Q. I've been diagnosed with BPD following a bout of depression. I've been on Fluoxetine for 6 months but I'm still having real problems with anxiety, mood swings, inappropriate anger and particularly dissociative symptoms including amnesia and hearing internal voices, among others. I'm 31 but have had problems since a young age and was a hyperactive child.

I've been advised by my Psychiatrist that being given a monthly intra-muscular injection of Flupenthixol may possibly be of help, perhaps greatly so. However the risks involved with taking an anti-psychotic of this nature mean that I could develop Tardive Dyskinesia and that it is a permanent condition once developed - but that risk is low since I am not schizophrenic, especially on lower doses.

My questions are, Is the use of Flupenthixol appropriate for BPD? - and if so, Are there any statistics on it's efficacy in BPD patients?

A. The available data in the literature shows typical neuroleptics are not appropriate for use in BPD. They will acutely help with agitation in very ill inpatients or outpatients, but show little to no long-term benefit. Paul Soloff did these studies at the University of Pittsburgh (Western Psych) about 10 years ago. Typical neuroleptics do not work. There is very little well controlled data on atypical neuroleptics (Risperdal, Clozapine, Zyprexa, and Seroquel), but the open data looks pretty good.

If you are taking less than 80 mg/day of Prozac, you are not taking enough (my article in Am. J. Psych 1991). If Prozac fails, use Serzone at 500-600 all at bedtime if you are not obsessive or Effexor XR at 300-450 mg/day if you have obsessionality or not. Effexor seems to have the broadest spectrum of efficacy overall, but Serzone has the lowest cost and side effects. Serzone has a more limited number of patients with BPD it works in.