Q. I have been diagnosed with BPD, and am a 34 yr. old female. Since 1991, I have taken Nardil, and just in the last 10 days, have come off it, under the supervision of my doctor. In order to cope with the side effects of withdrawal and the return of depression, he has placed me on Perphenazine, 4mgs every 4 hours. I now am experiencing itching and rashes, but am not sure if it is this new drug, that's causing it, since soon after stopping the Nardil, I have broken out in patches of severe itching causing blisters, like a burn. The nightmares are still horrific, and while awake, I find myself in a sort of "twilight zone", unable to associate, and emotionally identify any relationship to my family, or world I find myself in.
Is there any other drug available to help with these ongoing symptoms? I keep hoping the worst of it is over, that it has to get better, but as of yet it hasn't.
A. Your letter is very interesting, and really covers what was probably the best treatment for BPD until the late 1980s. MAOIs have been around a long time, and Don Klein, MD in New York did a lot of work with them in folks with what we would now call BPD. It is a phenomenal body of work going back almost 40 years through the present. MAOIs work really well, but have a number of untoward side effects. Also, like the serotonin re-uptake inhibitors, they can stop working after a while.
The reaction you are getting could be to the perphenazine, but probably is not. The reaction, particularly if it is more localized to your face, upper arms and upper chest is probably neurodermatitis. This is caused by your illness, not the medications. Perphenazine (Trilafon) is an antipsychotic agent, and most commonly used in schizophrenia. This group of medications are referred to as neuroleptics. They will tranquilize you, but will not help with the BPD. Paul Soloff, from the University of Pittsburgh, has shown that over the long haul, neuroleptics in BPD are no better than placebo. They are okay short term, but not likely the answer for which you are looking.
I would strongly recommend using Prozac (80 to 120 mg/day), Zoloft (200 to 400 mg/day), Effexor XR (300 to 600 mg/day) or Serzone (500 to 750 mg all at bedtime). Dosage levels are crucial. If you have been on 60 mg of Prozac and it did not work, it could be you were not on enough. In any case, take the medication in increasing dosages until your carbohydrate craving/sweet tooth goes away, and/or your somatic complaints (irritable bowel, fibromyalgia, TMJ, PMS, neurodermatitis, headaches, or migraines) go away. One this happens, you have enough in you to work. All of this data has been published except the Serzone data which will be out in March or April of 2000.
The twilight feeling sounds like depersonalization/derealization and probably represents an anxiety symptom. Sleep will get better if the medications work, and usually takes 4-6 weeks to really improve after successful pharmacotherapy.
