I Hate You--Don't Leave Me - Jerold J. Kreisman [87]
Just as most medical specialties (e.g., ophthalmology) have developed subspecialty areas for complicated situations or for the parts of the organ involved (e.g., retina, cornea), optimal treatment of BPD may be heading in the same direction. Specialized centers of care for BPD, for example, featuring experienced, specially trained professionals could offer more efficient treatment regimens.
Chapter Nine
Medications: The Science and the Promise
One pill makes you larger, and one pill makes you small ...
—From “White Rabbit,” by Jefferson Airplane
Doctors are men who prescribe medicines of which they know little, to cure disease of which they know less, in human beings of whom they know nothing.
—Voltaire
While psychotherapy is the recognized primary treatment for BPD, most treatment plans include recommendations for inclusion of drug therapy. However, medications often present highly charged dilemmas for borderline patients. Some are bewitched by the alluring promise of drugs to “cure” their “borderline.” Others fear being transformed into zombies and resist any medication. As scientists have not yet isolated the borderlinus virus, there is no single “antibiotic” that treats all aspects of BPD. However, medications are useful for treating associated symptoms (such as antidepressants for depression), and for taming self-defeating characteristics, such as impulsivity.
Despite Voltaire’s plaint, doctors are learning more and more about how and why medications treat disease. New discoveries in the genetics and neurobiology of BPD help us understand how and why these medications can be effective.
Genetics
Nature-nurture arguments about the cause of physical and mental disease have raged for decades, of course, but with the expansion of knowledge of heritability, gene mapping, and molecular genetics over the past quarter century, the role of nature has become better understood. One approach to this controversy is through the use of “twin studies”: in this type of study, identical twins (possessing the same genetic makeup) who are adopted into different households are examined years later for the presence of the disease. If one twin exhibits BPD, the likelihood that the other, reared in a different environment, will also be diagnosed with BPD is as much as 35 percent to almost 70 percent in some studies, thus giving greater weight to the nature argument.1 Specific borderline traits, such as anxiety, emotional lability, suicidal tendencies, impulsivity, anger, sensation-seeking, aggression, cognitive distortions, identity confusion, and relationship problems, can also be highly genetic.
Heritability also extends to family members. Relatives of borderlines exhibit significantly greater rates of mood and impulse disorders, substance abuse, and personality disorders, especially BPD and antisocial personality.2
Our humanness emerges from the elaborate and unique chain of chromosomes that determine the individual. Although one specific gene alone does not determine our fate, a combination of DNA codings on different chromosomes do contribute to vulnerability for illness. Individual genes have been associated with Alzheimer’s disease, breast cancer, and other maladies; however, other chromosomal loci and environmental factors also contribute. Molecular genetics has identified specific gene alterations (polymorphisms) that are associated with BPD. Interestingly, these genes are involved with production and metabolism of the neurotransmitters, serotonin, norepinephrine, and dopamine. These neurotransmitters facilitate communication