The Borderline Experience
Borderline and  Instability
Medical Treatment of the Borderline Personality Disorder


Dr. Leland Heller Discusses
Borderline Experience

"...Epilepsy was once thought to be a psychiatric problem, until the underlying neurological abnormalities were understood.  Researchers have uncovered medical and neurological abnormalities in borderlines.  Many symptoms are likely due to malfunction in the brain's limbic system. In my opinion, the borderline personality disorder is primarily a medical problem.   

The Borderline Experience

Imagine you are faced with a minor stress - a flat tire, a clogged-up sink, or a trivial disagreement with your spouse, friend, lover, child, etc.  Instead of finding an acceptable solution, your mind seems to panic.  A sense of unease develops, possibly causing discomfort in the stomach or chest.  Feelings of anxiety complicate the increasing sense of uneasiness and restlessness.  This is followed by progressively worsening anger - eventually becoming a rage so strong it overwhelms you - even though you realize it's excessive.  Over the next few minutes to hours, other negative sensations creep in - including memories of past hurts - until you are experiencing virtually every bad emotion a human can feel.

You feel trapped and vulnerable.  Your psychological defenses are overwhelmed by unbearable emotional pain.  You feel depressed.  You find yourself unable to cope as your mind and body are now in a full scale panic, in a futile effort to make sense of what's happening.  As the pain continues to intensify the nervous system creates bizarre sensations such as emptiness, numbness, and unreality.  

Your mind now desperately tries to find a way out of the pain and searches for solutions.  It recalls past activities that have made you feel better.  Once a method is found, your mind frantically forces you to pursue that activity to a self-destructive excess - finally resulting in a biochemical rescue.  Brain chemicals are released that stop the pain and let you feel 'normal' again.

But how can you ever feel normal again knowing that such a horrible experience will return?  How can you feel normal again when your self-destructive and inappropriate behaviors are witnessed by family, friends, employers and/or co-workers?  How can you feel normal again when those behaviors result in financial, interpersonal or physical trouble?

For those not afflicted with the Borderline Disorder this is a nightmare we hope never happens to us.  

Borderlines experience it over and over - especially when confronted with stress.  While individual borderlines may feel some symptoms differently, the horrible feelings described in the first paragraph (called 'dysphoria') intrude frequently into a borderline's life.

Borderlines will do almost anything to make dysphoria go away.  Most impulsiveness and self-destructiveness is an effort to relieve dysphoria.  Some borderlines, especially those suffering very severely, will literally cut their bodies during dysphoria.  The self-mutilation is itself painless (the cuts don't hurt), yet it relieves the dysphoria.

Borderlines also suffer from intense, frequent and unpredictable mood swings that can cause 'dysphoria' even without stress.  The mood swings cripple a borderline's efforts to live a happy, successful life.

Borderlines are victims of an incredibly painful illness...

Like victims of epilepsy, muscular dystrophy, and neurofibromatosis (the 'Elephant Man's' disease), victims of borderline neither asked for, deserved or caused their affliction.  The symptoms can be so unpleasant to those interacting with borderlines that feelings of compassion and understanding may be difficult or impossible to feel.  Borderlines desperately want to be loved, but their illness makes them at times seem unlovable.  They are terrified of being abandoned, yet are powerless to keep the illness from destroying relationships.

This is the borderline experience.

The Facts

...Genetic factors are important - borderline tends to RUN in families.  The risk of developing borderline is 6 times higher when a close relative has the disorder.  In studies of identical twins, researchers have discovered that many personality traits are genetically determined.  There is an association between some personality characteristics and blood type (called 'blood group antigens').

Borderlines commonly suffer from other disorders as well.  PMS, depression, hypothyroidism, vitamin B 12 deficiency, other personality disorders, anxiety, eating disorders, and substance abuse problems are the most common.  

Intelligence is not affected by the disorder, but the ability to organize and structure time can be severely impaired.  There is no association with Schizophrenia.

...While many borderlines suffered from abuse or neglect in childhood, some developed the disorder from head injuries, epilepsy, or brain infections.  Early parental loss and incest are commonly associated with borderline.

The facts indicating a medical origin are impressive: Brain wave studies are frequently abnormal.  Neurological physical examinations are abnormal.  Memory and vision are impaired.  Glandular function may be abnormal.  Sleep is abnormal.  The response to some medications is bizarre.  When injected intravenously, the medication procaine normally causes drowsiness, but a borderline will feel the 'dysphoria' described in the first paragraph.  If borderline was exclusively an emotional illness, why would all these medical neurological abnormalities be present?

Borderlines likely have abnormalities with the neurotransmitter 'serotonin' - an incredibly important brain chemical.  Serotonin problems can cause anxiety, depression, mood disorders, improper pain perception, aggressiveness, alcoholism, eating disorders and impulsivity.  Excess serotonin can depress behavior.

Serotonin deficiencies can cause many problems, especially suicidal behavior.  Low levels of serotonin increase the risk of self-destructive or impulsive actions during a crisis.  The most violent suicides (hanging, drowning, etc.)  are usually committed in patients with low serotonin metabolite (waste product) levels in the spinal fluid.  In those who attempted suicide unsuccessfully, 2% will likely be dead within one year.  If the serotonin metabolite level is low, that risk increases to 20%.


Due to new developments in medicine, borderlines can now be treated.  The medication fluoxetine (Prozac) usually stops most of the mood swings in a few days.  It is, in my opinion, as big a breakthrough for borderlines as insulin was for diabetics.  Borderlines generally see themselves very profanely.  I frequently tell my borderline patients 'you're not an *#%@*, your brain is broken.' Once this concept is understood, the borderline patient usually feels an enormous sense of relief.  They need to know they have value as a human being.  Feelings of desperation and hopelessness are often replaced by optimism and motivation once Prozac stops the mood swings and the patient begins to realize that a happier, more successful life is possible.

All borderlines need psychological counseling.  It's almost impossible to live for years as a borderline and not need psychological help.  While the underlying problems are probably structural within the brain, the borderline is left with a lifetime of bad experiences and inadequate skills for recovery.

No medication should be given without proper medical supervision.  This is particularly true for the drugs used to treat the borderline disorder.  Some medicines make the symptoms of borderline worse, especially amitryptilline (Elavil) and alprazolam (Xanax).  Possibly a third of borderlines may suffer from low thyroid (hypothyroidism) - despite a normal 'TSH' blood test.  They may need to take thyroid medication.

The antidepressant fluoxetine (Prozac), a serotonin increaser, virtually eliminates the mood swings.  Feelings of anger, emptiness and boredom are often eliminated or reduced as well.  Most borderlines I've treated consider Prozac to be a miracle.  While some need the medication indefinitely, many have been able to stop it after a year without the mood swings returning.  Side effects are rarely a significant problem.

Neuroleptics...have been proven effective.  They are remarkably helpful for treating dysphoria and psychosis, and can be preventive when the borderline is undergoing stress.  They seem to 'put on the brakes' when the thoughts are racing.  They should only be used as needed, like using an antacid for heartburn.  These medications can be effective at low doses, and must be taken with great caution.

While medications can help with some symptoms, the brain is clearly broken.  After a stroke, the brain needs therapy to let the healthy areas take over for the broken ones.  The same is true for recovering borderlines.  I feel strongly that the brain must be retrained.  

Sometimes symptoms of 'temporal lobe' involvement (similar to epilepsy) complicate the disorder.  Common symptoms include unawareness spells, feeling like things are unreal, and numbness of body parts.  These symptoms are more common under stress, depression, severer dysphoria, and incest crisis.  They can be treated with the epilepsy medication carbamazepine (Tegretol)...

Borderlines are VICTIMS - they did not cause their illness. 
They do not want their illness.  They want to be carefully treated and loved.  They deserve that opportunity.

(The National Institute of Mental Health (NIMH) has been the single most influential source of unbiased study and information regarding the true biology behind the borderline personality disorder.

Landmark studies, such as those produced by Drs. Cowdry and Gardner in 1987 showed the effectiveness of Tegretol (carbamazepine) and neuroleptics, and the dangers of Xanax (alprazolam).  This article was published in the Archives of General Psychiatry Feb 1988.)  

By Leland M. Heller, M.D.

Borderline and  Instability

Joel Paris, M.D. 

 A professor of psychiatry at McGill University in Montreal

"The central feature of Borderlines is instability, affecting them in many sectors of their lives...

Borderlines creates enormous suffering in those afflicted with it. Most of them describe a continuous state of emotional chaos, swinging from extremes of depression, anger, and anxiety. Borderline patients often need to feel suicidal in order to know that they can escape from their dysphoric feelings. The road to recovery for Borderlines is often long and difficult. However, Borderlines are often attractive and productive people. When treatment help them, the patient, the therapist, and the family can all feel that it was well worth the trouble to see things through.

The social factors in BPD reflect many of the problems of modern society. We live in a fragmented world, in which extended families and communities no longer provide the support they once did. In contemporary urban society, children have more difficulty meeting their needs for attachment and identity. Those who are vulnerable to Borderline personality disorders may have a particularly strong need for an environment providing consistent expectations and emotional security.

Children who are at risk by virtue of their temperament can still grow up perfectly normally if provided with a supportive environment. However, when the family and community cannot meet the special needs of children at risk, they may develop serious impulsivity and emotional instability."

Medical Treatment
 of the 
Borderline Personality Disorder

Leland M. Heller, M.D.
January 18th, 1998

The Borderline Personality Disorder (BPD) is a devastating neurological illness that causes enormous psychological damage, and usually destroys lives.  The risks of substance abuse, auto and work accidents, and early death are high enough to take this disorder very seriously.  Treatment includes medication, counseling, and "retraining the brain."  Medication is virtually always needed, and can make a profound difference.

 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.  Dosage increases usually are effective very quickly, often in one day.  Dosage increases or decreases should not be more often than every week, unless directed to do so by a physician. The main symptoms treated include: mood swings, chronic anger, emptiness, boredom.

NEUROLEPTICS: Excess production and/or increased sensitivity to the brain chemical "dopamine" seems to be a major cause of rage, anxiety, despair, self-destructive thoughts and impulses, weird body sensations, paranoid thoughts, impulsive behavior and dysphoria (anxiety, rage, depression and despair).  There are many drugs in this class, but Haldol appears to be the best - it works quickly, with minimal side effects and in low doses (generics usually don't work).  The antihistamine Benadryl will reverse a potential side effect where the muscles go into spasm - notify your physician(s) should this happen. 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.

EPILEPSY DRUGS: The most severe BPD symptoms are likely a form of epilepsy and include "dissociation" (unreality, body parts going numb, deja vu, etc.) and chronic "dysphoria" (anxiety, rage, depression and despair).  When neuroleptics like Haldol are ineffective, epilepsy drugs like Tegretol (carbamazepine), Neurontin, and Depakote can often stop the symptoms in hours.  Depakote (valproic acid) can also control the bipolar disorder.  Blood levels are very important to monitor, as are liver blood tests and blood counts.

Patients who are well educated about the disorder and its treatment can use extra doses when needed, however the risk of side effects (especially grogginess) is increased.