Meds and personality

“Medications should not be used as the primary treatment for BPD as the benefits are unclear.” -- https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

Today I’m going to talk psychiatric medication from a position of full ignorance about meds other than the elementary facts a counselor absorbs. Logic, of sorts, will co-opt knowledge. A client with Borderline Personality Disorder has been medicated for the past thirty days with a mood stabilizer and an antidepressant. Their effect has been injurious, she says. What had always been verbal aggression transformed into physical violence. Micro-dissociations and amnesias occurred throughout the day – locking her keys in the car three times in one afternoon; forgetting to go to work the entire day, thinking it was the weekend. More “borderline-ish” extremes than usual. The client had come to her Psychiatric Nurse Practitioner with two diagnoses – Bipolar II (from a doctor) and Borderline (from a family member’s Internet research) – along with my first-glance diagnosis of the personality disorder. Looking for the quarter beneath a street lamp rather than in the dark alley where it was lost, the NP prescribed only to the Bipolar and hoped for the best.

In session, we worked a thought experiment. Give a baseline “normal” person a mood stabilizer and Xanax – or two beers, for that matter – and he may react more benignly toward a slow or unsolicitous waiter. Give the same drugs to a Narcissistic Personality. Would he react so temperately to the waiter’s behavior? I suspect the Narcissist would be as entitled and arrogant as ever. He might even be worse, with his feeling of intrinsic “unique specialness” – critical to inflate his prosthetic ego – chemically flattened.

Or – Imagine giving Jeffrey Dahmer an antidepressant to deal with his ‘anger’ (catch-all term for the bad, monstrous feelings of a psychopathic Antisocial Personality). Do you think this would stifle his cannibalistic urges and the view of life that supported them? The logic of a personality disorder says the serial killer’s moods are not simply chemicals in his brain, but chemicals embedded in his formative identity – the “psychological birth of the human infant.”*

From a progress note on my Borderline: We looked at possible reasons for the difficulty of medicating her personality disorder, based on the understanding that Borderline has its origin in the dys-formative mother-child bond and creates a “full-body chemistry” that supports the global warp of the personality. From this perspective, it seems likely that there would be greater difficulties in medicationally addressing symptoms that have an “identity basis.” We considered an example: Her mother was aware that as a child, her daughter had to create chaos (which might be seen as a cry for justice or help – to unmask the “cover-up” of rightness and OKness): When things were going smoothly, she would invariably “scrape the needle across the record.” Forcibly numbing or “chemically lobotomizing” (Breggin) the feelings behind this need would create a psychic turbulence that was even more uncomfortable – the equivalent of putting a straitjacket on someone running from a wolf.**

We all know that psychiatric medications have different effects on different people (no perceptible effect, to life-saving, to suicidal and homicidal, to the stripping of one’s emotions or one’s conscience) just as alcohol does. Here I’m saying that one reason for this difference is the chemistry of personality, which could be considered the global, seamless defense that has become the Self. To medicate the person is to change this radical survival Self into – it must be said – the non-self. How could that feel right to anybody?

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* Borrowing the title of Margaret Mahler’s seminal book that deals with “separation and individuation” of the self.

** Borrowing from the title of Theresa Sheppard Alexander’s book, Facing the Wolf – Inside the Process of Deep Feeling Therapy.