I Hate You—Don't Leave Me (27 page)

Most research has examined the use of antidepressants, particularly serotonin reuptake inhibitors (SSRIs or SRIs). These medicines include Prozac (fluoxetine), Zoloft (sertraline), Paxil or Pexeva (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram—related to citalopram). Predictably, these drugs have been effective for mood instability and related symptoms of depression, such as feelings of emptiness, rejection sensitivity, and anxiety. Additionally, SRIs have been shown to decrease inappropriate anger and temper outbursts, aggressive behavior, destructive impulsivity, and self-mutilating actions, even in the absence of depressive symptoms. In many studies, higher than usual doses of these medicines (for example, >80 mg of Prozac; >200 mg of Zoloft per day) were necessary to have a positive effect. A related group of drugs, serotonin-norepinephrine reuptake inhibitors (SNRIs), have not been as extensively studied, but may have similar positive effects. These include Effexor (venlafaxine), Pristiq (desvenlafaxine—related to venlafaxine), and Cymbalta (duloxetine).

Older antidepressants, such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), have also been studied. TCAs include Elavil (amitriptylene), Tofranil (imipramine), Pamelor or Aventyl (nortriptylene), Vivactil (protriptylene), Sinequan (doxepin), Norpramin (desipramine), Asendin, (amoxapine), Surmontil (trimipramine), and others. These drugs have generally been less effective and in some cases have decreased emotional control. Therefore, the patient diagnosed with BPD should be wary of prescribed drugs in the TCA class.

MAOIs—Nardil (phenelzine) and Parnate (tranylcypromine) being the most commonly used in the United States—have shown efficacy in BPD comparable to that of SRIs. However, MAOIs tend to have more side effects, are more dangerous in overdose, and require dietary and concurrent medication restrictions, and are therefore utilized much less.

This group of medications includes Lithium, a naturally occurring element, and antiseizure drugs—Depakote (valproate), Tegretol (carbamazepine), Trileptal (oxcarbazepine—related to carbamazepine), Lamictal (lamotrigine), and Topamax (topiramate). APA guidelines recommend this group as adjunctive treatment when SRIs or other interventions are ineffective or only partially effective. These medicines, in typical doses, help stabilize mood, decrease anxiety, and better control impulsivity, aggression, irritability, and anger. Neurontin (gabapentin), Dilantin (phenytoin), Gabatril (tiagabine), Keppra (levetiracetam), and Zonegran (zonisamide) are also in this class of drugs, but studies testing their effectiveness in BPD patients have been limited.

These drugs are recommended for initial treatment of cognitive-perceptual distortions in borderline patients. Paranoia, dissociative symptoms, and feelings of unreality (criteria 9 in the DSM-IV-TR—see chapter 2) are primary targets. In combination with SRIs, these medicines, usually in lower than common doses, relieve feelings of anger and aggressiveness; stabilize mood; and decrease anxiety, obsessional thinking, impulsivity, and interpersonal sensitivity.

Early studies were done with older neuroleptics, such as Thorazine (chlorpromazine), Stelazine (trifluoperazine), Trilafon (perphenazine), Haldol (haloperidol), Navane (thiothixene), and Loxitane (loxapine). Newer medicines, called atypical antipsychotics, have also demonstrated efficacy with generally less complicated side effects. These include Zyprexa (olanzapine), Seroquel (quetiapine), Risperdal (risperidone), Abilify (aripiprazole), and Clozaril (clozapine). Other medicines in this class—Invega (paliperidone—related to risperidone), Fanapt (iloperidone), Saphris (asenapine), and Geodon (ziprasidone)—have either not been studied or have yielded contradictory results.

Antianxiety agents, although acutely helpful for anxiety, have been shown to increase impulsivity and can be abused and addictive. These tranquilizers, primarily in the class known as benzodiazepines, include Xanax (alprazalom), Ativan (lorazepam), Valium (diazepam), and Librium (chlordiazepoxide), among others. Klonopin (clonazepam), a longer-acting benzodiazepine that may have greater effect on serotonin, has had success in treating symptoms of aggression and anxiety and so is perhaps the only benzodiazepine that may be useful for BPD.

Revia (naltrexone) blocks the body's release of its own endorphins, which induce analgesia and euphoric feelings. Some reports suggest that this medicine may inhibit self-mutilating behavior.

Homeopathic or herbal treatments have generally been unsuccessful, with the exception of omega-3 fatty acid preparation. One small study found that the substance did decrease aggressiveness and depression among women.
¹⁰

Two substances that modulate the neurotransmitter glutamate have been investigated in BPD. The amino acid N-acetylcysteine and Rilutek (riluzole)—a drug used for the treatment of amyotrophic lateral sclerosis (Lou Gehrig's disease)—were reported to significantly diminish self-injurious behavior in two borderline patients.
¹¹

The APA's Practice Guideline recommends that medications target a specific symptom cluster. Guidelines divide BPD symptoms into three primary groups: Mood Instability, Impulse Dyscontrol, and Cognitive-Perceptual Distortions. An algorithm of recommended treatment approaches, with alternative tactics if the previous choice is ineffective, is summarized in Table 9-1.

TABLE 9-1.
Pharmacotherapy for treating BPD symptoms

The FDA (Food and Drug Administration) has not formally approved any drug for the treatment of BPD, so all of the medicines commonly used for treating BPD are considered “off-label.” Though the term “off-label” may be off-putting, if not seem downright risky to the uninitiated, off-label prescribing is quite common for a wide variety of conditions. Because a pharmaceutical company spends almost $1 billion on average to bring a drug to market, many companies do not seek approval for a wide range of conditions or outside narrow dosage ranges, as these strategies might narrow the chances for FDA approval and greatly increase the cost of development. For example, even though it is known that SRIs benefit several conditions, including depression, PTSD, anxiety illnesses, and some pain disorders, the drug manufacturer may not want to absorb the extra expense of gaining FDA approval—nor risk FDA rejection—by applying for label use for all of these indications and/or broad dosage ranges. Whenever a physician prescribes a medicine for an unapproved condition, or at a dose outside of recommendations, it is considered “off-label.” Unfortunately, managed care agencies may refuse approval of these (sometimes expensive) “off-label” prescriptions.

In simplest terms, a generic drug contains the same primary or active ingredient as the original formulation; generally speaking, it is almost always less expensive. However, this does not mean that a generic medication is
identical
to its brand-name counterpart. The FDA considers a generic drug “equivalent” to a branded medicine if blood levels in healthy volunteers are within 20 percent variation, a significant difference in some patients. A generic may also differ from the original in its inactive ingredients and its delivery system (e.g., tablet or capsule). Moreover, one generic may vary widely from another (theoretically, up to a 40 percent variation in blood level). The lesson here is that if a switch to a generic drug will result in significant savings, it may be worth trying. However, if symptoms recur, it is best to return to the brand medicine. Additionally, if you are taking a generic medicine that is working, do not change to a different generic. Also, be aware that some pharmacies and some doctors receive bonuses for switching patients to generic drugs.

Many patients receive care from more than one provider. Often, therapy may be administered by a nonmedical professional (psychologist, social worker, or counselor), while medications are administered by a physician (psychiatrist or primary care doctor). Advantages of this protocol include less expense (thus accounting for its encouragement by managed care companies), involvement of more professionals, and separation of therapy and medication issues. But this separation can also be a disadvantage, since it allows the potential for patients to split providers into “good doctors” and “bad doctors” and to become confused about the treatment. Close communication among professionals treating the same patient is essential for the process to be successful. In most cases, a psychiatrist skilled in both medical management and psychotherapy techniques may be the preferred approach.

Much like the disorder itself, professionals' opinion about the prognosis for those afflicted with BPD has whipsawed from one extreme to the other. In the 1980s Axis II personality disorders were generally thought to be enduring and stable over time. DSM-III asserted that personality disorders “begin in childhood or adolescence and persist in stable form (without periods of remission or exacerbation) into adult life.”
¹²
This perception was in contrast to most Axis I disorders (such as major depression, alcoholism, bipolar disorder, schizophrenia, etc.), which were thought to be more episodic and responsive to pharmacological treatment. Suicide rates in BPD approached 10 percent.
¹³
All of these considerations suggested that prognosis for BPD was likely to be poor.

However, longer-term studies published over the last several years demonstrated significant improvement over time.
^14
,
15
In these studies, tracking borderlines over a ten-year period, up to two-thirds of the patients no longer exhibited five of the nine defining criteria for BPD, and therefore could be considered “cured,” since they no longer fulfilled the formal DSM definition. Improvement occurred with or without treatment, although treated patients achieved remission sooner. Most patients remained in treatment, and relapses diminished over time. Despite these optimistic findings, it was also discovered that although these patients no longer could be formally designated as “borderline,” some continued to have difficulty with interpersonal functioning that impaired their social and vocational relationships. This suggests that the more acute and prominent symptoms of BPD (which primarily define the disorder), such as suicidal or self-mutilating behaviors, destructive impulsivity, and quasi-psychotic thinking, are more quickly responsive to treatment or time than the more enduring temperamental symptoms (fears of abandonment, feelings of emptiness, dependency, etc.). In short, although the prognosis is clearly much better than originally thought, some borderlines continue to struggle with ongoing issues.

Those who conquer the illness display a greater capacity to trust and establish satisfactory (even if sometimes not very close) relationships. They have a clearer sense of purpose and a more stable understanding of themselves. In a sense, then, even if borderline issues remain, they become better borderlines.

Understanding and Healing

Now
here
, you see, it takes all the running
you
can do to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that.

—From
Through the Looking-Glass
, by Lewis Carroll

 

 

 

“I feel like I have a void in me that I can never quite fill.” Elizabeth, an attractive, witty twenty-eight-year-old woman, was originally referred for therapy by her family doctor. She had been married for six years to a man who was ten years older than her and had been her boss at one time. Five months before, she had given birth to her first child, a daughter, and was now severely depressed.

She yearned for something she could call her own, something that would “show that the rest of the world knew I was here.” Inside, she felt her “real self” was a swamp of childish emotions, and that she was always hiding her feelings, which were “ugly and bad.” These realizations turned into self-hate; she wanted to give up.

By her count, Elizabeth had engaged in nine extramarital affairs over the previous six years—all with men she met through work. They began soon after the death of her father. Most were relationships that she totally controlled, first by initiating them and later by ending them. She had found it exciting that these men seemed so puzzled by her advances and then by her sudden rejections. She enjoyed the physical closeness, but acknowledged she dreaded being too emotionally involved. Although she controlled these relationships, she never found them sexually satisfying; nor was she sexually responsive to her husband. She admitted that she used sex to “equalize” relationships, to stay in control; she felt safer that way. Her intellect and personality, she felt, were not enough to hold a man.