Borderline Personality Disorder
Borderline personality disorder (BPD), is a serious mental illness, though less commonly known than schizophrenia or bipolar disorders. It is a form of pathology lying on the border between psychosis and neurosis. Persons with borderline personality disorder often exhibit intense bouts of anger, depression and anxiety. This may last for hours or sometimes a day. Impulsive aggression, self injury, abuse of drug and alcohol are some other symptoms.
BPD sufferers primarily see the world as extremes, either black or white. They either idealize or vilify everyone they meet. They veer between idealized love and distressing hatred and misery. They are known to develop sudden and stormy attachments toward family, friends and loved ones. Their emotions range from great love to intense hatred.
Usually, the diagnosis of BPD on these parameters is done on adults and not on children as signs and symptoms of BPD may go away with maturity. For diagnosis of BPD, five signs should be significantly present:
According to statistics, dementia affects about 36 million people globally and about 10% of people develop the disease at some point in their lives. It becomes more common with age. As more people are living longer, dementia is becoming more common in the population as a whole. Also known as Senility, dementia is a broad category of brain diseases that causes gradual decrease in the ability to think and remember. It is a collective term that is used to describe various underlying brain disorders or damage that can lead to memory loss, language and thinking.
While the likelihood of dementia increases with age, it is not to be misunderstood with normal part of aging. Light cognitive impairments and poorer short-term memory can happen as normal part of aging and this is known as age related cognitive decline and not dementia.
Alzheimer's disease is the best known and most common form of dementia, although there are others types including Vascular Dementia, Lewy Body Dementia and Frontotemporal dementia.
The loss or damage of nerve cells or neurons in the brain can cause dementia. Alzheimer's disease is the leading cause. Dementia can also be caused by head injury, a stroke or brain tumor. Brain cell death caused by conditions such as cerebrovascular disease like stroke can cause vascular dementia. This prevents adequate blood flow, depriving brain cells of oxygen.
Post traumatic dementia is directly related to brain cell death caused by injury. Some repetitive injuries suffered by sports players are linked to certain form of dementias appearing later in life. Dementia can also be caused by diseases such as Prion disease, from certain types of proteins, HIV infection, medication interactions, depression and vitamin deficiencies. A small proportion of dementia cases run in families.
Signs and symptoms
Other than the decrease in the ability to think and remember even daily functions, some common symptoms of dementia are:
The first thing is to assess memory performance and cognitive health. A healthcare professional would ask a set of questions to test knowledge of facts that should be known to any adult to get an indication whether there is dementia or not. The patient is asked to complete the standard tests, and answers are recorded to form a diagnostic indication. Tests to assess a person's mental ability are conducted and test scores are ascertained. Questions such as 'What is your age', 'What is the time', 'What is the year', Counting 20 backward etc are asked. One task for the patient is to write the hours of a clock face around a blank circle on a piece of paper and with accurate relative spacing. These cognitive tests measure dementia symptoms and other tests help to narrow down, if for example, it is Alzheimer's disease.
As brain cell death cannot be reversed, there is no known treatment to cure a degenerative cause of dementia symptoms or fully halt its progress. The aim is to provide care and treat symptoms rather than their underlying cause and manage the disorder. If dementia symptoms are due to reversible, non-degenerative cause, treatment is possible to prevent or halt further brain tissue damage.
Symptoms of Alzheimer's can be reduced by drugs to improve the person's quality of life. Educating and providing emotional support is imperative. Exercise programs are beneficial. Treatment of behavioral problems of psychosis with antipsychotics is not usually recommended due to increased risk of death.
Other than age which is the biggest predictor of dementia, certain risk factors are modifiable. These risk factors include:
Depression is a very common medical disorder that affects every 1 in 5 individual in the U.S. It is often said that depression results from chemical imbalance in the brain, either too little or too much of certain chemicals in the brain. Factors that lead to chemical imbalance could be one or a combination of recent events, past issues, genetic vulnerability, medications, medical problems etc.
Antidepressants, as the name suggests treat depressants. About 50% of people who take antidepressant find their depression symptoms halved. The first antidepressant drug was Imipramine (Tofranil). It was marketed in 1958. Today, there are close to 30 antidepressants that are grouped into five categories. Each has different chemical structures to treat moderate to severe depression.
Types of antidepressants
There are five main types of antidepressants. They differ in the neurotransmitters they affect.
1. Monoamine oxidase inhibitors (MAOIs)
2. Serotonin and norepinephrine reuptake inhibitors (SNRIs)
3. Selective Serotonin Reuptake Inhibitors (SSRIs)
4. Tricyclic antidepressants (TCAs)
5. Atypical antidepressants
Under these five types of antidepressants, there are around 30 antidepressant medicines. They are grouped based on how they work. Each antidepressant is different and affects different systems of the brain to different degrees. Considering the difference to be as small as 3-4%, it can have an enormous impact on an individual to alleviate depression symptoms.
Patients respond to antidepressants differently. Some may respond to or tolerate one antidepressant and not respond to or tolerate another antidepressant. Each antidepressant has different use, adverse effects and drug interactions. Prescription of anti-depressants is based on the symptoms, patient's age, family history, drug tolerance, side effects and past response to antidepressants.
Monoamine oxidase inhibitors (MAOIs)
How MAOIs work: When depressed, the brain chemistry is impacted. The level of three neurotransmitters, norepinephrine, serotonin and dopamine is low. Collectively, these three are called monoamines. An enzyme called monoamine oxidase is linked to removing the three neurotransmitters from the brain.
Antidepressants such as MAOIs inhibit monoamine oxidase and allow more of the three neurotransmitters to remain in the brain. The levels of the chemicals rise. This elevates mood as there is improved brain cell communication.
MAOIs have been replaced by antidepressants that are far safer and cause fewer side effects. MAOIs carry the risk of considerable side effects and drug interactions.
The Food and Drug Administration has approved these MAOIs to treat depression.
Of the four, Selegiline (Emsam) is a skin patch approved to treat major depressive disorder. The other three are available as oral medications.
Side effects of MAOIs
MAOIs carry the risk of considerable side effects and drug interactions. Hence, MAOIs are prescribed when other depressants fail to provide desired results.
Common side effects of MAOIs are dry mouth, nausea, diarrhea or constipation, headache, drowsiness, tiredness, weakness, insomnia, dizziness or lightheadedness, skin reaction at the patch site.
Other possible serious side effects include fainting, mental/mood changes, muscle stiffness, swollen ankles and legs, involuntary muscle jerks, shaking (tremor), low blood pressure, reduced sexual desire, sudden weight gain, eye pain, double/blurred vision, difficulty starting urine flow, muscle cramps, prickling or tingling sensation in the skin.
MAOIs interactions with other medicines
When two or more drugs interact, it can reduce the efficacy of the drug. Possibility of unexpected side effects is high. Knowing drug interactions is critical for your health. It is best to discuss with health care provider before taking MAOI anti-depressant medication.
MAOIs can cause serious reactions if taken with certain other drugs.
MAOI interaction with other antidepressants
MAOI interaction with asthma medicines
MAOIs interact with cold, cough, allergy, sinus, decongestant and hay fever medications. The medicines can be in the form of tablets, ointment, sprays or drops.
MAOIs interaction with diabetes medicines
MAOIs interaction with medicines to treat low blood pressure.
MAOIs interaction with medicines to treat high blood pressure.
MAOIs interaction with mood-stabilizer medicines
MAOIs interaction with pain-killers and anesthetic medicines.
MAOIs interaction with sedatives and tranquilizers
MAOIs interaction with stimulants and street drugs
MAOIs interaction with weight loss and appetite suppression medication
MAOIs interaction with other MAOI medicines
MAOIs interaction with food and beverages
MAOIs with certain foods and beverages can cause dangerous interactions. It is best to consult your doctor for a complete list of foods and beverages to be abstained from. Take for example tyramine, an amino acid which occurs naturally in the body and helps regulate blood pressure. When MAOI is recommended, foods and beverages with tyramine should be restricted as it can quickly reach dangerous levels and spike blood pressure.
MAOIs are not the first choice
MAOIs are prescribed only when all the other anti-depressants don't work. It's mainly due to the 'cheese effect'. The connection is established. Yes, those who ate products containing cheese while on an MAOI experienced severe headaches. Further, MAOI is not recommended for children or teenagers.
MAOI is given to people:
MAOI and psychotherapy
MAOI works best when paired with some form of psychotherapy. An antidepressant alone would not suffice to meet the behavioral, emotional or underlying mental health issues. A qualified psychotherapist can help in coping with the condition.
SNRIs type of anti-depressant
How SNRIs work: Serotonin and Norepinephrine Reuptake Inhibitors affect two important brain chemicals, serotonin and norepinephrine. Serotonin is regarded as a 'feel-good' chemical. It is associated with positive feelings of wellbeing. Norepinephrine is associated with alertness and energy. An imbalance can cause depression.
SNRIs block the reabsorption (recycling) of the neurotransmitters in the brain. Reabsorption is going back into the cells that released them. When reabsorption happens, the levels go down. When SNRIs block reabsorption, the levels of the two neurochemicals increase and helps improve and elevate mood, enhances the alertness of the person experiencing symptoms of depression.
This type of anti-depressant is also called dual reuptake inhibitors or dual-acting antidepressant as they affect two important brain chemicals-serotonin and norepinephrine. The Food and Drug Administration has approved these MAOIs to treat depression.
SNRIs interaction with other medications
Interactions between medicines can cause reactions which can be life-threatening. Before taking an anti-depressant, inform doctor of any/all medicines being taken. SNRIs interact with medicines like:
Besides some medicines, intake of certain substances as given below, can increase the toxicity of SNRIs.
Side effects of SNRIs
Compared to other types of anti-depressants, SNRIs have fewer side effects. In most cases, the side effects go away after few days or weeks of taking SNRIs. Anti-depressant medications take four to six weeks to start working.
It is always best to inform the doctor of any side effect if experienced while taking any antidepressant. While taking an anti-depressant, it is not necessary for the patient to experience all the side effects. It may be any one or a few of these side effects.
Women who are pregnant or thinking of becoming pregnant and breastfeeding mothers should let the healthcare provider know while being prescribed an anti-depressant medication, including SNRIs.
Serotonin syndrome may occur when the levels of serotonin in the brain reaches high levels. It is triggered when an SNRI antidepressant is taken with another drug with high levels of serotonin (example – St.John's wort). Seek emergency medical help. The symptoms of severe serotonin level rise are very high fever, seizures, irregular heartbeat and unconsciousness.
Seek immediate medical attention, if while taking SNRIs, the patient:
1. Has abnormal bleeding
2. Has suicidal thoughts or behavior
3. Blood pressure levels rise (may increase when taking SNRIs)
4. Pressure of the fluid inside eye changes (narrow angle glaucoma)
Contraindication of SNRIs
Two SNRIs, namely Duloxetine and Milnacipran (approved to treat Fibromyalgia) is contraindicated in patients with uncontrolled narrow angle or angle-closure glaucoma. SNRIs can cause liver problems, including hepatitis. SNRIs are not recommended for people with liver problems and kidney problems (renal failure).
There is a high possibility of SNRIs affecting activities requiring mental or motor concentration. At least for the first few days or till such time the patient is accustomed to the effect, it is best to have family or friends or paid support.
Tricylic antidepressants (TCAs)
Also known as cyclic antidepressants or TCAs, this type of antidepressant is best suited for patients and is prescribed by doctor only when other drugs have failed to treat depression. TCAs are similar to SNRIs. TCAs increase levels of norepinephrine and serotonin, the two neurotransmitters and block the action of acetylcholine, another neurotransmitter. By restoring the balance in the brain Tricyclic antidepressants alleviate depression.
FDA approved Tricyclic antidepressants are:
Besides these, Maprotiline is a Tetracyclic antidepressant that is FDA approved to treat depression.
Side effects of Tricyclic antidepressants
40% of people taking antidepressants have side effects. Initially in most cases, the side effects may cause problem but would improve with time. Benefits of treatment outweigh the initial problems.
Tricyclic antidepressants are associated with many side effects. This is a reason why doctors prescribe other antidepressants with fewer side effects. Side effects are due to the interference of tricyclic antidepressants with autoimmune nervous system. Common side effects of TCAs are:
It is best to seek medical attention if the person experiences symptoms like:
Drug interaction includes interaction of drugs with other drugs, interaction of drugs with food (drug-food interaction) and other substances. The interaction may increase or decrease the effectiveness of the drugs and/or its side effects. Sometimes, the interactions may lead to psychological sufferings.
Prior to starting treatment with any medication, including antidepressant, make a list of all the medications being taken and provide it to the health care provider.
While taking TCAs it is best not to drink alcohol, as it can add to the side effects. People who have seizures, difficulty urinating, glaucoma or heart conditions (coronary heart disease) the symptoms can get worse.
SSRIs or Selective serotonin reuptake inhibitors
Of the different types of antidepressants for depression, SSRIs or Selective Serotonin Reuptake Inhibitors are most commonly prescribed. SRIs are relatively safe and have fewer side effects.
SSRIs ease symptoms of moderate to severe depression by increasing the levels of serotonin in the brain. Serotonin is one of the chemicals (neurotransmitter) that help to relay messages from one area of the brain to another. Serotonin is believed to influence a variety of psychological and other body functions. An imbalance in serotonin levels may influence mood and lead to depression. Low brain cell production of serotonin, a lack of receptor sites to receive the serotonin that is made, inability of serotonin to reach the receptor sites, shortage of tryptophan – chemical from which serotonin is made, any of these can lead to depression.
SSRIs are designed to boost serotonin levels. This enables production of new brain cells which in turn allows the depression to ease. SSRIs are called selective as they primarily affect serotonin and not other transmitters. SSRIs approved by the FDA for the treatment of depression are:
SSRIs and drug interaction
SSRIs are subject to extensive oxidative metabolism (a chemical process wherein oxygen is used to make energy from carbohydrates) in the liver. Drug interactions with SSRI are either due to overdosing of the drug combined.
Foods or substances to avoid while taking SSRIs
SSRIs are not suitable for people with certain medical conditions. While an antidepressant medication is being prescribed, the health care provider should be informed if the patient has any of these medical conditions to weigh the benefits vs. risks.
Side effects of SSRIs
The object of knowing side effects of any medication is to be aware of what to expect and to work out a strategy to continue medication and speed up recovery. Though SSRIs are the most commonly prescribed antidepressant, their side effects cannot be ignored.
All SSRIs tend to work in a similar way. But the active ingredient differs. Some people may experience side effects and some people may not. And even if experienced, common side effects of SSRIs are most likely to improve after few doses once the body adjusts to the medication. Talk to health care provider to know possible ways of reducing these side effects. For example, taking medication with food can reduce risk of nausea.
There are risks associated with taking any type of antidepressants during pregnancy. The medication does cross the placenta and are found in both amniotic fluid and breast milk. Associated risks are preterm birth, low birth weight, birth defects and delays in developmental milestones. The health care provider would recommend use of antidepressant during pregnancy based on the balance between risks and benefits. SSRIs have the best safety record. To treat depression during pregnancy SSRIs like Citalopram (Celexa), Fluoxetine (Prozac) and Sertraline (Zoloft) are recommended by health care providers.
How it works: Typically, these antidepressants do not fit into other types of antidepressants. Each atypical antidepressant is unique and works in a different way to treat depression. Atypical antidepressants are recommended for patients with major depression with inadequate responses or intolerable side effects during first-line treatment with SSRIs.
The link between the three main monoamine neurotransmitters in the brain i.e. dopamine, norepinephrine and serotonin and depression symptom is certain. Increase or decrease of specific neurotransmitter brings about specific symptoms which in turn suggest that depression can be assigned to specific neurochemical mechanism. Accordingly, doctors prescribe specific antidepressant drug that target symptoms-specific neurotransmitters to treat patient.
Atypical antidepressants work in this manner by effecting changes in brain chemistry. They change the levels of one or more neurotransmitters, such as dopamine, serotonin or norepinephrine. Changing the balance of these chemicals help brain cells send and receive messages, which in turn boosts mood and provide a sense of relaxation.
Atypical antidepressants approved by the FDA to treat depression are:
Side effects of atypical antidepressants
Some patients may not experience any side effect. Those who experience can feel assured that it may go away after a time. In case it persists, the health care provider may prescribe a different medication. Each atypical antidepressant is unique, side effects too vary.
Atypical antidepressants can cause some problems in some circumstances. While atypical antidepressant is prescribed for treatment of depression, the patient should inform the healthcare provider of any health issues and related medicines being taken.
Atypical antidepressant - Drug and food interaction
Certain drugs or substances may increase blood levels and toxicity.
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Bibliography / Reference
Collection of Pages - Last revised Date: January 30, 2023