Q. I have been diagnosed as bpd, bipolar, GAD, bulimic, ADD, and on and on. I am currently participating in a study noting the effects of zyprexa on borderlines. I haven’t started the medication yet, as they are still doing the very thorough diagnosis, but I am quite sure I am BPD as I have been diagnosed by four different doctors.

I haven’t had any medication for two weeks, I was on depakote. This past week, I had an episode of intense anger. I will have these every few months or so. I am violent towards myself and others, I feel very unreal, very powerful, and I think it is very funny while it is happening. Last time it happened, I was hitting my husband, and had my hands around his throat. It lasts for about an hour on average.

I also have what I think are dissociative episodes. I had more severe episodes in the past where I had another person come forward, while I went in the back. But this is more like I am dreaming. I feel like I am floating, my hands feel disconnected, my head is fuzzy, I am not real when this happens. I think that it is disassociation. but I read through the past letters and you frequently mentioned temporal-lobe seizures, and my little sister had epilepsy, so I am asking your opinion on that.

I also can not seem to find an answer to this question. What exactly is psychosis? What is a psychotic episode? That was my real question. I just can’t find that information anywhere.

A. Psychosis is a state of grossly impaired perception or interpretation of reality (called “reality testing). It generally causes people to believe things that are not true and at times to act on incorrect assumptions. There have been many definitions over the years, and there are grey areas.

I personally believe psychosis is the last line of defense to protect the brain and/or psyche from permanent damage when facing overwhelming pain and/or stress. It’s something all of us can experience, it is not limited to borderlines. Due to damage within the brain, borderlines develop psychosis too easily and at times too quickly. When psychotic, people usually behave very RATIONALLY from their misconception of reality. It is often perceived as “crazy.”

When awakened from a powerful dream by an alarm clock, it can take a few minutes for the person to correctly interpret that the dream was only a dream. If the person does something out of character because he/she believes the dream to be true, that person is clearly misinterpreting reality and can be interpreted as psychotic. “Reality” needs to be compared to a person’s normal experiences, as there can be significant cultural and religious variation to “normal” reality.

Two examples: a person is exhausted, temporarily wakes up realizing he/she has to urinate. He/she then falls back asleep and dreams he/she has walked to the bathroom and it’s appropriate to urinate, then wets the bed. It’s clearly an inappropriate behavior caused by a misinterpretation of reality. Another example is a new widow overwhelmed with grief who misinterprets what someone said to her, believes that person killed her husband, and then tries to kill that person – something completely out of character. Whether these are “psychotic” behaviors or not depends on the exact definition of the person defining psychosis.

There are many types of psychoses, such as delusions (believing one is Jesus, Lincoln, etc.), catatonia (where a person lies essentially unresponsive), and paranoia. During psychosis, the person absolutely believes their perception of reality is correct. They usually act very rationally from the incorrect framework – for example it’s reasonable to be mistrustful if you genuinely believe everyone is out to hurt you. Schizophrenia is a brain disease where both reality perception AND the thought process are abnormal.

A psychotic episode is simply a period of time where the perception of reality is sufficiently abnormal as to impair part of a person’s life. A psychotic episode occurs when pain and/or stress (real or imagined) overwhelms psychological defenses. Psychotic episodes in borderlines tend be associated with brain cells firing inappropriately and out of control, which is a form of epilepsy.

Borderlines appear to have three distinct types of psychotic experiences: moods, perceptions, and physical sensations.

Psychotic moods are called “dysphoria” (anxiety, rage, depression and despair) and can be accompanied by other experiences such as a sense of worthlessness. Self-destructive urges usually come from dysphoria, as can violence. These sensations and beliefs are clearly inappropriate and/or out of proportion for the actual stress. I believe chronic dysphoria is an persistent epileptic process.

Psychotic perceptual distortions include misinterpretation of motives (paranoia), “transference,” and occasionally hallucinations. “Transference” (not the psychoanalytical term) almost always occurs during rages, and essentially means blaming someone for things others have done. Tragically, borderlines usually remember these psychotic beliefs as real, often holding grudges or blaming someone for things they did not do – it’s a major cause of relationship breakup and other problems. I teach my borderline patients that while they can probably trust good memories, they can’t trust bad ones. Some bad memories may indeed be true, but not all – particularly if remembered while psychotic. Counseling can help, but generally if dysphoria accompanies the bad memories, it cannot be relied upon as actually having happened.

Physical sensations are the ones you described: dissociation and what appear to be either or both “complex partial seizures” or “temporal lobe epilepsy.” There is still some controversy in this regard, but EEG (brain wave) studies during dysphoria indicate epilepsy in most borderlines. Symptoms can include deja vu, body parts feeling numb or weird, looking through someone else’s eyes, weirdness to the physical world, and a sense of unreality. These sensations can also happen to someone experiencing psychosis who doesn’t have the BPD.

Psychosis appears to be a NORMAL part of the human existence that is malfunctioning in the BPD. It is assumed that the brain neurotransmitter dopamine is involved in psychosis because medications that block dopamine (neuroleptics like Haldol and Mellaril) stop psychosis. Zyprexa and Risperdal appear to work on more than the dopamine system. The next decade should yield many breakthroughs about how and why psychosis develops, and how these medications work.

Regarding your personal situation: You described a very scary event where you went into psychosis, became rageful (with violent, out of control behavior) and experienced dissociation and/or temporal lobe seizure activity. I’ve heard borderlines describe themselves as “empowered” during rage, rather than powerless and weak, but rarely is the word “powerful” used. I’ve only heard BPD rages and violence described as pleasant or “funny” in victims of severe childhood abuse.

Obviously I don’t know you, I’m merely responding to your question. If I was to make an educated guess, I’d interpret that you were very badly abused as a child, and as an adult you experience an overwhelming sense of powerlessness that only goes away with rage. I suspect you experience dysphoria (anxiety, rage, depression and despair) constantly (and likely a sense of unreality as well) and have for a very long time.

Your violent behaviors are very scary and must be taken seriously. Many, many murders have occurred because of BPD rages. If your diagnoses of BPD and bipolar are correct, you almost certainly need to be on an SSRI medication (like Prozac), Depakote or Tegretol , and either Zyprexa or Risperdal until the violence is completely under control for a long time. Doses and medication combinations can usually be found that will prevent or minimize side effects. A trial off some of these medications can be given under carefully supervised conditions at some future time when you have done well. Violence must always be stopped, and hitting your husband and having your hands around his throat is extraordinarily dangerous and frightening. It may not be your fault that you have the BPD, but it is 100% your responsibility to control yourself, using medications if necessary. I wish you well.

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