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Friday, September 8, 2017

Everything You Ever Wanted to Know About Borderline Personality Disorder

Borderline personality disorder (BPD) is a misnomer. The term "borderline" originated in the 1930s when psychiatrists thought that emotionally unstable patients dwelt on the border between neurosis and psychosis. The classification, Emotional Instability Disorder, better describes those individuals who demonstrate the following:
Ø  Ambivalent feelings about others—an “I hate you, don’t leave me” attitude. The borderline has intense love-hate relationships—thinking that a person is angel or a devil with no realization that all of us have “good” and “bad” traits. A few minutes or hours later, the borderline might idealize an individual and the next hour (or minute) the borderline will consider the individual worthless or evil.
Ø  Chaotic relationships
Ø   Frantic efforts to avoid real or imagined abandonment
Ø   An unstable self-image
Ø   Self damaging impulsivity such as overspending, sexual indiscretion, substance abuse, reckless driving, binge eating
Ø   Recurrent suicidal behavior, gestures, or threats
Ø   Self-mutilating behavior—cutting or burning self
Ø   Rapid onset of intense and profound depression
Ø   Rejection sensitivity—considered the slightest inattention of an individual as a totally rejecting attitude
Ø   Chronic feelings of emptiness
Ø   Inappropriate, intense anger—screaming, yelling, throwing things
Ø   Transient paranoid thinking
Ø   Emotional instability that disrupts family and work life
            People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). They may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. Suicide threats and attempts occur as a maladaptive attempt to prevent abandonment. Intense anger develops when the borderline feels rejected. Self-mutilation results from an attempt to reduce emotional stress. For the borderline, physical pain is preferred over emotional distress. People with BPD exhibit other impulsive behaviors, such as excessive spending and risky sexual activity.
            Anyone who has a child knows that around 18-months of age the youngster toddles out of the room plays alone for a few minutes and then toddles back in the room looking for mother. With a wide-eyed smile, mama picks up her toddler, gives a warm hug, and coos encouragement. Consistent maternal and paternal affection enables the child to develop a stable sense of self and, with dependable parental behavior, the child develops the ability to sooth the self—the ability to tolerate the vicissitudes of life.  
         When the-soon-to-become borderline toddles back into the room, mama has disappeared or is drunk or is verbally, emotionally, physically, or sexually abusive. Inconsistent, negligent, and abusive parental behavior generates a fear of abandonment and retards the toddler’s emotional development. The toddler feels alone, lost, and worthless.
In some cases over gratification and establishing an atmosphere that the child’s uniqueness and special talents put him or her above all others contribute to borderline dynamics. Sometimes poor parent-child bonding fails to develop.
         As the years pass, feelings of worthlessness, and a poor sense of self cause frequent changes in careers, jobs, friendships, and values. Borderlines view themselves as fundamentally bad or unworthy. They feel unfairly misunderstood or mistreated, bored, and empty. These feelings result in frantic efforts to avoid being alone. The emotional clinging behavior exhibited by borderlines repulses others. The fear of abandonment felt by the borderline generates hostile behavior that results in the very rejection that the borderline fears.
         Although no gene has been identified as a precursor to borderline personality disorder, neuroimaging studies are intriguing. PET scanning and fMRI studies demonstrate enhanced amygdala and prefrontal activation in subjects with BPD. Excess activity in the cingulate gyrus is associated with borderline personality disorder. These findings are nonspecific indicators of intense emotional activity.
         Common sense indicates that some children are more sensitive than others. Just as some geneticists believe they have isolated a gene for shyness, a gene that serves as a biological marker for BPD may be identified. Remember—a gene must be activated before an illness occurs. That is, many of us may have a genetic marker for schizophrenia, but a stable emotional life prevents the gene from becoming activated.
         The chemical messenger serotonin helps regulate emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. An imbalance of dopamine, the so-called pleasure neurotransmitter, may contribute to impulsivity and anger. Antipsychotic medications can help regulate dopamine balance.
         BPD often occurs together with other psychiatric problems, particularly bipolar disorder and depression. While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger and depression that may last only hours, or at most a day.
            BPD is one of four related personality disorders associated with dramatic-erratic behavior, poor impulse control, and emotional instability. Narcissistic, histrionic, and antisocial personality disorders are also distinguished by dramatic-erratic behavior. While almost 75% of borderlines are female, the vast majority of sociopaths (antisocial personality disorder) are male.
            Bulimia and other eating disorders, dissociate states, and anxiety syndromes are commonly associated with BPD. Substance abuse is a common problem in BPD. 50% to 70% of psychiatric inpatients with BPD are drug or alcohol dependent.
Seven elements of PSYCHODYNAMIC dialectic behavior therapy:
  1. Corrective Emotional Response: A trustworthy therapist who demonstrates non-possessive warmth (love without controlling behavior) and genuine respect for the patient enables the patient to learn self-soothing behavior that failed to develop due to childhood emotional abandonment and poor parent-child interactions. Through verbal and nonverbal behavior the therapist demonstrates emotional stability when the patient exhibits angry outbursts, intense depressive episodes, frustration, impulsivity, mutilation behavior, and excessive emotional dependency. The therapist models and teaches self-discipline by setting limits on emotional outbursts. The therapist avoids rescuing the patient from conflicts of daily living while remaining kind and understanding. 
  2. Psychodynamic Emotional Connections: By reviewing childhood experiences the patient feels the connection between the childhood emotional conflicts and present emotional distortions.
  3. Cognitive Behavior Therapy: The patient practices changing thoughts to have better feelings.
  4. Improving Responses to Day-to-Day Events: The patient keeps a daily journal that records events, feelings and thoughts generated by daily events. The therapist asks a series of questions to enable the patient to learn better ways of handling conflict.
  5. Developing Emotional Skills: Through a series of questions the therapist explores the what, where, when, why, and how of conflict and stress. The therapist teaches skills to deal with stress and interpersonal conflict in the following areas:
v Evaluation of distorted thinking: The patient is helped to see different viewpoints in a conflict.
v Dealing with stress: The patient learns to manage emotions that are triggered by distressing events, including those that cannot be immediately resolved.
v Dealing with interpersonal conflict: The therapist teaches the patient to maintain healthy relationships. The patient learns that certain rules of society must be followed to get along in the world and to break social, ethical, and moral rules leads to self-destruction. The therapist helps the patient find ways to fulfill emotional needs while allowing others to fulfill their needs.
v Developing emotional stability: The patient learns self-soothing behavior by changing distorted beliefs and inappropriate actions. For example, a series of questions can help improve the patient’s response to perceived rejection:
ü  What are you thinking (or doing) right now?
ü  Is what you are thinking (or doing) helping you?
ü  What thoughts (or actions) can help you feel better about yourself? (Several options may be formulated until the best solution is discovered.)
ü  Will you commit to changing your thoughts (or actions)?
ü  How will you demonstrate that you have committed to change?
6. Family/Marital Therapy:            The crux of family therapy involves educating family members regarding BPD. Improving communication will help resolve the two poles of inappropriate family response: over involvement (rescuing) and neglect.

7. Medication Education: The risk and benefits of medications, how medications work and medication side effects are explained to the patient.

Friday, August 11, 2017

Alzheimer's Disease Part IV: Preventing and Slowing Down AD

The Princeton train conductor coming down the aisle punching the tickets of every passenger noticed the brilliant physicist, Dr. Albert Einstein frantically looking for his ticket. The conductor said, “Dr Einstein, I know who you are. I’m sure you purchased a ticket. Don’t worry about it.”

Einstein relied, “Young man, I too, know who I am. What I don’t know is where I’m going.”

As normal citizens we don’t know where our life is going, but there are ways to stop or slow down the Alzheimer’s train:

Stay physically fit
  • In a study involving 4,600 men and women age 65 years or older those who exercised regularly reduced the chance of developing AD by 30%.
  • Studies indicate that regular exercise builds brain cell synapses and improves brain blood flow. 
Reduce stress
  • Stress reduction prevents cell death in the hippocampus, the memory switch of the brain. 
  • Contemplative prayer, meditation, and yoga are stress reducers that can be incorporated into a daily schedule. 
  • Cultivating friendships also reduces stress.
Reduce brain shrinkage with a “good fat” diet
  • The risk of developing AD goes up with the number of calories in the diet. 
  • Those individuals who consume the most calories double the risk of AD when compared with those who consumed a low calorie, good fat diet.
Drink 3 ½- 5 ounces of red wine each night (Baptists can eat red grapes.) 
  • Resveratrol, abundant in grape seed and in red wine, is a powerful antioxidant. 
  • Alcohol also dilates arteries by enhancing nitric oxide, just like Viagra.
    • Viagra is dandy, but liquor is quicker
    • A little wine increases desires, too much gives ceasefires
Take aspirin 
  • Anti-inflammatory drugs (NSAID) such as aspirin, ibuprofen and naproxen prevent brain inflammation that plays an important role in the development of AD. 
  • Several studies have shown that long-term NSAID use may reduce the risk of Alzheimer's disease by as much as 50%.
Consider estradiol for post-menopausal women
  • Estrogen docking sites—places where estrogen attaches itself to brain tissue, including the hippocampus—have been identified indicating estrogen plays a role in memory and cognitive functioning in the brain. 
  • Declining levels of estrogen have a negative impact on language skills, mood, concentration and attention. 
  • Parenthetically, estrogen has a major role in preventing the development of osteoporosis in women. 
    • Because estrogen replacement therapy may increase the risk for heart disease and certain cancers, each woman’s personal and family history must be evaluated before estrogen is prescribed. 
    • Most experts recommend the use of natural, soy-based estrogens—estradiol—for replacement therapy because estradiol is the main type of estrogen made by the ovaries.
  • A Big Thicket East Texas doctor once said, “Most people don’t drink enough water and their brains shrivel-up.”
Taking these vitamins will help us remember how to put on our clothes when we are 103 years old:
  • B Vitamins
    • An MRI study showed that a group that failed to take B vitamins had significantly greater loss of brain tissue when compared to the group which did take B vitamins. 
    • Vitamin B12 helps maintain the Myelin sheath, the covering and insulating layer of nerve cells. 
    • Vitamin B6 helps the body produce neurotransmitters 
    • Vitamin B3 helps brain neurons repair themselves.
  •  Vitamin D
    • Multiple studies have shown a "clear link" between a vitamin D deficiency and a risk for Alzheimer's.
    • Vitamin D stimulates nerve growth within the brain,.
    • Vitamin D is one of the nutrients which our body has difficulty producing as we age
    • Almost 95% of those over the age of 65 are deficient in vitamin D
  •  Vitamin E
    • In a United States trial, 613 individuals with mild to moderate Alzheimer's disease were assigned to take either a vitamin E supplement or a placebo. At the end of the 24 month study, researchers found that individuals taking vitamin E showed that were able to complete everyday tasks that individuals in the placebo group failed to complete.
A growing number of herbal remedies and dietary supplements are promoted as memory enhancers 
  • Claims about the safety and effectiveness of these products are based largely on testimonials, rather than scientific research.
  • Although some may be valid candidates controversy abounds:
    • Effectiveness and safety are unknown
    • Purity is unknown
    • There exists no guarantee that the products contain the ingredients or amounts listed on the label. 
    • Dietary supplements can have serious interactions with prescribed medications. 
Brain boosters
  • Crossword puzzles
  • Jigsaw puzzles
  • Word scrambles (e.g. nabir = brain)
  • Drawing or painting
  • Playing brain games (Simon Says, Charades, Cranium, Trivial Pursuit, Pictionary, Scattergories, Scrabble, Outwages, etc)
  • Playing a musical instrument (Einstein played the violin. Look what it did for him.)
  • Learning a foreign language (Texans can learn to speak American.)
  • Memory work
    • Memorizing Bible verses, Shakespeare, poems
    • After a movie name four or five of the main characters
    • Memorize countries and capitals
    • Write a one-paragraph summary of a book or magazine article

If you follow all these suggestions you won't have time to "catch" Alzheimer's.

Wednesday, August 9, 2017

Alzheimer's Disease Part III: Treatment

Cicero told of Damocles who wished the pleasures of a king. Saracen magic placed him at the king’s table eating sumptuous food, drinking the finest wine and enjoying more pleasures than his imagination had conceived. Glancing upward, his eyes transfixed on a sword dangling by a single horsehair just above his head. Damocles turned pale. His hands trembled. His joy vanished as he realized that much pleasure brings much danger.

Perhaps the myth of Damocles over dramatizes the risk of Alzheimer’s. After all over 50% of 90-year-olds never experience the illness. Nonetheless as we grow older we sometimes contemplate the threat of Alzheimer’s dangling by a single horsehair just above our eyes’ imagination.

Scientists still search for a cure.  They’re looking for a little more horsehair for that sword.

The U.S. Food and Drug Administration (FDA) has approved five medications to treat the symptoms of Alzheimer's Disease (AD):

  • Aricept (donepezil)—approved in 1996 for all mild to moderate stages of AD
    • Can help AD patients do things longer
    • Dose: 5 mg daily for one month then 10 mg daily
    • Side effects are mild but occasionally consist of nausea, diarrhea, anorexia 
    • Useless for severe AD
  • Exelon (rivastigmine)—approved in 2000 for all stages
    • Dose: Initial dose 1.5 mg twice daily then, if tolerated, 3 mg twice daily and gradually increase to the maximum dose of 6 mg twice daily until maximum benefit is reached.
    • 70% of patients who responded poorly to Aricept responded to Exelon.
    • As many as 40% of patients may develop intolerable nausea, vomiting, diarrhea and anorexia.
  • Razadyne (galantamine)—approved in 2001 for mild to moderate AD
    • Initial dose 4 mg twice daily. May gradually increase to 12 mg daily
    • GI side effects predominate
  • Namenda (memantine)—approved in 2003 for moderate to severe AD
    • Dose: 5 mg daily, gradually increase to 10 mg twice daily
    • First medication approved to treat severe AD
    • Impressively benign side effects
  • Namzaric (a combination of donepezil and memantine)—approved in 2014 for moderate to severe AD
    • The first and only once-a day capsule that works on two pathways to fight symptoms of moderate to severe AD.
    • Initial dose 7mg of memantine and 10 mg of donepezil gradually increase to maximum dose of 28 mg/10mg daily
How Medications for Alzheimer’s Work:

  • Brain nerve cells (neurons) connect at the junction of neurons called synapses where tiny bursts of chemicals called neurotransmitters transfer information from one cell to another. AD impairs the function of several neurotransmitters. 
  • The neurotransmitters acetylcholine and glutamate seem particularly important in AD.
    • Cholinesterase inhibitors—Aricept (donepezil) and Razadyne (galantamine)—block acetylcholinesterase, an enzyme responsible for the normal decomposition of acetylcholine. This inhibition of acetylcholinesterase allows an increase of acetylcholine so that information is passed through the synapse more effectively.
    • Exelon (rivastigmine) inhibits two enzymes, acetylcholinesterase and butyrylcholinesterase, increasing the effectiveness of acetylcholine.
    • Namenda (memantine) works by regulating the activity of glutamate thus preventing excess calcium to flow into nerve cells that kill neurons. Restoring normal glutamate levels improves learning and memory.
Unfortunately these FDA approved medications fail to treat the underlying disease process or stop cell damage. Instead they merely slow the development of the disease.

Other medications may be useful in treating or preventing the AD. Evaluating the benefit-risk ration is especially important with these meds:

  • Premarin(conjugated equine estrogen) improves verbal memory, vigilance and reasoning, and has been associated with decreased dementia risk.
    • Contraindicated with blood clots in the calf or lung, infection of leg vessels, severe liver disease and estrogen-dependent cancer.
    • 10-20 years of estrogen replacement gives a modest chance for breast cancer.
  • Estrace (estradiol) has the same benefits and warnings as Premarin but the tablet is half as expensive.
  • Eldepryl (selegiline) inhibits monoamine oxidase that breaks down neurotransmitters
    • Serious side effect of a hypertensive crisis when certain foods are eaten
  • Non-Steroid Anti-Inflammatory Drugs (NSAIDs) such as Aspiring, Motrin, Naprosyn 
    • Clinical research indicates NSAIDs may help prevent AD. 
    • Serious side effect: Gastric ulcers
  • Statins—Lipitor, Mevacor, Zocor
    • May reduce the production of beta-amyloid proteins that cause nerve cell death
    • Serious side effect: Liver abnormalities
Medications for symptoms of AD:

  • Rexulti is useful for paranoia and agitation. (See my blog entry for info on Rexulti.)
  • Seroquel is useful for sedation and sleep in acutely agitated AD patients
  • SSRIs, especially Zoloft or Celexa, are useful for AD depression 
  • Trintellix, a non-SSRI, is my favorite AD antidepressant because it increases serotonin-7 that has been found to increase cognition.
    • Trintellix has yet to catch on as "popular" antidepressant
    • Academics would be displeased with Trintellix use in AD depression
    • Nausea is a limiting factor
    • See my blog entry on Trintellix for more information.
  • Trazodone for sleep
    • May have some efficacy in treating agitation and aggression associated with AD

Warning: Avoid benzodiazepines such as Valium, Xanax, Ativan and others 

  • These medications can act as disinhibitors in the elderly resulting in increased agitation.
  • Benzodiazepines often cause confusion in the elderly.
  • One longitudinal study involving over 400 AD patients has shown long term use of benzodiazepines to be an associated with AD, not a cause for AD.
    • Another longitudinal study of over 400 AD patients refuted these findings.
    • Longitudinal studies become extremely complicated because complex statistical analysis is necessary for factoring out multiple variables.

Fortunately, 19 AD drugs are in Phase 3 clinical trails (people are taking the drug, not animals) that are on pace to launch in the next five years if proved to be safe and effective and if the FDA does not delay the process. 

Irony: The FDA has delayed many effective drugs that treat life-ending disease because of safety reasons. I guess the members failed college Logic 101. 

The FDA sword cuts off speedy development of AD medications.