The BPD New Management Concepts
1. Prozac 20 mg daily (clomipramine) Anafranil and other SSRI’s may prove to be just as effective
2. Haldol 0.5 mg q 4-6h prn (thioridazine, 10 mg and thiothixene 1 mg can be equally effective)
3. check for hypothyroidism, treat if suspicious
4. check for vitamin B12 deficiency
5. psychological counseling
6. stress reduction
7. help with spiritual issues
8. develop self-esteem
9. retrain the brain with books, tapes and affirmation
INTRODUCTION
The Borderline
Personality Disorder (BPD), a psychoneurological disorder affecting tens
of millions [1,2] is now treatable with a combination of medication and
other therapies. Fortunately fluoxetine (Prozac) [3] and low dose
intermittent neuroleptics [4] can stop most of the mood swings, and many
of the irrational behaviors. Untreated, these patients suffer from very
painful, difficult lives – and a caring health care professional can
make a profound difference.
GENERAL DESCRIPTION
According to Dr. Rex
Cowdry of the NIMH the “BPD is characterized by tumultuous interpersonal
relationships, labile mood states, and behavioral dyscontrol set
against the background of a relatively stale character structure. While
the syndrome can be identified with reasonable reliability, the
fundamental nature of the disorder remains unclear…” [ 5] See Table 1
for the DSM-III-R criteria. It is a worldwide phenomenon, being
described in the U. S., England, Scotland, Switzerland, Germany, France,
Norway, and Japan. [6] It likely affects approximately 2-3% of men and
5-10% of women. [1]
Prior to effective
medical therapy, managing borderlines was a difficult struggle. Articles
in Family Physician [7] and Nursing [8] journals describe them as
demanding, manipulative, disruptive, frustrating, non-compliant, and
hostile – especially when not medicated properly.
WHAT BORDERLINES EXPERIENCE
Untreated, a borderline
lives an emotional vertigo – experiencing totally unstable moods. These
mood swings and most any stress cause a horribly progressive dysphoria.
They intensely feel almost every painful emotion at once.
Borderlines desperately
search for relief, usually by endorphin releasing behaviors that are
ultimately self-destructive – such as binge eating, binge spending,
aberrant sexual behavior, substance abuse, and reckless driving. When a
severe borderline is extremely dysphoric, cutting the skin causes no
physical pain and actually relieves the dysphoria.
Because untreated
borderlines live with constant mood swings and frequent dysphoria,
normal psychological functioning is crippled. Understanding this enables
the Family Physician to help. Borderlines need to understand their
illness, and to be treated properly.
MAJOR SYMPTOMS
Mood Swings:
Mood swings are a fundamental devastating symptom of borderline. Moods
can shift inappropriately from hour to hour, even minute to minute.
Without appropriate environmental of though-provoked justification. [9]
Dysphoria:
A combination of depression, rage, anxiety, and despair – often
complicated by shame, humiliation, embarrassment, excitement, terror,
jealousy, and self-hate. It can be triggered by mood swings, stress, and
emotional pain. Once dysphoria begins, it tens to steadily intensify –
possibly due to limbic system malfunction. [5] The sensation is so
painful that borderlines will desperately search for a way out – often
relying on drugs, alcohol, self-destructive and impulsive behaviors,
self-mutilation, and suicide. [9.10]
Psychosis:
Psychotic thinking often develops when the dysphoria becomes severe.
Because of the psychotic episodes, borderlines are said to live at the
“border” between reality and psychosis. The main psychotic symptoms are
moods, physical sensations and perceptual distortions.
The dominant psychotic
moods center around worthlessness, badness, rage, and self-destruction.
The physical sensations are remarkably similar to temporal lobe epilepsy
and include unreality, derealization (familiar things become unreal).
Deja-vu, out-of-body experiences, depersonalization (as though no longer
yourself), unawareness spells, and feeling like body parts are numb and
no longer part of oneself. [9]
Psychotic perceptual
distortions primarily include transference (incorrectly perceiving a
present day person to be like someone hurtful from the past),
inappropriate interpretation of motives, and hallucinations. Psychosis
can also be brought on by drugs, especially alcohol and marijuana. [1]
Splitting:
Small children see everything in life as being all good or all bad.
This immature psychological defense persists in borderlines, resulting
in “black and white thinking.” When life events are perceived as bad,
dysphoria usually results. When things are good, the borderline
frequently feels vulnerable, and fears the black returning – often
leading again to dysphoria.
Other symptoms:
A borderline’s life is defined by inconsistency – mood, identity,
trust, behavior, attitudes, values and thoughts. While intelligence is
not impaired, [11] organization and structure are [12] – borderlines
have trouble following through and completing tasks. Access to memory is
frequently impaired. Chronic anger, fear of abandonment (often
resulting in manipulative behavior), lack of trust, impulsivity,
feelings of emptiness and/or boredom, jumping to incorrect conclusions,
and severe PMS are commonly experienced.
Comorbidity:
Borderlines frequently suffer from other psychiatric illnesses. The
most common include depression, [1] anxiety, [13] substance abuse,
alcohol abuse, [14] other personality disorders, and eating disorder
(approximately 40% of eating disorder inpatients suffer from the
borderline). [15] There is no association with schizophrenia. [16]
ETIOLOGY
Psychological theories
alone cannot explain the BPD. Borderlines have significant biological
abnormalities – see Table 2. CNS serotonin malfunction is likely
involved. Temporal lobe dysfunction is often associated with stress. The
BPD is probably a medical predisposition combined with environment
insult.
There are many
psychological theories and concepts, with considerable disagreement
among experts in the field. Both overprotective and underprotective
parents have been “blamed” as the cause. [16] Most theories center
around traumatic childhood experiences, arrested psychological
development (especially at the separation/individuation phase), and
reliance on maladaptive coping and survival mechanisms. [23,28]
Adoption, early parental
loss, and incest are often associated with the BPD. [14] The most
severe borderline patients suffered from both sexual and physical abuse,
usually while very young [6] – chronic dysphoria and derealization are
the best predictors. [29] In one study, 81% reported major childhood
trauma, 71% physical abuse, 68% sexual abuse, and 62% witnessed serious
domestic violence. [30]
Genetics:
The BPD tends to run in families, six times more likely in first degree
relatives. There is an increased family history of alcoholism,
substance abuse, other personality disorders, and depression, but not
schizophrenia. [16]
DIAGNOSIS
Psychological tests,
such as the MMPI and NIMH Diagnostic Interview Schedule, are only
accurate between 85 and 89%. [31,32] Most knowledgeable psychologists
can easily arrange for an MMPI. The NIMH test may be more difficult to
obtain.
If I encounter a patient
who has multiple complaints, especially fatigue, headaches, stress,
depression, etc. I will often review and discuss the DSM-III-R
Borderline criteria to determine if he/she feels 5 or more symptoms are
present. If yes, I will usually initiate treatment with fluoxetine
(Prozac), evaluating the patient and diagnosis 1 week later.
TREATMENT
Medications:
Prozac (fluoxetine):
Prozac appears to increase serotonin. It is a breakthrough medication
for borderlines – eliminating most mood swings, chronic anger, chronic
emotional pain, emptiness and boredom within 3 days. A daily a.m. 20 mg.
dose is usually effective. For most side effects (nausea, jitteriness,
agitation), reduce the frequency to every 2 or 3 days. If fatigue
develops, switch to an evening dose. While for a few patients the
serotonin deficiency symptoms resolve permanently in 6-12 months, most
need to take the medication long term. In my experience, clomipramine
(Anafranil) and sertraline (Zoloft) have shown similar efficacy.
Neuroleptics:
Can be effectively used on a prn basis during stress or dysphoria, or
prophylactically for stressful situations. I prefer Haldol 0.5 – 1 mg
every 4-6 hours as needed (side effects are rarely a problem at this low
dose). Navane (thiothixene) [3] and Mellaril (thioridazine) [4] have
been proven effective. High doses, especially in hospitalized patients,
are also effective. [4]
Tegretol (carbamazepine):
Can markedly reduce episodes of behavioral dyscontrol. [5] Extremely
effective for unreality, chronic dysphoria, incest crisis, relationship
dissolution, extreme anger, dissociative symptoms, and when neuroleptics
are ineffective. Dosing and blood levels are comparable to treating
temporal lobe epilepsy.
Thyroid:
Many borderlines have symptoms of hypothyroidism, with “low normal”
thyroid blood tests. Approximately 1/3 of borderlines have an impaired
TSH response to TRH. [33,34]
Vitamin B12 deficiency: Approximately 20% of borderlines have low vitamin B12 levels, with symptoms of fatigue, leg stiffness, and dysesthesias.
Medications to Avoid:
Xanax (alprazolam) can markedly worsen behavioral dyscontrol. [5]
Elavil (amitriptyline) increases suicide threats, demanding and
assaultive behavior, and paranoid ideation. [35] MAO inhibitors have
helped borderline symptoms, but may be dangerous due to the impulsivity
and behavioral dyscontrol borderlines can experience.
Psychological Counseling:
Borderlines need a multidisciplinary approach. A good therapist is
necessary, and borderlines should be strongly encouraged to get into
counseling. For some, a psychologist/family physician team is very
effective. Referral to a psychiatrist may be necessary. Psychiatric
hospitalization is occasionally required, especially for strong suicidal
ideation.
Stress Reduction:
Borderlines need to keep their stress level down, and to use
neuroleptics when under stress. Physical exercise, relaxation
techniques, and TM (Transcendental Meditation) can be very helpful.
Spiritual Healing:
Making peace with God and one’s spiritual self is very important. The
AA (Alcoholics Anonymous) approach can help, especially with destructive
behavior patterns. Borderlines generally hate themselves. I try to get
them to understand that they have a “good” soul that has been “stuck” in
a broken biological computer.
Self-esteem: Since most borderlines experience self-hate, strong efforts must be made to build a strong and secure self-esteem.
Retraining the Brain:
Borderlines must learn to think differently. Cassette tapes, books, and
affirmations can teach them how. I strongly encourage borderlines to
purchase and listen to the “How to Stay Motivated” tape series (or at
least “Success and the Self-Image”) by Zig Ziglar. (1-800-527-0306).
Borderlines need to
listen to positive/motivational tapes frequently and persistently. Brian
Tracy’s “The Psychology of Achievement,” and others (Earl Nightingale,
Denis Waitley, Robert Schuller) from Nightingale /Conant
(1-800-323-5552) are excellent subsequent tapes.
Borderlines must be convinced to read positive/inspirational books. I recommend How to Win Friends and Influence People by Dale Carnegie, The Power of Positive Thinking by Norman Vincent Peale, Seeds of Greatness by Denis Waitley, Unlimited Power by Anthony Robbins, Your Erroneous Zones by Wayne Dyer, and books by Leo Buscalia and Norman Cousins.
Affirmations: Saying a
meaningful phrase in a repetitive, broken record like manner – are very
effective. The borderline needs to say these affirmations dozens of
times daily, and within a few weeks they will subconsciously accept new
and much needed positive concepts. I recommend phrases like “I like
myself and feel terrific,” “I am lovable,” and “I’m a success.” This
technique is very powerful.
FINAL COMMENTS
The borderline
personality disorder is common and now treatable with a combination of
medications, psychological counseling, and self-help approaches.
Untreated borderlines suffer painful, destructive lives. They are
victims of an illness they don’t want and didn’t cause. They deserve to
be helped, and the primary care physician is in the best position to
initiate treatment.
TABLE 1 – DSM – III-R CRITERIA
“A pervasive pattern of
instability of mood, interpersonal relationships, and self-image,
beginning by early adulthood and present in a variety of contexts, as
indicated by at least five of the following:
1) a pattern of unstable
and intense interpersonal relationships characterized by alternating
between extremes of overidealization and devaluation.
2) impulsiveness in at
least two areas that are potentially self-damaging, for example,
spending, sex, substance abuse, shoplifting, reckless driving, binge
eating, (do not include suicidal or self-mutilating behavior covered in
No. 5)
3) affective
instability: marked shifts from baseline mood to depression,
irritability, or anxiety, usually lasting a few hours and only rarely
more than a few days
4) inappropriate,
intense anger or lack of control of anger, for example, frequent
displays of temper, constant anger, recurrent physical fights
5) recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior
6) marked and persistent
identity disturbance manifested by uncertainty about at least two of
the following: self-image, sexual orientation, long-term goals or career
choice, type of friends desired, preferred values
7) chronic feelings of emptiness or boredom
frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-mutilating behavior covered in No. 5)”
Those who suffer from the Borderline Personality Disorder have at least 5 of the 8 criteria.
TABLE 2 – BIOLOGICAL ABNORMALITIES
1) Abnormal neurological
soft signs (such as awkward gait, left-right confusion, and difficulty
with pronation/supination and finger-thumb opposition). [17]
2) Abnormal REM sleep. [18,19]
3) IV procaine, normally sedating, causes dysphoria in BPD. [20]
4) Abnormal auditory P300 on EEG – sharing a dysfunction of auditory neurointegration with schizophrenia. [21]
5) EEG abnormalities in 1/3 – ½, not usually correlating with symptoms. [22,23]
6) Altered platelet alpha 2-adrenergic receptor bind sites. [24]
7) Low platelet monoamine oxidase activity. [25]
Low circadian melatonin profile. [18]
9) Abnormal lithium transport. [26]
10) Normal head CT’s. [22,27]
11) Cases of BPD have been described from CNS trauma and infection. [27]
TABLE 3 – SUMMARY OF TREATMENT
1. Prozac 20 mg daily (clomipramine) Anafranil and other SSRI’s may prove to be just as effective
2. Haldol 0.5 mg q 4-6h prn (thioridazine, 10 mg and thiothixene 1 mg can be equally effective)
3. check for hypothyroidism, treat if suspicious
4. check for vitamin B12 deficiency
5. psychological counseling
6. stress reduction
7. help with spiritual issues
8. develop self-esteem
9. retrain the brain with books, tapes and affirmations
For Primary Care Physicians
by Leland M. Heller, M.D.
November 2, 1991
SUMMARY OF TREATMENT1. Prozac 20 mg daily (clomipramine) Anafranil and other SSRI’s may prove to be just as effective
2. Haldol 0.5 mg q 4-6h prn (thioridazine, 10 mg and thiothixene 1 mg can be equally effective)
3. check for hypothyroidism, treat if suspicious
4. check for vitamin B12 deficiency
5. psychological counseling
6. stress reduction
7. help with spiritual issues
8. develop self-esteem
9. retrain the brain with books, tapes and affirmation
INTRODUCTION
The Borderline
Personality Disorder (BPD), a psychoneurological disorder affecting tens
of millions [1,2] is now treatable with a combination of medication and
other therapies. Fortunately fluoxetine (Prozac) [3] and low dose
intermittent neuroleptics [4] can stop most of the mood swings, and many
of the irrational behaviors. Untreated, these patients suffer from very
painful, difficult lives – and a caring health care professional can
make a profound difference.
GENERAL DESCRIPTION
According to Dr. Rex
Cowdry of the NIMH the “BPD is characterized by tumultuous interpersonal
relationships, labile mood states, and behavioral dyscontrol set
against the background of a relatively stale character structure. While
the syndrome can be identified with reasonable reliability, the
fundamental nature of the disorder remains unclear…” [ 5] See Table 1
for the DSM-III-R criteria. It is a worldwide phenomenon, being
described in the U. S., England, Scotland, Switzerland, Germany, France,
Norway, and Japan. [6] It likely affects approximately 2-3% of men and
5-10% of women. [1]
Prior to effective
medical therapy, managing borderlines was a difficult struggle. Articles
in Family Physician [7] and Nursing [8] journals describe them as
demanding, manipulative, disruptive, frustrating, non-compliant, and
hostile – especially when not medicated properly.
WHAT BORDERLINES EXPERIENCE
Untreated, a borderline
lives an emotional vertigo – experiencing totally unstable moods. These
mood swings and most any stress cause a horribly progressive dysphoria.
They intensely feel almost every painful emotion at once.
Borderlines desperately
search for relief, usually by endorphin releasing behaviors that are
ultimately self-destructive – such as binge eating, binge spending,
aberrant sexual behavior, substance abuse, and reckless driving. When a
severe borderline is extremely dysphoric, cutting the skin causes no
physical pain and actually relieves the dysphoria.
Because untreated
borderlines live with constant mood swings and frequent dysphoria,
normal psychological functioning is crippled. Understanding this enables
the Family Physician to help. Borderlines need to understand their
illness, and to be treated properly.
MAJOR SYMPTOMS
Mood Swings:
Mood swings are a fundamental devastating symptom of borderline. Moods
can shift inappropriately from hour to hour, even minute to minute.
Without appropriate environmental of though-provoked justification. [9]
Dysphoria:
A combination of depression, rage, anxiety, and despair – often
complicated by shame, humiliation, embarrassment, excitement, terror,
jealousy, and self-hate. It can be triggered by mood swings, stress, and
emotional pain. Once dysphoria begins, it tens to steadily intensify –
possibly due to limbic system malfunction. [5] The sensation is so
painful that borderlines will desperately search for a way out – often
relying on drugs, alcohol, self-destructive and impulsive behaviors,
self-mutilation, and suicide. [9.10]
Psychosis:
Psychotic thinking often develops when the dysphoria becomes severe.
Because of the psychotic episodes, borderlines are said to live at the
“border” between reality and psychosis. The main psychotic symptoms are
moods, physical sensations and perceptual distortions.
The dominant psychotic
moods center around worthlessness, badness, rage, and self-destruction.
The physical sensations are remarkably similar to temporal lobe epilepsy
and include unreality, derealization (familiar things become unreal).
Deja-vu, out-of-body experiences, depersonalization (as though no longer
yourself), unawareness spells, and feeling like body parts are numb and
no longer part of oneself. [9]
Psychotic perceptual
distortions primarily include transference (incorrectly perceiving a
present day person to be like someone hurtful from the past),
inappropriate interpretation of motives, and hallucinations. Psychosis
can also be brought on by drugs, especially alcohol and marijuana. [1]
Splitting:
Small children see everything in life as being all good or all bad.
This immature psychological defense persists in borderlines, resulting
in “black and white thinking.” When life events are perceived as bad,
dysphoria usually results. When things are good, the borderline
frequently feels vulnerable, and fears the black returning – often
leading again to dysphoria.
Other symptoms:
A borderline’s life is defined by inconsistency – mood, identity,
trust, behavior, attitudes, values and thoughts. While intelligence is
not impaired, [11] organization and structure are [12] – borderlines
have trouble following through and completing tasks. Access to memory is
frequently impaired. Chronic anger, fear of abandonment (often
resulting in manipulative behavior), lack of trust, impulsivity,
feelings of emptiness and/or boredom, jumping to incorrect conclusions,
and severe PMS are commonly experienced.
Comorbidity:
Borderlines frequently suffer from other psychiatric illnesses. The
most common include depression, [1] anxiety, [13] substance abuse,
alcohol abuse, [14] other personality disorders, and eating disorder
(approximately 40% of eating disorder inpatients suffer from the
borderline). [15] There is no association with schizophrenia. [16]
ETIOLOGY
Psychological theories
alone cannot explain the BPD. Borderlines have significant biological
abnormalities – see Table 2. CNS serotonin malfunction is likely
involved. Temporal lobe dysfunction is often associated with stress. The
BPD is probably a medical predisposition combined with environment
insult.
There are many
psychological theories and concepts, with considerable disagreement
among experts in the field. Both overprotective and underprotective
parents have been “blamed” as the cause. [16] Most theories center
around traumatic childhood experiences, arrested psychological
development (especially at the separation/individuation phase), and
reliance on maladaptive coping and survival mechanisms. [23,28]
Adoption, early parental
loss, and incest are often associated with the BPD. [14] The most
severe borderline patients suffered from both sexual and physical abuse,
usually while very young [6] – chronic dysphoria and derealization are
the best predictors. [29] In one study, 81% reported major childhood
trauma, 71% physical abuse, 68% sexual abuse, and 62% witnessed serious
domestic violence. [30]
Genetics:
The BPD tends to run in families, six times more likely in first degree
relatives. There is an increased family history of alcoholism,
substance abuse, other personality disorders, and depression, but not
schizophrenia. [16]
DIAGNOSIS
Psychological tests,
such as the MMPI and NIMH Diagnostic Interview Schedule, are only
accurate between 85 and 89%. [31,32] Most knowledgeable psychologists
can easily arrange for an MMPI. The NIMH test may be more difficult to
obtain.
If I encounter a patient
who has multiple complaints, especially fatigue, headaches, stress,
depression, etc. I will often review and discuss the DSM-III-R
Borderline criteria to determine if he/she feels 5 or more symptoms are
present. If yes, I will usually initiate treatment with fluoxetine
(Prozac), evaluating the patient and diagnosis 1 week later.
TREATMENT
Medications:
Prozac (fluoxetine):
Prozac appears to increase serotonin. It is a breakthrough medication
for borderlines – eliminating most mood swings, chronic anger, chronic
emotional pain, emptiness and boredom within 3 days. A daily a.m. 20 mg.
dose is usually effective. For most side effects (nausea, jitteriness,
agitation), reduce the frequency to every 2 or 3 days. If fatigue
develops, switch to an evening dose. While for a few patients the
serotonin deficiency symptoms resolve permanently in 6-12 months, most
need to take the medication long term. In my experience, clomipramine
(Anafranil) and sertraline (Zoloft) have shown similar efficacy.
Neuroleptics:
Can be effectively used on a prn basis during stress or dysphoria, or
prophylactically for stressful situations. I prefer Haldol 0.5 – 1 mg
every 4-6 hours as needed (side effects are rarely a problem at this low
dose). Navane (thiothixene) [3] and Mellaril (thioridazine) [4] have
been proven effective. High doses, especially in hospitalized patients,
are also effective. [4]
Tegretol (carbamazepine):
Can markedly reduce episodes of behavioral dyscontrol. [5] Extremely
effective for unreality, chronic dysphoria, incest crisis, relationship
dissolution, extreme anger, dissociative symptoms, and when neuroleptics
are ineffective. Dosing and blood levels are comparable to treating
temporal lobe epilepsy.
Thyroid:
Many borderlines have symptoms of hypothyroidism, with “low normal”
thyroid blood tests. Approximately 1/3 of borderlines have an impaired
TSH response to TRH. [33,34]
Vitamin B12 deficiency: Approximately 20% of borderlines have low vitamin B12 levels, with symptoms of fatigue, leg stiffness, and dysesthesias.
Medications to Avoid:
Xanax (alprazolam) can markedly worsen behavioral dyscontrol. [5]
Elavil (amitriptyline) increases suicide threats, demanding and
assaultive behavior, and paranoid ideation. [35] MAO inhibitors have
helped borderline symptoms, but may be dangerous due to the impulsivity
and behavioral dyscontrol borderlines can experience.
Psychological Counseling:
Borderlines need a multidisciplinary approach. A good therapist is
necessary, and borderlines should be strongly encouraged to get into
counseling. For some, a psychologist/family physician team is very
effective. Referral to a psychiatrist may be necessary. Psychiatric
hospitalization is occasionally required, especially for strong suicidal
ideation.
Stress Reduction:
Borderlines need to keep their stress level down, and to use
neuroleptics when under stress. Physical exercise, relaxation
techniques, and TM (Transcendental Meditation) can be very helpful.
Spiritual Healing:
Making peace with God and one’s spiritual self is very important. The
AA (Alcoholics Anonymous) approach can help, especially with destructive
behavior patterns. Borderlines generally hate themselves. I try to get
them to understand that they have a “good” soul that has been “stuck” in
a broken biological computer.
Self-esteem: Since most borderlines experience self-hate, strong efforts must be made to build a strong and secure self-esteem.
Retraining the Brain:
Borderlines must learn to think differently. Cassette tapes, books, and
affirmations can teach them how. I strongly encourage borderlines to
purchase and listen to the “How to Stay Motivated” tape series (or at
least “Success and the Self-Image”) by Zig Ziglar. (1-800-527-0306).
Borderlines need to
listen to positive/motivational tapes frequently and persistently. Brian
Tracy’s “The Psychology of Achievement,” and others (Earl Nightingale,
Denis Waitley, Robert Schuller) from Nightingale /Conant
(1-800-323-5552) are excellent subsequent tapes.
Borderlines must be convinced to read positive/inspirational books. I recommend How to Win Friends and Influence People by Dale Carnegie, The Power of Positive Thinking by Norman Vincent Peale, Seeds of Greatness by Denis Waitley, Unlimited Power by Anthony Robbins, Your Erroneous Zones by Wayne Dyer, and books by Leo Buscalia and Norman Cousins.
Affirmations: Saying a
meaningful phrase in a repetitive, broken record like manner – are very
effective. The borderline needs to say these affirmations dozens of
times daily, and within a few weeks they will subconsciously accept new
and much needed positive concepts. I recommend phrases like “I like
myself and feel terrific,” “I am lovable,” and “I’m a success.” This
technique is very powerful.
FINAL COMMENTS
The borderline
personality disorder is common and now treatable with a combination of
medications, psychological counseling, and self-help approaches.
Untreated borderlines suffer painful, destructive lives. They are
victims of an illness they don’t want and didn’t cause. They deserve to
be helped, and the primary care physician is in the best position to
initiate treatment.
TABLE 1 – DSM – III-R CRITERIA
“A pervasive pattern of
instability of mood, interpersonal relationships, and self-image,
beginning by early adulthood and present in a variety of contexts, as
indicated by at least five of the following:
1) a pattern of unstable
and intense interpersonal relationships characterized by alternating
between extremes of overidealization and devaluation.
2) impulsiveness in at
least two areas that are potentially self-damaging, for example,
spending, sex, substance abuse, shoplifting, reckless driving, binge
eating, (do not include suicidal or self-mutilating behavior covered in
No. 5)
3) affective
instability: marked shifts from baseline mood to depression,
irritability, or anxiety, usually lasting a few hours and only rarely
more than a few days
4) inappropriate,
intense anger or lack of control of anger, for example, frequent
displays of temper, constant anger, recurrent physical fights
5) recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior
6) marked and persistent
identity disturbance manifested by uncertainty about at least two of
the following: self-image, sexual orientation, long-term goals or career
choice, type of friends desired, preferred values
7) chronic feelings of emptiness or boredom
frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-mutilating behavior covered in No. 5)”Those who suffer from the Borderline Personality Disorder have at least 5 of the 8 criteria.
TABLE 2 – BIOLOGICAL ABNORMALITIES
1) Abnormal neurological
soft signs (such as awkward gait, left-right confusion, and difficulty
with pronation/supination and finger-thumb opposition). [17]
2) Abnormal REM sleep. [18,19]
3) IV procaine, normally sedating, causes dysphoria in BPD. [20]
4) Abnormal auditory P300 on EEG – sharing a dysfunction of auditory neurointegration with schizophrenia. [21]
5) EEG abnormalities in 1/3 – ½, not usually correlating with symptoms. [22,23]
6) Altered platelet alpha 2-adrenergic receptor bind sites. [24]
7) Low platelet monoamine oxidase activity. [25]
Low circadian melatonin profile. [18]9) Abnormal lithium transport. [26]
10) Normal head CT’s. [22,27]
11) Cases of BPD have been described from CNS trauma and infection. [27]
TABLE 3 – SUMMARY OF TREATMENT
1. Prozac 20 mg daily (clomipramine) Anafranil and other SSRI’s may prove to be just as effective
2. Haldol 0.5 mg q 4-6h prn (thioridazine, 10 mg and thiothixene 1 mg can be equally effective)
3. check for hypothyroidism, treat if suspicious
4. check for vitamin B12 deficiency
5. psychological counseling
6. stress reduction
7. help with spiritual issues
8. develop self-esteem
9. retrain the brain with books, tapes and affirmations
