Q. I am a social worker. Currently, I am working with two individuals that have been diagnosed with borderline personality disorder. However, this particular disorder, is secondary to their Axis I diagnosis of schizoaffective disorder. One of my clients, has been diagnosed with the following; schizoaffective disorder, major depression with suicidal ideation and borderline personality. My question is, what series of medications do you think will work best for this individual? Furthermore, do you have any advice as to how to I can stop this woman from engaging in self injurious behavior (cutting), as I am having difficulty keeping her out of the hospital. Any advice that you can provide would be greatly appreciated.

A. Self injury is the best prognosticator for response to medications. So for starters, you have what are medially easy borderlines to work with. Do not flip out over the self-injury. They do it because it makes them feel better. Self-injury does not necessarily equal suicidality. They are part and parcel of the same disease, like fever and cough with the flu, but not the same symptom.

The diagnoses in DSM-IV are largely irrelevant. I know that is heretical, but it is true. Axis I, II and III are all the same in most cases. None cause the other. Instead, they flow from the same chemistry. Most borderlines have headaches, PMS, anxiety, migraines, TMJ, and so on. They are all symptoms of the same illness. Do not teat any as more important than any of the others. Truth be told, other than malpractice (a big issue) suicidality and panic and headaches are all interchangeable chemically in any individual. Your treatment should address everything.

Since most borderlines are also schizotypal (about 60%), the diagnosis of schizoaffective is likely just depression with psychosis. We know borderlines get psychotic as well as schizotypes. I would treat your clients as borderlines from a medication perspective. If they have carbohydrate craving, dose their medications (Zoloft, Prozac, Effexor, Luvox, Celexa, or Serzone) until carbohydrate craving goes away. Only use Serzone if they have no OCD. Simple on paper, hard in real life. I reviewed BPD treatments in the book Impulsivity and Aggression edited by Eric Hollander and Dan Stein published about 5 years ago if you need a reference. It is in the CV on this web site for specific details. Medicate, medicate, medicate. Then make sure you medicate adequately. Cannot treat a chemical illness by talking to it. Therapy is always after you fix the physical deficit, not before.

If you have no access to a doctor, be cognitively supportive. Borderlines do exactly what they are supposed to do based on their chemistry. It is impossible to change them much without changing the chemistry back to a more normal level. I like rational emotive therapy because it is black-white in structure, which is perfect for borderlines since they think in a black- white fashion.

Lastly, no borderline ever gets totally back to normal. Heck, nobody is totally normal. Borderlines have a certain slant on the world, and it never changes to a highly flexible, rational, well-thought-out, view of the world. Assess where they are, where they want to go, and help them get there as best possible based on their abilities. Do not try to make them think differently, just maximize their abilities. My golf pro did this with me. I never was, nor never could get into single digits with my handicap. I did go from a 22 to a 12. Borderlines can have their handicaps reduced, but will never be scratch golfers. That is okay, though, because there just are not many scratch golfers in the world.