusers where benzodiazepines can be dangerous.2002 Borderline Personality Disorder: 1)  Abilify (aripiprazole), a new antipsychotic, can replace Risperdal (risperidone) for many borderlines experiencing severe dysphoria (anxiety, rage, depression and despair).  60% have no side effects, and when it works it generally works within 3 hours.  Many get just as sedated as they do with Risperdal.  In that case I prefer Risperdal because Risperdal always works, and Abilify (aripiprazole) doesn’t always work. 2)  In his wonderful new book “Where God Lives,” Dr. Melvin Morse reports that many researchers, particularly at the University of California, San Diego, have discovered the part of the brain that is attached to God and the Universe.  It’s above the right temporal lobe in the Sylvian Fissure.  When an individual with the BPD has a dysphoric spell, it’s a seizure that temporarily cuts the person off from God and spirit.  This is why the borderline can act antisocially when dysphoric and feel so much remorse afterwards. 3)  The medical research has shown additional evidence of the medical nature of the BPD. 4)  Prozac (fluoxetine) has been shown to improve the function of glial cells.  90% of the cells in your brain are support cells called glial cells, not neurons.  I strongly suspect the BPD is largely due to glial cell malfunction.  This may explain why Prozac is so much more effective than the other SSRI’s in treating the BPD, such as Zoloft (sertraline) Paxil (paroxetine), Luvox, Celexa or Lexapro. 5)  Effexor (venlavaxine) in high doses (450-600mg daily) can be helpful with the BPD, but I’ve never seen a patient who did better with Effexor than the Prozac/Tegretol (carbamazepine) combination.ADD & ADHD: 1)  The major change has been the addition of many long acting formulations that mean individuals don’t have to take a mid-day dose. 2)  Focalin, a “stereoisomer” of methylphenidate, is particularly useful for early evening stimulant use without causing insomnia. 3)  While substance abuse has gone up enormously in our society, treating ADHD lowers substance use.  The use of psychostimulants in children has gone up 800% in 10 years, but substance use is down 50%. 4)  The combination of the antidepressant Remeron (mirtazapine) with a stimulant can counteract the appetite loss and insomnia. 5)  Many strides have been accomplished proving the biological, and mostly genetic cause of ADHD.  The study showing smaller frontal lobes in some ADHD individuals does NOT mean they are less intelligent.  I have routinely found that those with ADHD are brilliant, clever and creative.Major Depression and Prozac: Prozac (fluoxetine) is an amazing medication for the genetic depression I described as “Fractured Enjoyment” in Biological Unhappiness.  It’s also phenomenal for the BPD.  Other than those two diagnoses, I am prescribing more Remeron, Effexor and Wellbutrin (buproprion) for depression due to the sexual dysfunction SSRI’s can cause.Antidepressant induced sexual dysfunction: The major treatments for difficulty getting erections I prescribe are ginkgo in high doses (180-240mg daily) and Wellbutrin.  In males, if there is a lack of sexual interest or inability to get or maintain erections, the total or free testosterone should be measured and treated if low.Panic Disorder: It turns out that Prozac and the other SSRI antidepressants work about as well as Paxil does for panic disorder.Insomnia: 1)  The new medications Sonata and Ambien have a much lower risk of addiction and dependence than the older benzodiazepine medications like Xanax (alprazolam) or Ativan (lorazepam).  The sedation is usually completely gone by the next morning. 2)  Remeron (mirtazapine) can be very helpful for sleep, especially with those who have been traumatized and are having trouble sleeping due to “Hypervigilance.” 3)  The antipsychotic Seroquel (quetiapine) has been extremely useful for difficult to treat cases of insomnia. 4)  Insomnia causes many, many problems including work and auto accidents and impairment of the immune system. It’s not a minor problem and for most insomniacs it’s not a short term problem either. 5)  The FDA has expressed concern regarding melatonin.Lack of zest for life: This can occur with all SSRI antidepressants, including Prozac.  The development of the persistent blah’s or lack of interest in life can be due to an imbalance of serotonin with low dopamine and noradrenaline.  The addition of Wellbutrin, usually temporary, can solve this problem.Spiritual Healing: I believe strongly that we have to heal mind, body and spirit.  While some have a strong and successful spiritual base, most don’t – particularly with the BPD.  Spirituality is about how you see yourself, God, the Universe and your role in it.  No one, including me, has the right to tell you that you are wrong and they are right.  It’s a journey you have to make for yourself.  I’m sharing with you some of my teachers: The book “The Other Side and Back” by Sylvia Browne has been very helpful to many individuals, especially in determining their purpose for coming to Earth.  She is the psychic the FBI uses.  I usually recommend avoiding the predictions at the end.  While psychics may be right about their prediction, the time is usually wrong.  Individuals may lose sight of her message by focusing on what predictions came true, etc. Also in “Where God Lives,” Dr. Morse describes a 20 year reunion of children who had a near death experience.  They were not involved with drugs, not pregnant, had no problems with authority figures, and had a purpose in life. In “The Dancing Wu Li Masters,” Gary Zukov describes quantum physics, which can be very useful in understanding the universe and your spirituality. “Soul Stories,” also by Gary Zukov, describes a happy and spiritual life, including a clear and loving description of a true spiritual partnership. “Journey of Souls” by Michael Newton describes “life between lives” – based on reports of individuals who have undergone hypnosis. “The Dragon Doesn’t Live Here Anymore” by Alan Cohen describes the beautiful journey he has taken towards enlightenment and is extremely helpful towards an understanding of spirituality and healthy thinking. Dr. Wayne Dyer has a number of terrific spiritual books and tapes out in the past few years, especially “The Wisdom of the Ages,” “There’s a Spiritual Solution to Every Problem,” and “Manifesting Your Destiny.”  The tape “101 Ways to Transform Your life” has been extremely helpful to me and many of my patients and friends. 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