Q. My son has bpd traits and is on a cocktail of 5 meds. He is extremely overweight. He has gained about 80 lbs. in a short time and has a cholesterol count of 318. We are very concerned. The meds he is on are Paxil 80mgs. Remeron 30mgs (?), Neurontin 1200mgs. Seroquel 300mgs. and Adderall 30 mgs. I would appreciate your thoughts on these meds and if you would recommend doing something else. Any recommendations?

A. Perhaps the best thing to do is to give you an outline of how I view BPD in particular, and psychiatric illnesses in general. My underlying premise is that people do what they are supposed to do. Cutting, suicidal acts, mood swings, rage, etc are all logical behaviors based on the brain's chemistry. Just as vomiting, having a fever, tiredness, and aches are logical behaviors chemically caused by the flu, the cutting, suicidal acts, etc. are logical acts caused by the biochemistry of BPD. People with BPD have no more control over their acts than untreated/unmedicated diabetics, hypertensives, or cancer patients. You cannot change chemistry by thinking about it or talking to it.

BPD behaviors are illogical to do if an individual could control them. People with BPD wear coats in the winter, like nice houses, like nice cars, and wear shorts or cooler clothes in the summer. Things they can change they do. BPD patients are not going to wear down coats in the summer in southern California because it would be uncomfortable. Things that they do not like---being too hot, too cold, too hungry, etc.--they change. So doing something over and over like cutting or being suicidal is out of context with how they lead the rest of their lives. In all parts of the life that they have volitional control over, they change the parts that are changeable. BPD is a chemical illness just like diabetes or asthma and needs to be treated chemically.

I am not anti-therapy. But, psychiatry/psychology is the only field of medicine where we do therapy before we fix what is physically wrong. Good lord, I would be sued for malpractice if I tried to talk someone's sugar level down in diabetes and not use insulin. It is just as foolhardy to talk to BPD before providing pharmacotherapy. Once medications are on board and working, than you do the talking, which is a form of rehabilitation. After heart by-pass (the physical part equivalent to taking medications) you do the therapy (learning to run or walk which is equivalent to psychotherapy). The order is important. You do physical therapy before the by-pass and you can kill the patient. Data suggests psychotherapy is not very good or even harmful without good pharmacotherapy.

All individuals with BPD likely have one chemical problem causing their disease. It is not the same chemical cause in each patient. BPD is likely a mixture of 15 or 20 diseases, like hypertension, grouped under a simple title. That said, if one chemical thing is wrong in most people, one chemical should be able to fix them. I have a lot of patients with BPD who sound like your son from a pharmacotherapy standpoint. I try to get them on as few medications as possible that work. Many are on only one med. I cannot comment on his meds since I do not know anything about his case or prior medication trials. As a rule of thumb, I always maximize the dosage of each medication before adding another.