Borderline Personality Disorder Chat Conference Transcript with Richard Moskovitz M.D.: 10/26/00

We were very pleased to have Richard Moskovitz M.D. (author of "Lost in the Mirror:  An Inside Look at Borderline Personality Disorder") provide a chat conference about the borderline personality disorder.  Below are the transcripts. Dr. Moskovitz used the nick name of "LostintheMirror"

<TimLPN> Is the BPD a group of symptoms??

<LostintheMirror> BPD could be understood as a group of symptoms, but the symptoms are all different expressions of something more fundamental.

<LostintheMirror> I think that the essence of BPD is a failure to appreciate the continuity of one's life over time.

<LostintheMirror> That creates problems in establishing identity, but also leads to black-and-white thinking..

<LostintheMirror> because the impression of the moment feels like the only thing that counts.

<david__> Why, in your book, did you feel it useful and indeed reasonable to write a fictional account of a BPD sufferer's therapy and recovery?

<pattysanc> earned his undergraduate degree and his M.D. at Harvard University. After residency at Chapel Hill and eight years on the University of Florida College of Medicine faculty, he has spent over a decade in private practice. His book grew out of his passion for teaching and years of clinicial experience with patients with BPD.

<LostintheMirror> I felt that it would help make the picture of BPD more real to have a story, particularly an extended one that people could follow from chapter to chapter. It had to be fictional because using actual stories of patients I've seen would violate their confidentiality.

<poppy__> Do you think that ADD and BPD are related? or exist together?

<LostintheMirror> Great question! There is a lot of overlap between ADD and BPD and they can indeed coexist.

<LostintheMirror> Children with

<LostintheMirror> ADD often grow up to develop BPD.

<LostintheMirror> They certainly share impulsiveness and living in the moment without thinking very far ahead about the consequences of actions.

<Lauranator> I was wondering about meds......how much of a role do they play in bpd recovery vs. talk therapy, or other types of therapy?

<LostintheMirror> I believe that medications are often very important particularly in the early stages of treatment.

<LostintheMirror> Often, at the beginning, emotions are too chaotic even to engage in the cognitive part of therapy.

<LostintheMirror> The meds can help bring enough order and self control to be able to concentrate and process.

<LostintheMirror> Meds can also be important in controlling impulses so that the talk therapy doesn't trigger self-destructive behaviors.

<LostintheMirror> Sometimes in the later stages of therapy, the meds can be phased out, but some people need to continue on them indefinitely, even if they have done very effective work in therapy.

<pippylong> I have been on Zoloft, 100mg. per day, for over 3 years, I want to go to 200mg. is that o:k?

<LostintheMirror> There is no way that I could advise you regarding your particular medication and dose. That needs to be up to your doctor.

<LostintheMirror> What I can tell you in general is that any increase in medication should always be done very gradually.

<badblue^> Do you know any psychiatrist/therapist or institution that have made serious research and/or treat BPD in south America?

<LostintheMirror> Sorry, no. You might go to the DBT website (Dr. Linehan) and ask whether they have trainees there

<pippylong> i know i have bpd, without a doubt. this site has changed my life and so have you. my doctor is aware, because I copied all the info. ty

<Sukk> Dr. Moskovitz, thank you for taking the time to answer our questions, I have a question about medication, I was diagnosed with BPD about 3 months ago, and my doctor put me on Neurontine wich has settled my mood without sideeffects, he also tried Zoloft on me - it gave me horrible sideeffects, headaches, nausea, muscle pain, unequally dialated pupils, etcetera.. was on it for a month (quit today) and have been on sickleave for 3 weeks, my previ

<Sukk> Zoloft has also increased anxiety, dread going to work - just wanted to add that..

<LostintheMirror> What is your question?

<LostintheMirror> It is important to understand that medications are a very individual thing.

<Sukk> if there is any other drug that would have the same effect as Zoloft and Prozac are supposed to have.. and if you think this points to that I am SSRI "tolerant"

<Sukk> if there exists such a thing, because my pdoc doesn't want to put me on anything else for the moment..

<LostintheMirror> What works great for some people may make others feel awful, for no particular reason.

<Sukk> sorry if I didn't make myself clear eneugh

<LostintheMirror> There are now five SSRI's: Prozac, Zoloft, Paxil, Luvox, and Celexa.

<LostintheMirror> A bad reaction to one doesn't necessarily mean that another won't be tolerated.

<LostintheMirror> One crucial thing is dosing.

<LostintheMirror> I always start my patients on the smallest possible dose of most meds.

<LostintheMirror>  Most side effects tend to occur early and go away after a while.

<LostintheMirror> The SSRI's often are very stimulating at first. Starting low and going slow can get past the side effects unitl you can build to therapeutic doses.

<Sukk> thank you Mr. Moskovitz

<Velveteen_Wabbit> Dr M, I enjoyed your book, I couldnt get enough of it, your

<TimLPN> Please no extra talking use #bpdsanc for that

<Velveteen_Wabbit> second will be an addition to the first or a continuation? It taught me alot I am

<Velveteen_Wabbit> I am in month 9 of my dx and for the first in 5 years I have started to work full time and have my life somewhat back in order!

<LostintheMirror> The second edition will have updated and added chapters. The drug chapter will be brought up-to-date. Lots of changes in five years.

<LostintheMirror> There is also going to be a chapter with more specifics about types of psychotherapy.

<donasolakadonalema> LostintheMirror If you really believe you will not self-harm anymore, is it possible?

<LostintheMirror> It is definitely possible to stop self-harming.

<donasolakadonalema> What if you have done it recently?

<LostintheMirror> First, you need to want to, which is more complicated than it sounds since it has served you in various ways for a long time.

<Lauranator> I really enjoyed reading your book too, but one thing it didnt address very much was the depression that accompanies bpd, is it a special kind of depression needing specialized treatment to combat the emptiness and isolation, frustration and rejection?

<LostintheMirror> Some people with BPD have depressions that have all the same characteristics as people with depression but not BPD.

<LostintheMirror> The treatment...drug treatment...in those cases is the same as for others.

<LostintheMirror> The problem in BPD is the variability in moods.

<LostintheMirror> The depression is often in response to rejection and other external events. It can come in a flash and it can go away if circumstances change.

<LostintheMirror> A crucial goal of treatment is to help people weather adversity...

<LostintheMirror> Learn that painful things happen, but they can be endured.

<LostintheMirror> Once adverse events stop triggering feelings of hopelessness, the depression may come les often.

<tinky94> my shrink has said that i am bpd but my therapist doesnt think so... any suggestions?

<LostintheMirror> You might ask each of them to explain their conclusions.

<tinky94> they live in different states

<LostintheMirror> It would also be important to know whether they have communicated with each other, which is important if you are in treatment with them both.

<LadySnafu1972> Do you reccomend DBT to your patients if so do you think that with that and individual therapy and the right combo of meds...

<LadySnafu1972> that symptoms can be reduced or recovery can occur?

<LostintheMirror> I do not practice DBT. I believe that it is an excellent form of treatment and do recommend it when it is available.

<tinky94> dbt?

<LostintheMirror> It is an inclusive system of treatment that includes individual therapy along with various other modalities.

<pippylong> I have been on 200 mg. of Zoloft for about 1 month (after being on 100mg. 3 or 4 years. It has been unbelievable, that's all I can say. Thank you so much Patty, Tim, Dr. My Dr. now has your book (Amazon.com was sold out as of a couple days ago). He is very worried about me wanting to be on 300mg. a day. Did an EKG, said something was at the verge of not being in a safe range anymore. Could 200 mg. a day be effective? Thank You.

<LostintheMirror> Dialectical Behavior Therapy -- an integrated system of treatment designed by Dr. Marsha Linehan at the University of Washington.

<LostintheMirror> 200 mg is technically the highest dose of Zoloft recommended in the manufacturer's prescribing information.

<LostintheMirror> That doesn't mean that in some extraordinary circumstances, higher doses can't be used.

<LilTrillium> I have not been positively diagnosed with bpd but find that I possess many of the 'textbook' symptoms that you mention in your book. What would the best method be to go about to bring to my physician what bpd is? He has not done anything outside of prescribing zoloft (which I despise because the way it makes me feel) and sending me on my merry way despite my efforts to try and understand what is wrong with me

<LostintheMirror> LilTrillium, you might show your doctor the book and point out why you think the picture fits you.

<LostintheMirror> It may be that the doctor practices mainly biological treatments, in which case you would need to seek someone to work with you in psychotherapy as well.

<donasolakadonalema> How do I explain this disorder to my loved one who wants so bad to help me?

<LostintheMirror> You may want to provide your loved one things to read about BPD. Perhaps even read some of the materials together.

<donasolakadonalema> He thinks I can just stop the symptoms if I try hard enough.

<TimLPN> BadBlue?

<LostintheMirror> Of course, Lost in the Mirror would be one place to start. There are also other helpful books avalilable. The BPD Sanctuary website has lots of resources.

<badblue^> Dr, I would love to stay but my meds are making me very sleepy so sadly I will have to go to bed. I just wanted to thank you for writing Lost in the mirror. It really changed my life. That's all =)

 <tinky94> Dr i am up to 60 mg of prozac a day and it has alway worked

<tinky94> real well till a suicied attemp 6 weeks ago.  now they are wanteing to try me on a different

<tinky94> med and i'm not sure if i want to change....what do you suggest?

<tinky94> does prozac stop working?

<LostintheMirror> Your doctor must have assumed that your suicide attempt was a sign that the Prozac had stopped working. You might try to discuss what you were feeling at the time of the attempt.

<LostintheMirror> It is sometimes difficult to tell the difference between the biological part of the depression and the reactions to circumstances.

<tinky94> the depression came after the attempt

<pippylong> I have been doing everything in my power to bring this disorder to the media and important players. I WILL NEVER GIVE UP and I Thank You, Patty - for creating this website, Tim (who I know nothing about, except you must be an inspiration to Patty and very knowledgeable) and most of all to Dr. Moskovitz - your book has changed my life and I Thank You from the bottom of my heart and soul that you made this disorder REAL!  GOD Bless you all.

<LostintheMirror> Antidepressants can sometimes stop working. Nobody knows exactly why. Sometimes dose adjustments can help.

<LilTrillium> is there any evidence that taking hormonal meds (birth control/estrogen/and the like) have any effect on the severity/frequency of symptoms (i.e. depression, self-destruction, emptiness, identity crisis)?

<LostintheMirror> Yes, but its very complicated. I've seen symptoms get better with birth control pills and other estrogen preparations and I've seen them get worse.

<LostintheMirror> Sometimes BCP's can be helpful in regulating menstrual periods and may modify the worsening of symptoms that can occur premenstrually.

<LostintheMirror> Estrogens can also have positive effects on mood regulation after menopause or hysterectomy.

<poppy___> have you used provigil in your practice, I find it helps me alot

<LostintheMirror> Poppy, Provigil is a brand new drug that has been designed primarily to treat people with excessive daytime sleepiness (narcolepsy).

<LostintheMirror> There are starting to be studies using it for other things (not FDA approved applications). Some are interesting...

<poppy___> I take it to augment my anti-depressants

<LostintheMirror> For example, one study suggested that it was helpful in ADD. Other reasearchers are looking at the possibility that it may have antidepressant effects.

<LostintheMirror> Using it to augment the effects of antidepressants is certainly being studied. I have very little experience with it though so far.

<pattysanc> We can't take any more questions as we only have a few more minutes left.

<pattysanc> Dr., since we only have a few minutes left, after these questions have been answered, can you discuss EMDR and the BPD?

<LostintheMirror> I'm going to go directly to the question of EMDR.

<LostintheMirror> It's hard to address since many people may not know anything about it.

<LostintheMirror> It stands for Eye Movement Desensitization and Reprocessing.

<LostintheMirror> It is a treatment that was designed particularly to treat the effects of trauma. It uses a combination of imagery and eye movements to help people work through the intense emotions associated with memories of traumatic experiences.

<LostintheMirror> I do feel that it has a place in treating BPD since trauma histories are so common among BPD patients.

<LostintheMirror> It must be used cautiously, however...

<pattysanc> I have an appointment for EMDR next month and I will be writing about my experience in the newsletter.

<LostintheMirror> becuase the experience can become very intense at times.

<LostintheMirror> You should have a well established relationship with your doctor.

<LostintheMirror>  And you should already have learned techniques for dealing with emotional pain that help you to control urges to self-harm. EMDR therefore is one piece of a much larger puzzle...

<LostintheMirror> and must be  integrated within the whole treatment, including other aspects of psychotherapy and medications.

<LostintheMirror> I think, incidentally, that EMDR can be a way to learn about the changing nature of emotions, because

<LostintheMirror> feelings can change fairly drastically within minutes during the process.

<pattysanc> Well it is 7:00 and I want to thank Dr. Moskovitz for coming to speak with us. You have been very helpful! I hope you will come back again.

<TimLPN> Thank You Dr Moskovitz For being a Great Guest Speaker!!

<donasolakadonalema> thankyou

<tinky94> thank you Dr

<Sukk> Thank you Dr :)

<Lauranator> very well done......yay

<LadySnafu1972> thanks so much... =)

<LostintheMirror> Thanks. I've enjoyed meeting with you. Now everybody enjoy ER!