The borderline personality disorder and medication
(treatment by drugs)

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• Stage 1: The repair of its legs. Phase in which there will be perhaps surgery, drugs...
• Stage 2: The relearning of walk, then bicycle

- Second possibility, it wouldn't come to anybody, the idea to have physical therapy with the cyclist, to sit him on a bicycle whereas its legs are still broken. We would talk about cruelty, trying to cycle one person with broken bones

Well, for the borderline personality disorder it is a little similar.
Patient's recovery will have two stages (which will overlap each other)

• Stage 1: The brain's "repair". Stage during which we will prescribe adapted drugs. These drugs being there to restore a biological balance in order to decrease the symptoms like inappropriate ager, anxiety... In short to make "functional" the "brain plumbing" (we should say "electricity")
• Stage 2: Therapy . This is nothing more nor less than relearning (a reeducation) healthy and natural behaviors. The patient learning how to manage his emotions, to react in a "normal" way, to love itself, to make confidence. In short to learn how to do what he never did because of its disease

- Second possibility which would not come in mind from anybody for the cyclist case. It is to begin the traitment by the therapy whereas none of the necessary drugs is administered. The therapy then will look at to obtain behaviors from the patient which its brain cannot implement because of its disease. It is exactly like asking a paralytic to break into a run, it is unnecessarily cruel.
It is for this reason that a psychoanalysis on an untreated (by drugs) borderline patient can be very dangerous, because it can lead the person borderline to become aware of its affliction without providing him any solution. In these cases, suicideis not so far

The summary is thus "don't put the cart before the horse "
Stage 1
- Suitable psychopharmacological Treatment. This treatment is completely different according to patients, for some this can be extremely "light" whereas to others that it will be necessary to use neuroleptic drugs.

then just afterwards

Conclusion:
It is necessary to have a close cooperation between the specialist who manage the suitable pharmacological treatment and the therapist who makes the behavorial restoration of the patient (this can be the same person). Pharmacological treatment evolving in parallel with the advance of the therapy

-Selective Serotonin Reuptake Inhibitors (5 oht) SSRI. Serotonin being an essential chemical brain substance

In particular for depression, panic crises

-Anxiolytics

For anxiety, the panic crises

For schizophrenies, psychoses

- Omega3 acid,(please read study) and Vitamin B12,(please read study)

It should be noted that for each drug family, there are many different molecules.
Some are better appropriate than others according to individuals.
If you feel none desirable effects which cannot be corrected ajusting the dose, your doctor will have the possibility to suggest you another molecule.
For examples for the SSRI (serotonine). With some people Prozac is formidable whereas for others, this drug "knock them". He will then be able to use Zoloft, Celexa, floxyfral or deroxat which all are SSRI but with other molecules.

SSRI
• "Treatment of affective dysregulation symptoms

Patients with borderline personality disorder displaying this dimension exhibit mood lability, rejection sensitivity, inappropriate intense anger, depressive "mood crashes," or outbursts of temper. These symptoms should be treated initially with a selective serotonin reuptake inhibitor (SSRI) or related antidepressant such as venlafaxine
When affective dysregulation appears as disinhibited anger that coexists with other affective symptoms, SSRIs are also the treatment of choice
Treatment of impulsive-behavioral dyscontrol symptoms.
Patients with borderline personality disorder displaying this dimension exhibit impulsive aggression, self-mutilation, or self-damaging behavior (e.g., promiscuous sex, substance abuse, reckless spending). SSRIs are the initial treatment of choice
Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium" (American Psychiatric Association, “TREATMENT RECOMMENDATIONS FOR PATIENTS With Borderline Personality Disorder”, www.psych.org 2OO3 book1)
 
• "The main symptoms treated by SSRI's include: mood swings, chronic anger, emptiness, boredom, and depression.  Prozac has been the most thoroughly studied and is very effective.  Alternatives include Paxil and Effexor - choosing these medicines instead of Prozac would be for other illnesses and/or side effects" (Leland M. Heller, “Medical Treatment of the Borderline Personality Disorder”, www.biologicalunhappiness.com 1998)

 
• "Antidepressants can help with depression. Selective Serotonin Re-uptake Inhibitors (SSRIs) such as Prozac, Zoloft, and Paxil may help control impulsivity, as may Effexor, a related antidepressant" (Causes and Treatment for BPD )

 
• "Medications such as Prozac, an antidepressant, can also be helpful as an adjunctive treatment" (medhelp)
 
• "SSRIs to combat the deficiencies in serotonin absorption.

Zoloft is one of a group of medications referred to as SSRIs (Selective Serotonin Reuptake Inhibitors). They all seem to help folks with certain types of BPD. Selective serotonin reuptake inhibitors (SSRIs) have been effective in treating mood symptoms and impulsivity" (mhsanctuary)
 
• "Sertraline, Fluoxetine, Fluvoxamine, Paroxetine, Venlafaxine, Citalopram, Mirtazapine: The habit-forming potential is none" (psyweb,biam,...)

"Full Benefits in:  a week (Fluvoxamine), 1 to 3 weeks (Sertraline), 2 weeks (Venlafaxine), 4 weeks (Fluoxetine, Citalopram), 4 to 6 weeks (Paroxetine), ?? (Mirtazapine) "
 
• "Parkinsonism symptoms - Extrapyramidal effects of ssri - The use of SSRIs may be associated with the development of EPRs" (Ann Pharmacother 1997) - "SSRIs have been implicated. It has been estimated at about 1-2 cases per 1 000 patients" (« Extrapyramidal effects of SSRI antidepressants”, Prescrire Int. 2001)

.
Lithium, anticonvulsant mood stabilizers, antiepileptic
• "Treatment of impulsive-behavioral dyscontrol symptoms

Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium
Lithium carbonate and the anticonvulsant mood stabilizers carbamazepine and divalproex sodium are used to treat symptoms of behavioral dyscontrol in borderline personality disorder, with possible efficacy for symptoms of affective dysregulation
Subsequent case reports demonstrated that lithium had mood-stabilizing and antiaggressive effects
The anticonvulsant mood stabilizer carbamazepine has been studied in two double-blind, placebo-controlled studies that used very different patient groups, resulting in inconsistent findings" (apa)

• "Based on my experience, Tegretol (carbamazepine) is a sensational medication for BPD dysphoria (anxiety, rage, depression and despair), mania, hypomania, and some causes of neuropathic pain such as shingles. Once a BPD patient has been on Prozac for a week, Tegretol works miraculously in all but the most severe stressors in 3 hours or less. In combination with 3mg of Risperdal it always works to stop a dysphoric spell" (biological unhappiness Leland M. Heller, M.D)

 
• "Mood stabilizers such as Depakote, Tegretol, or Lithium can help with mood swings. Tegretol may be helpful for controlling excessive anger and irritability" (bpdcentral)

 
• "Tegretol (Carbamazepine) is prescribed primarily as an anticonvulsant. A number of studies now support its use in the treatment of bipolar disorder, cyclothymia, and impulsive or aggressive behavior associated with borderline personality disorder. Tegretol can be used alone, but is more commonly used as an adjunct to treatment with Depakote or Lithium, the two most accepted mood-stabilizers. Different physiological and biochemical theories have been proposed to explain how Tegretol works" (medhelp)

 
• "Anticonvulsant medications may affect impulsive and self-injurious behavior (eg, selfmutilation, suicide attempts). Some studies indicate that anticonvulsants sometimes interrupt impulses before they are acted out" (medscape)

 
• "Lithium carbonate and the anticonvulsant mood stabilizers may also be helpful in the context of impulsive aggression. Lithium has a possible effect in diminishing anger and suicidal symptoms" (mhsanctuary)

 
• "Lithium - The habit-forming potential is none. For long term use however may be related to thyroid and kidney problems. Renal and thyroid functions must be monitored ever six months" (psyweb)

 
• "Carbamazepine : The habit-forming potential is none. Complete bloord testing is required both before and after treatment starts

 
• "Valproic Acid : The habit-forming potential is none. For long term use liver function, platelet count and coagulation must be monitored." (psyweb)

.
• "Carbamazepine and lithium (aapel : together) is known to cause neurotoxicity. When considering adding carbamazepine to lithium, careful follow-up of the patients is warranted to prevent this indirect drug in interaction" (Pharmacother 2001)

.
• "Oxcarbazepine : As yet, oxcarbazepine has not been studied in the treatment of BPD. However, as it is related to carbamazepine and is though to be of a similar efficacy, it is likely that it will be tried in patients who are unable to tolerate carbamazepine due to unpleasant side effects" (wardrobehudson.co.uk - may 2OO3)

.
Neuroleptics
• "The primary goal of treatment with neuroleptics in borderline personality disorder is to reduce acute symptom severity in all symptom domains, particularly schizotypal symptoms, psychosis, anger, and hostility

Treatment of affective dysregulation symptoms
Clinical experience suggests that for patients with severe behavioral dyscontrol, low-dose neuroleptics can be added to the regimen for rapid response and improvement of affective symptoms
Treatment of impulsive-behavioral dyscontrol symptoms
When behavioral dyscontrol poses a serious threat to the patient's safety, it may be necessary to add a low-dose neuroleptic to the selective serotonin reuptake inhibitor
Treatment of cognitive-perceptual symptoms
Patients with borderline personality disorder displaying this dimension exhibit suspiciousness, referential thinking, paranoid ideation, illusions, derealization, depersonalization, or hallucination-like symptoms. Low-dose neuroleptics (see Appendix 3 of original guideline) are the treatment of choice for these symptoms" (apa)

• Leland M. Heller, M.D

"Medical treatment og borderline disorder. Neuroleptics like Haldol should be used whenever anger, stress, paranoia, rage, or self-destructive impulses are present.  They give a BPD patient control over their illness, and can be taken before stressful events to prevent problems.  It is far better to take the medicine when in doubt than suffering the consequences of losing control.  For severe symptoms caused by temporary stress, Risperdal is the strongest and most effective emergency medicine to take as needed, but usually causes profound sleepiness" (biological unhappiness)
 
• (nothing found) (bpdcentral)

 
• "Low-dose neuroleptics are effective in the short term for control of transient psychotic symptoms. Antipsychotics have long been used to control impulsivity and aggression in patients with BPD, although SSRIs are preferred because of their more benign adverse effect profile. If an antipsychotic agent is necessary, avoid butyrophenones in favor of atypical agents such as risperidone. Antipsychotic medications might cause serious and permanent adverse effects, such as tardive dyskinesia or neuroleptic malignant syndrome" (Elizabeth A Finley-Belgrad, MD,“Personality Disorder: Borderline”,emedecine)

 
• "Neuroleptics at low doses reported a short-term efficacy on BPD hostility and aggression, but more recent studies have questioned the efficacy of these drugs in this symptomatologic domain. Furthermore, the persistent and recurrent nature of symptoms in BPD often requires a continuation of pharmacotherapy. Longterm neuroleptic administration to borderline patients, even if at low doses, can lead to important neurologic side effects like akathisia, which has been linked to increased violence in psychiatric

New class of medication termed atypical antipsychotics, combining serotonergic and dopaminergic properties, seems to offer wide opportunities for the treatment of BPD. In recent open-label studies, the new antipsychotics clozapine and olanzapine, at low-to moderate doses, have been usefully employed for the management of BPD impulsive-aggressive behavior with fewer side effects in comparison with neuroleptics" (mhsanctuary)
 
• "During brief reactive psychoses, low doses of antipsychotic drugs may be useful, but they are usually not essential adjuncts to the treatment regimen, since such episodes are most often self-limiting and of short duration.

It is, however, clear that low doses of high potency neuroleptics (e.g., haloperidol) may be helpful for disorganized thinking and some psychotic symptoms. Neuroleptics are particularly recommended for the psychotic symptoms mentioned above, and for patients who show anger which must be controlled. Dosages should generally be low and the medication should never be given without adequate psychosocial intervention" (psychcentral Phillip W. Long, M.D)

• "Antipsychotic drugs may also be used when there are distortions in thinking." (psychology today)

Anxiolytic
• "Anxiolytic medications are used to treat the many manifestations of anxiety in patients with borderline personality disorder, both as an acute and as a chronic symptom.

Use of alprazolam (mean dose=4.7 mg/day) was associated with greater suicidality and episodes of serious behavioral dyscontrol
Case reports suggest that clonazepam is helpful as an adjunctive agent in the treatment of impulsivity, violent outbursts, and anxiety in a variety of disorders, including borderline personality disorder
Benzodiazepines, in general, should be used with care because of the potential for abuse and the development of pharmacological tolerance with prolonged use. These are particular risks in patients with a history of substance use."  (apa)

• "Some medicines make the symptoms of borderline worse, especially amitriptyline (Elavil) and alprazolam (Xanax)" (biological unhappiness. Leland M. Heller, M.D.)(amitryptilline)

 
• (nothing found) (bpdcentral)

"While waiting for medications like SSRI's or mood stabilizers to work, a benzodiazepine like Ativan can assist with anxiety

Anxiety in the PD patient may present as a chronic and nonspecific complaint, the "pan-anxiety'' of older description, or as an exaggerated response to a social stressor. The use of benzodiazepines is problematic in the treatment of patients with PD, raising the risk of abuse and even behavioral toxicity. The short-acting benzodiazepine alprazolam has been associated with precipitating serious dyscontrol in one placebo-controlled crossover study of patients with BPD (Gardner & Cowdry, 1985). Abuse potential is significant and tolerance problematic over time. Case reports demonstrate some efficacy in the PD patient for the long half-life benzodiazepine clonazepam, which has anticonvulsant and antigenic properties" (mhsanctuary)
 

"Alprazolam : USE UP TO EIGHT MONTHS ONLY! Overdose:  Coma and can be fatal. The habit-forming potential is high. It is possible to become dependent in the first few days" (psyweb)

"Lorazepam : The habit-forming potential is high" (psyweb)

"Clonazepam : The habit-forming potential is high. If used for antianxiety treatment: This drugs should not be taken for more then four weeks ( Yudofsky, Hales and Ferguson . )" (psyweb)

"Meprobamate : The habit-forming potential is very high. This drug should not be taken longer then three weeks" (psyweb)

"Prazepam / Flurazepam / Clorazepate : The habit-forming potential is high. It is possible to become dependent in only two weeks. This drugs should not be taken for more then four weeks ( Yudofsky, Hales and Ferguson . )" (psyweb)

"Bromazepam : Administration of therapeutic doses of benzodiazepines for 6 weeks or longer can result in physical dependence" (inchem)

French Laboratory	Name	Other names	Molecule	Usage
Pfizer	Zoloft	Lustral (UK) Serlain (BE)	Sertraline	Antidepressant Selective Serotonin Reuptake Inhibitors (5HT) SSRI To depression (APA Studies)
Lundbeck	Seropram	Celexa (USA) Cipramil (GB)	Citalopram
Lilly	Prozac	Fluxtine (CH)	Fluoxetine (studies)
Solvay pharma	Floxyfral	Faverin (UK) Floxyfral (B)(CH) Luvox (CA)	Fluvoxamine
Smithkline  Beecham	Deroxat	Paxil (CA)	Paroxetine
Wyeth lederle	Effexor	-	Venlafaxine	Antidepressant serotonin norepinephrine reuptake inhibitor To depression (APA Studies)
Riom Laboratoires	Norset	Mirtazapine (usa) Remeron	Mirtazapine	Antidepressant Norepinephrine Antagonist Serotonin Antagonist  Blocks Pre-synaptic Alpha 2 Adrenergic Receptors . To depression (APA Studies)
-	-	Nardil (USA)(UK)	Phenelzine sulfate	Antidepressant MAOI To depression (APA Studies)
-	-	Parnate USA)(UK)	Tranylcypromine IMAO
Merck Roche	Elavil Laroxyl	Amavil (usa) Amitid (usa) Amitril (usa) Triavil (usa) Saroten (CH) Redomex (B)	Amitriptyline	Antidepressant Tricyclic For depression (APA Studies) Studies
Servier	Stablon		Tianeptine	Antidepressant ?? For depression ??
Laboratory	Name	Other names	Molecule	Usage
Pharmacia Upjohn Biogaram	Xanax Alprazolam	Apotex (CA)	Alprazolam Study	Anxiolytic . Benzodiazepine . Psycholeptic . To depression (APA Studies)
Biogaram Labo biotherap Wyeth lederle	Lorazepam Equitam Temesta	Alzapam (USA) Ativan (USA)(GB) Loridem (B) Serenase (B)	Lorazepam
Roche	Rivotril	Klonopin USA)	Clonazepam
Sanofi Ldm santé	Equanil Novalm	Meprospan (Usa) Oasil (CH) Pertranquil (BE)(CH)	Meprobamate
Jouveinal	Lysanxia	Centrax (Usa) (UK) Demetrin (CH)	Prazepam
Thomson PDR	-	Dalmane	Flurazepam
Roche Irex	Lexomil Anxyrex	Bromiden (B) Lexotan (B) Lexotanil (CH) Lectopam (CA)	Bromazepam
Sanofi	Tranxene	Belseren (B) Tranxilium (B)(CH)	Clorazepate
Bouchara	Nordaz	Calmday (B) Stilny (B)  Vegesan (CH)	Nordazepam pharmaco dependance  - risque modéré (biam)
Laboratory	Name	Other names	Molecule	Usage
Lilly	Zyprexa		Olanzapine	Anti psychotic Neuroleptic atypical or new generation To schizophrenia (APA studies)
Janssen	Risperdal		Risperidone
Merck	Clozapine	Clozaril	Clozapine
-	-	Seroquel (USA)	Quetiapine fumarate
Synthelabo	Solian		Amisulpride
-	-	Serdolect (USA)	Sertindole
-	-	Zeldox (USA)	Ziprasidone
-	-	Zoleptil (USA)	Zotepine
Bristol-Myers Squibb	Abilify		Aripiprazole
Schering	Trilifan (no more)	Trilafon (USA)	Perphenazine	Anti psychotic Neuroleptic To schizophrenia (APA Studies)
Specia	Terfluzine	Stelazine (USA)	Trifluoperazine
Janssen	Haldol		Haloperidol
Novartis	Melleril		Thioridazine
-	-	Navane (USA)	Thiothixene
Lundbeck	Fluanxol		Flupentixol
Specia	Tercian		Cyamemazine
Laboratory	Name	Other names	Molecule	Usage
Specia	Teralithe	Lithium (USA) (UK) Camcolit (B) Hypnorex (CH) Lythane (USA) Priadel (B)	Lithium carbonate	Anti psychotic Mania Hypomania Bipolar disorder (APA Studies)
Laboratory	Name	Other names	Molecule	Usage
Novartis Merck	Tegretol Carbamazepine	Epitol (USA) Timonil (CH)	Carbamazepine	Antiepileptic - Anticonvulsant To epilepsy (APA Studies)
Janssen	Epitomax	Topamax (USA)	Topiramate
Jouveinal	Dilantin  Neurontin		Phenytoin Gabapentin
Sanofi	Depakine	Depakene (USA) Valprotate	Valproic acid
Synthelabo	Depakote		Divalproex sodium
GlaxoWellcome	Lamictal		Lamotrigine
Novartis pharma	Trileptal		Oxcarbazepine
Laboratory	Name	Other names	Molecule	Usage
Pierre Fabre	Maxepa	-	Omega 3 Eicosapentaenoic Acid (EPA)	Diverse
-	Vitamin B12	-	Cyanocobalamin

• Zanarini MC, Frankenburg FR. - Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA USA.

2OO3 Am J Psychiatry 2OO3 - Omega-3 Fatty acid treatment of women with borderline personality disorder
OBJECTIVE: The purpose of this study was to compare the efficacy of ethyl-eicosapentaenoic acid (E-EPA) and placebo in the treatment of female subjects with borderline personality disorder.
METHOD: The authors conducted an 8-week, placebo-controlled, double-blind study of E-EPA in 30 female with borderline personality disorder.
RESULTS: Twenty subjects were randomly assigned to 1 g of E-EPA; 10 subjects were given placebo. Analyses that used random-effects regression modeling and controlled for baseline severity showed E-EPA to be superior to placebo in diminishing aggression as well as the severity of depressive symptoms. CONCLUSIONS: The results of this study suggest that E-EPA may be a safe and effective form of monotherapy for women with moderately severe borderline personality disorder

"the brain is made up of at least 60 percent lipids, so these findings by Zanarini and Frankenburg make a lot of sense" (Hyla Cass, M.D)
.

• * Dommisse J.

1991 Med Hypotheses - Subtle vitamin-B12 deficiency and psychiatry: a largely unnoticed but devastating relationship ?
A long list of psychiatrically inclined illnesses or symptoms, especially some cases of mood disorder, dementia, paranoid psychoses, violent behavior and fatigue, have been documented to be caused by vitamin-B12 deficiency, among other causes
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* Silver H. - Clinical Research Unit, Flugelman (Mazra) Psychiatric Hospital, Israel
2000 Isr J Psychiatry - Vitamin B12 levels are low in hospitalized psychiatric patients.
CONCLUSION: Vitamin B12 deficiency is common in chronically ill psychotic patients with adequate nutrition and is not readily detected by routine hematology tests

"There is no data to suggest vitamins have any effect on BPD" (Mhsanctuary)
.
"Approximately 20% of borderlines have low vitamin B12 levels, with symptoms of fatigue, leg stiffness, and dysesthesias." (Dr Heller)