THE BORDERLINE PERSONALITY DISORDER
NEW MANAGEMENT CONCEPTS

(cont.)

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.

Table1 - 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
8. 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.

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