Q. I left my husband after 3 years of marriage when I was 25 (he was an alcoholic). I began having severe, suicidal depression during my marriage and actually started therapy when he didn't show up for marriage counseling which I scheduled. I was hospitalized within a year after the divorce, and have been hospitalized for suicidal thoughts 7 times since.

My nickname in high school was Smiley because I was so happy all the time, my moods were very stable, I had a pleasant personality, and never experienced anger. I did very well in school and seemed to be able to achieve everything I set my mind on. There was a lot of violence in my family as a child, which I was determined not to repeat.

Through therapy, I began to experience anger and a lot of other emotions. I became very moody, unstable, and started having trouble getting along with people because of my sensitivity (my husband always used to say I was too sensitive), problems with rejection, and my getting angry and defensive in response. My self-esteem disappeared. I became very isolated and it is a struggle for me to even go to work. Anything that has a slight hint of a social aspect scares me away. I used to have a lot of lifetime friends and casual friends, whereas now I don't have any. Every day is a struggle. To make matters more difficult, even though medications seem to help my suicidal thoughts and stabilize my moods, I can't tolerate the side effects. I have a strong tendency to have fatigue and drowsiness as a side effect and problems with concentration. I also have a severe binge eating problem and I weight 265 lbs. currently. I take insulin for diabetes and 3 blood pressure medications, Accupril, Verapamil, and Lozol. I have experiences severe hair loss in the last couple of years, and even though thin hair runs in my family, I can't find the reason for this. I have a thyroid goiter and nodules and my thyroid levels are normal.

I have come close to getting fired numerous times for absenteeism, and am not getting along with co-workers at the present time very well, which is causing a lot of stress for me. They think I am crazy, moody, and when I'm hospitalized or off, they get very angry and they, as well as supervisory personnel express openly their disgust and how there is nothing wrong with me that they don't experience.

Never in my lifetime did I experience a thought to hurt another person (I know people who have these thoughts regularly) until less than a year ago when I called Western Psychiatric Institute and Clinic ER feeling very out of control and suicidal and they refused to call my backup therapist when mine was not available, even though that was the arrangement we had. I had suicidal thoughts (was on my way to purchase a gun) and began to have homicidal thoughts toward the ER staff. I shared these with my therapist (big mistake) who took this as a threat and I was hospitalized. I had seen him for 5 years in therapy, and it had deteriorated the last couple of years, and I began experiencing out of control RAGE for the first time in my life. Being such a passive person, I would have never dreamed I was capable of these thoughts, and was very petrified about it.

I have a few questions. I have been diagnosed with BPD and recurrent major depression. 1. Why did I never have these symptoms until after starting therapy at age 25?? I never felt suicidal in my life before that, didn't have trouble in relationships, didn't isolate, never had self-mutilation problems (Which a family doctor accused me of having Munchausen's Syndrome because my therapist forced me to get medical attention every time I cut myself--which was humiliating for me. I felt the only way to get control over this --which I now have--was to be honest with my therapist. I almost didn't survive what my family doctor said to me. My therapist said this was not the reason for the self-mutilation. I still have a lot of rage about this.)?
2. Why can't I get back to the person I used to be -- I hate the person I currently am?
3. Is there something that can happen during therapy where your therapist begins expressing anger, rage, vindictiveness toward you, when this had previously been a supportive therapy, and he taps into your rage, which you didn't even know you had?
4. What happens to make a person have homicidal thoughts for the first time in their life at age 43?
5. I was taking 200 mg of Serzone, and starting take 1/2 tablet of 37.5 mg of Adipex to lose weight. I had a very severe reaction recently where I thought people were meeting in the conference room all day at work to talk about me. Later in the day I told myself, this can't possibly be true, but I was too traumatized to go to work for almost a week (taking vacation days). I never had such paranoid thoughts before. I am very scared about it. Could it be a medication interaction?
6. Is there any hope for a person whose life fell apart 18 years ago and has never been the same since? (I have had therapy all this time which I feel has made my functioning worse and feel much worse about myself).?
7. Is there any medications to help depression, anxiety, that do not cause drowsiness, weight gain, or concentration problems?

I don't know where to turn. I feel like no one understands. I get judged by people constantly for missing work, not losing weight, not being about to get out socially. I hate myself! Please help! I can't seem to make the changes in my life I need to make.

A. All good questions. I do not have correct answers for many of them, just opinions. Truth be told, that is all any psychiatrist or therapist can offer is a synthesis of their ideas to best serve you.

1. I have no idea why your illness started so late. Perhaps the symptoms of suicidality and depression came later but you had eating problems before. In any case, you need to be better now, so it almost does not matter what the cause of the illness might be, but only the cure.
2. You cannot go back because there is no volitional control over your illness. It is like your diabetes or hypertension. You cannot go back by thinking differently. All three of your illnesses arise from a biological cause, and need to be treated biologically. Thinking different is a waste of time for diabetes and hypertension, and also is for your type of depression.
3. Many studies suggest therapy is bad for BPD. If you are doing what you are supposed to do day to day, e.g., being suicidal is logical based on your chemistry, asking you to change the behavior will only make you feel worse, since it is impossible to volitionally change. Perhaps the rage is your manifestation of frustration.
4. I do not know why you are homicidal. Perhaps you are frustrated, perhaps overstating your true emotions, or perhaps really homicidal as part of the evolution of the illness. Conservatism in treating homicidal patients is a legal requirement, and often ends in hospitalization.
5. I doubt it is a medication interaction between Serzone and Adipex. You are not on enough Serzone to work, and the Adipex causes transient weight loss at best. If low energy is a concern, trying Provigil may help.
6. Plenty of hope, you just need to get on the right medications. Without them, things will not work out near as well. If you have goals and aspirations, correct pharmacotherapy should allow you to start to reach them. Therapy is best after you fix what is physically wrong, not before.
7. Effexor and Zoloft tend to cause not much weight gain over the long term. At the beginning, you actually determine the dosage by taking either until your carbohydrate craving goes away. That is the right dosage. Weight loss usually occurs for 6-12 weeks, and then slowly returns. This can be controlled in other ways, and we can discuss those later if either of the above works. Average dose of Zoloft is about 325 mg/day to make the carbo craving go away and about the same for Effexor. Go gingerly with the Effexor as you increase it. I have not had any problems with increases in blood pressure, but it is a low risk. If you get drowsy with either of these, just use Provigil or Adderoll to increase alertness. The Provigil is expensive, but will not increase your blood pressure or anxiety.