Tara Peyman, ND
Borderline personality disorder (BPD) is one of the most challenging conditions to manage in practice. Some physicians believe that this disorder does not respond well to medical treatment. However, I have found that patients with BPD can experience dramatic improvements in mood stability using homeopathic medicine alone. If homeopathic treatment is paired with dialectical behavior therapy (DBT), the patient can enjoy long-term relief and permanent improvements in behavior.
One of the most difficult aspects of managing these patients is the continuous idealization alternating with devaluation of others, causing a persistent pattern of instability in relationships. The patient will typically idealize the physician on first meeting him or her and soon after will become offended by some interaction and flip into a state of hating the physician and suddenly wanting to quit treatment. Other challenging aspects are the hypersensitivity to perceived abandonment and the rapidly fluctuating intense moods, leading to unpredictable behavior or threats of suicide. Despite these potential problems, BPD is readily treatable with naturopathic medicine. When I discovered how effective homeopathic treatment is for relieving the symptoms of this condition, I realized that, rather than letting ourselves be intimidated by its challenges, we can provide a desperately needed service to this population of patients.
Diagnostic Considerations and Differentials
Most patients with BPD whom I have seen in practice come in for their initial visit with an inaccurate diagnosis. Most are misdiagnosed as having bipolar disorder, others are misdiagnosed as having depression and anxiety, and some have multiple other mental health diagnoses. I ask several specific questions during my new-patient intake to sufficiently differentially diagnose BPD from other conditions that cause similar symptoms.
One of the most helpful questions is regarding triggers and timing of emotional distress. I ask about patterns of mood episodes. For someone with an episodic mood disorder, such as recurrent depression or bipolar disorder, episodes will usually last for weeks or months at a time, often triggered by changes in seasons or significant stress. Many individuals have depressive or manic episodes even if nothing is wrong in their life. For patients with BPD, they will usually be unable to report a natural internal pattern. For them, emotional distress is almost always triggered by external situations, and there are much faster and less predictable changes in mood.
I always ask about significant shifts in energy and need for sleep. For individuals with bipolar disorder, there is persistently high energy and decreased need for sleep during manic episodes. For those with BPD, they typically say that they always feel tired. Many patients having BPD experience anxiety with insomnia, which can be misdiagnosed as mania, but actual energy levels are still low. They might tell you that they feel nervous and exhausted at the same time and that they never feel rested.
Another good question to ask is concerning stability of relationships. Look for patterns of idealization alternating with hatred in relationships. Ask about previous physicians the patient has seen, and ask why the patient stopped seeing their previous physicians, if applicable. Individuals with BPD experience intense fears of abandonment, which lead to self-sabotaging behavior and severing ties to attempt to avoid feeling hurt by others. Unfortunately, this pattern leads to more isolation and emotional distress. Patients with BPD will classically tell you: “I get hurt too easily. I have serious abandonment issues. I always feel lonely, but I can’t seem to stay in a relationship long enough to make that feeling go away.”
An important consideration when differentially diagnosing is that there is sometimes a dual diagnosis for patients with BPD. Substance abuse is common in this population. The patient will sometimes fit the diagnostic criteria for BPD, but there may be symptoms and signs that are not covered by this condition and require an additional psychiatric diagnosis. We have to be sufficiently thorough in our medical intake process to establish the most accurate diagnosis. This way, the physician and the patient are well informed about what to expect over time and about which treatment options are most indicated.
Case Study Using Natrum muriaticum
Because of my niche in treating bipolar disorder, I end up seeing a large number of BPD cases. I always use homeopathic treatment because I find that it has the best effect in the shortest amount of time. When prescribed well, homeopathic treatment often works when allopathic drugs fail to improve mood and behavior in patients with BPD.
Elizabeth was 42 years old when she presented to my office with concerns about severe emotional instability. She described herself as an “emotional extremist.” She would overreact to little things with severe anger and then feel totally disabled with anxiety or sadness just a few minutes later. She had been previously diagnosed as having bipolar disorder, attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and anxiety. She was unresponsive to allopathic mood stabilizers. My first goal was to determine an accurate diagnosis for her case.
I concluded that Elizabeth in fact had BPD, attention-deficit/hyperactivity disorder, and posttraumatic stress disorder. Her attention-deficit/hyperactivity disorder had started in early childhood and persisted throughout her adult life. She had found it almost impossible to complete tasks that she started or to remember what she was going to do from one moment to the next. With her attention-deficit/hyperactivity disorder, she was restless, inattentive, and forgetful. She would become angry with herself for not being able to remember things. These problems with her inability to focus caused low self-esteem and self-consciousness. She became fearful that she would fail at everything she tried.
Also at a very young age, Elizabeth had been severely sexually abused and emotionally neglected by her family. She developed the belief that she was unloved, and she felt abandoned. She was angry with the person who repeatedly assaulted her as a child, and every day she would think hateful thoughts about him, dwelling on how she wanted him to pay for what he had done to her. She experienced posttraumatic stress disorder symptoms of flashbacks, insomnia, nightmares, and physical tension when anything reminded her of the abuse.
Elizabeth was highly sensitive to criticism, so much so that she would feel overwhelmed with anxiety and anger if her husband made a small comment about her behavior. Her anger from feeling criticized then led to yelling, crying, and a desire to run away and be left completely alone. In addition to her primary symptoms, she was generally aggravated by the heat of the sun, was highly sensitive to noise, and craved salt and bread.
I prescribed Natrum muriaticum 6C, 2 pills once daily. I spoke with Elizabeth about 1 week after she started the homeopathic medicine, and she reported that she felt emotionally stable for the first time in years. She was able to concentrate and get things finished without needing lists to keep her mind on track. She felt like her mind was more clear and calm. She was much less sensitive to criticism and felt more relaxed overall. She has only needed Natrum muriaticum, at a few different potencies over time, to keep her moods stable and her mind clear. With this one simple therapeutic intervention, she told me that she felt like she was finally getting her life back.
Management Issues and Referrals
Usually, the easiest part of treating BPD is taking the case and starting your protocol. The real challenge comes with managing a patient’s emotional distress and insecure attachment issues over time. I have found that with the right remedy the patient feels so much better I have rarely been the target of the “I hate you, don’t leave me” attitude that can arise with this condition. Of course, it has still happened. One of my patients who has BPD and narcissistic personality disorder traits has been particularly cruel to me at times. It is essential not to take these outbursts personally because, if you do, you fall into the trap of the patient’s insecure attachment issues and become part of the problem. I have found a few techniques to be helpful in managing these concerns.
First, Protect Yourself by Maintaining Perspective
Remember that your patient is suffering and that his or her erratic behavior is an expression of this, which is not your fault. It is easy to feel responsible for the emotional distress that arises with these patients. Take a step back, and remember that this behavior is part of the patient’s illness and that you are a physician, not a savior. With enough compassion, you can see through a patient’s cruel behavior and find that he or she is just hurting.
Second, Draw the Line
Individuals with BPD have a difficult time with boundaries. Establish clear guidelines for the patient about how to contact you between visits, and inform your office staff of these rules. Be transparent with your visit fees. Let the patient know what to expect in terms of when you can return phone calls. These small details can make or break a successful patient-physician relationship in cases of BPD. Being clear on these issues also helps your practice run smoother in general, so everyone benefits.
Third, Use the Golden Rule
Always treat patients with respect, no matter how abusive they are to you. As long as you are their physician, you are at their service, and they deserve respectful treatment. Universally, individuals with BPD have felt hurt and dejected in most of their relationships, so let this one be different. Show them that it is possible to feel unconditionally cared for, whether they feel angry, sad, or anxious. Let them know you truly are there for them, and then go back to rule 2 and make sure they understand the rules of this professional relationship, so they can learn to be respectful of you too.
Finally, one of the most important aspects of BPD is fear of abandonment. If you want your patient to start DBT as an adjunct to your care, it is vital that the patient must know you are not abandoning him or her by making this referral. In contrast, you are providing the best resources possible to help the patient feel better. I used to believe that DBT was crucial in the treatment of BPD. I have since learned that homeopathic medicine alone can treat the disorder. However, with DBT skills training, patients relapse less often and find more permanent relief. I always refer my patients with BPD for DBT, but now I feel more confident in the knowledge that what I have to offer can be enough. Just recently, I had 2 new patients with BPD who have started homeopathic treatment, and both are showing tremendous improvements in the first few months of taking their remedies. This was a relief to me to dispel the myth that patients with BPD do not respond well to medical treatment. With compassion, patience, and a disciplined approach, we can help bring peace and health into the lives of individuals who otherwise would continue to suffer.
Tara Peyman, ND is a licensed naturopathic physician with an expertise in the homeopathic and integrative treatment of bipolar disorder and mental illness. Dr Peyman mentors students and physicians who have an interest in learning her methods of managing bipolar disorder. She practices at Arizona Natural Health Center, in the Phoenix area. She offers a free 15-minute consultation for patients. Visit www.AZNaturalHealth.com for more information.
References
Gunderson PG, Links PS. Borderline Personality Disorder: A Clinical Guide. Arlington, VA: American Psychiatric Publishing; 2008.
Linehan M. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press, 1993.
