INTRODUCTION TO LIFE AT THE BORDER

Introduction

I wanted to be a doctor since I was 5 years old. Nothing else captured my interest and imagination, and nothing brought me greater pleasure than helping others. The television character "Marcus Welby" was a significant role model for me, as was a Family Physician uncle.

I always believed in the importance of Family Physicians, and it's the career I chose. Most residency trained Family Physicians are extremely dedicated doctors, who believe in what a good Family Doctor can accomplish. We enter this specialty knowing our income will be at the bottom of the physician pay scale, that the "prestige" is not as high as other specialties, and that we will have to read more and work harder to maintain our skills. There are other rewards: "Marcus Welby" was much happier and got more out of life than "Ben Casey"!!!

The Psychiatrist in my residency program, Dr. James Alford, a former rural Family Physician, became a Psychiatrist after 20 years in practice. He was an excellent teacher and role model. My residency program strongly emphasized psychology and the "behavioral sciences." We were especially well trained in the treatment of depression, an extremely common problem that I have enthusiastically treated in my practice. Dr. Alford was a pioneer in the treatment of alcoholism, and I was very fortunate to spend 2 months during my residency program working under his direction with an inpatient alcohol treatment facility. I learned a lot.

In 1988, I started prescribing the antidepressant "Prozac" (fluoxetine). While it is no better than other antidepressants, it has far fewer side effects, and it' s safe even if overdosed. The problem with other antidepressants was a moderately small overdose could be fatal - a big problem with patients who are already thinking about suicide.

My first Prozac patient told me a month later that she had stopped fighting with her kids since she was on the medication..While antidepressants often could reduce irritability and anger, I had not heard a remark like that before. I heard comments from other Prozac patients like "my mood swings have stopped," "I'm not angry all the time," "I don't feel hollow any more," and "my boredom went away." These remarks were especially common among my patients with bad PMS and obesity.

Shortly thereafter, a Ph.D. Psychologist told me that a particularly difficult woman was a "borderline." I knew nothing about it. Personality Disorders were rarely discussed in my training (medical school, residency, and post-graduate courses), primarily to avoid "labeling" someone. She showed me the DSM-HI-R criteria, and an article.

The article described abnormal brain waves, abnormal neurological exams, and other biological abnormalities. The more I read, the more I became convinced that this was a medical problem masquerading as an emotional illness. Epilepsy was once thought of as an emotional illness as well.

As I read more articles about borderline, I became convinced Prozac was working to stop or at least markedly reduce the mood swings, anger, emptiness and boredom borderlines suffer. I reviewed the criteria and the information I had read with patients who made those remarks about Prozac. An astonishingly high percentage felt they suffered from borderline. When they understood this was a medical Problem, and not their fault, a profound change occurred - they had hope, often for the first time.

As I did more research, I found that more could be done for these patients. Borderlines are not crazy, but they go crazy too easily. I discovered that using neuroleptic medications like low dose Haldol (haloperidol) could work as needed for psychosis (craziness), much like antacids work as needed for heartburn. I found other medical problems associated with borderline that could be treated and make a profound difference.

I discovered that most psychiatrists and psychologists don't want to take care of borderlines - they are too difficult to manage (at least without the proper medication). I consistently heard that a therapist should have no more than 1-2 borderlines in their practice, and many psychiatrists and psychologists have told me they prefer to not take care of them. 7-20 million Americans suffer from an incredibly painful illness they didn't cause, and virtually no one wants to help them.

I usually recommend books for my patients to read. There was nothing available for my borderline patients to read. Many patients literally begged me to write a book about it. I decided to do so. I read virtually every journal article that had been written since 1986. I read many psychiatric books on borderline, two psychiatric textbooks, a neurological textbook, and books on the mind and body. If there was one truth about borderlines, it was that no one knew for sure what was going on, and there was enormous disagreement among "experts" in the field.

I also discovered that there were some extremely dedicated physicians trying to sort out the borderline disorder. Drs. Gunderson, McGlashen, Soloff, and particularly Drs. Cowdry and Gardner at the NIMH were doing excellent scientific research on borderlines. Most of the literature is about opinion and not scientifically proven facts.

The scientific literature has confirmed the medication aspects of my treatment program. My program is working wonders for many borderlines. Not all. I have diagnosed and treated approximately 200 borderlines since I first learned about it in 19.88. I have an active support group. Those that want to get better can do so by using the entire treatment approach.

(all the medical terms are explained for non-medical people in the book and in the glossary)

Borderline is clearly a medical problem - the limbic system is malfunctioning. It is also an emotional problem- borderlines have no self-esteem, no effective psychological defenses, and have spent a lifetime with crippling mood swings, horribly painful dysphoria, and frequent bouts of psychosis that have distorted their understanding of life and people. It is not their fault - they didn't cause it and they have been powerless to stop it. Until the proper medication came along they had essentially no chance to recover - even with counseling.

My explanation of borderline is:

A) through a combination of medical/genetic predisposition and emotional trauma (most commonly adoption, incest, early parental loss and child abuse), the brain is damaged, and uncontrollable mood swings result.

B) Dysphoria (a profoundly painful emotional state) is triggered by mood swings, stress, and emotional pain. The pain is so severe that borderlines will do almost anything to make the pain go away - the dominant cause of self-destructive behaviors, manipulation, drug and alcohol abuse, suicide and self-mutilation. The borderline is desperate for relief, and often finds it in drugs and endorphan releasing behaviors such as reckless driving, binge eating and binge spending.

C) Psychosis develops from even mild stress, dysphoria, fear of abandonment, and emotional pain. It can be severe, and is frequently destructive. It is often associated with symptoms of temporal lobe epilepsy.

My treatment approach has 4 steps:

1) Stop the mood swings. Prozac (fluoxetine) stops most mood swings, chronic anger, emptiness and boredom in 3 days, although it can take a month when severe depression is present.

2) Stop the dysphoria and psychosis. Neuroleptics like Haldol (haloperidol) work well even in very low doses.

3) Improve stress tolerance. This involves psychological counseling and other techniques to develop a healthy self-esteem and better psychological defense mechanisms.

4) Retrain the brain. Borderlines think like borderlines - they've spent their entire live with instability and pain. Aggressively retraining with motivational books and tapes works - if the patient will do it. Borderlines live in the black and white. When they are in the "white," they can be charming, kind, and very loving. Unfortunately the "white" lasts only a short time, as they tend to feel vulnerable and become dysphoric relatively quickly. That "white" is who they really are, when all the symptoms of the illness are taken away.

I feel very strongly that this disorder can be beaten. Untreated, it has a dismal prognosis. It's important to acknowledge the diagnosis, and fight for a better future. Denial won't make it go away. I've seen miraculous improvement in many borderline patients. They deserve the opportunity to recover. We may not like the behavior and attitudes this illness can cause, but we must remember that borderlines are fellow human beings who have no choice in the matter.

This book is written for borderlines, their loved ones, those who are interested in mental health issues, and health care professionals who want to help. It is designed to give the borderline all the information needed to get help, to understand medical/psychiatric facts and concepts, and how to recover. I have tried to write in layman's language, and have included a glossary at the end.

This book explains what I do and why for my patients. It is. not my intent to be the reader's physician. Do not take any medications based just on this book - you must have your own physician evaluate you, prescribe appropriate medications, and do the proper follow-up.

I say to to my borderline patients "you've been stuck in a pit all your life with no way out. I've given you a ladder, but only you can climb the ladder." It is my hope that borderlines who read this book will overcome whatever needs to be overcome and climb the ladder to a life of love, happiness and mental health.

Leland M. Heller, M.D. 9/13/91

	A) through a combination of medical/genetic predisposition and emotional trauma (most commonly adoption, incest, early parental loss and child abuse), the brain is damaged, and uncontrollable mood swings result.
	B) Dysphoria (a profoundly painful emotional state) is triggered by mood swings, stress, and emotional pain. The pain is so severe that borderlines will do almost anything to make the pain go away - the dominant cause of self-destructive behaviors, manipulation, drug and alcohol abuse, suicide and self-mutilation. The borderline is desperate for relief, and often finds it in drugs and endorphan releasing behaviors such as reckless driving, binge eating and binge spending.
	C) Psychosis develops from even mild stress, dysphoria, fear of abandonment, and emotional pain. It can be severe, and is frequently destructive. It is often associated with symptoms of temporal lobe epilepsy.

	1) Stop the mood swings. Prozac (fluoxetine) stops most mood swings, chronic anger, emptiness and boredom in 3 days, although it can take a month when severe depression is present.
	2) Stop the dysphoria and psychosis. Neuroleptics like Haldol (haloperidol) work well even in very low doses.
	3) Improve stress tolerance. This involves psychological counseling and other techniques to develop a healthy self-esteem and better psychological defense mechanisms.
	4) Retrain the brain. Borderlines think like borderlines - they've spent their entire live with instability and pain. Aggressively retraining with motivational books and tapes works - if the patient will do it. Borderlines live in the black and white. When they are in the "white," they can be charming, kind, and very loving. Unfortunately the "white" lasts only a short time, as they tend to feel vulnerable and become dysphoric relatively quickly. That "white" is who they really are, when all the symptoms of the illness are taken away.