I. 5 . Although mood stabilizers, antipsychotic

I.                  
Introduction

Prescribing
psychotropic medications for persons with Borderline Personality Disorder (BPD)
can be complicated by both medical and psychological concerns.  BPD is commonly co-morbid with other
psychiatric disorders such as depression and post-traumatic stress disorder
that are commonly addressed with psychotropic medications in addition to other
non-psychiatric medical problems 1
2 3 4.  Also, people with BPD may
be more sensitive to medication side-effects and to the interpersonal dynamics
with the medical professional prescribing their medication. We propose that
alongside the current best evidence for prescribing in BPD, an awareness of the
aforementioned issues can inform a flexible approach to work with BPD patients,
and is most likely to yield positive outcomes.

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            People suffering from Borderline Personality Disorder (BPD) are
often prescribed a large number of psychotropic medications as a result of
intense affective and psychotic symptoms, concerns over self-harm  and impulsive behavior or even a sense of
helplessness in the prescribing provider 5
. Although mood stabilizers, antipsychotic medications and antidepressants can
reduce the intensity of symptoms, their benefits need to evaluated frequently
due to the transient nature of these symptoms and due to the exquisite
stress-sensitivity of persons with BPD 5.
Further, medications may be less safe in the context of impulsive substance use
and/or self-harm. Hence, for people with BPD the risk-benefit ratio of
medications may fluctuate significantly in a short period of time.

            Prescribers may hesitate to reduce
psychotropic medications due to lack of time for conducting these discussions
with the patient, inadequate training, a ‘fear of rocking the boat’ and often
due to the absence of a framework for implementing this process. In this paper,
we attempt to fill this void by using the framework of deprescribing to parse
medication regimes to the minimum helpful treatment. Deprescribing is an
intervention originally described in geriatric medicine and involves the
reduction and/or cessation of medications whose current or potential risks may
outweigh their current or potential benefit keeping in consideration the
patient’s medical and functional status as well as values and preferences 6. The process of deprescribing has
recently been expanded for use in psychiatry 7 and strong arguments have been made for its utility in
children and adolescents on psychotropic medications 8. Using a case example in this paper, we
demonstrate how deprescribing may be further modified for use in the patient
with BPD.

 

II.               
Case history

We begin with
an example of a case developed based on a series of patients we have worked
with.

Jackie,
a 27-year-old single woman, presents to your clinic after discharge from the
psychiatric hospital.  She is a slightly
overweight, casually dressed young woman. 
She is glad you were willing to see her so quickly and asserts that she needs
her medications sorted out as the inpatient doctors did not pay attention to
what she was saying.  She asks to be
restarted on dextroamphetamine, clonazepam, and fluoxetine in addition to the
valproate and quetiapine that she is already taking. She adds that you seem
like the kind of doctor who will really listen.

 

Records
indicate that Jackie was admitted for a possible suicide attempt.  She had taken 4mg of clonazepam together with
four shots of vodka after an upsetting phone call with her long-distance
husband.    She endorsed feelings of
emptiness and worthlessness that worsen with relationship problems, and feeling
desperate to communicate her strong feelings to the people she loves.  Though people initially seem to understand,
they often leave her feeling alone and betrayed.  In those situations, she finds herself
feeling odd, as though she’s not part of the world everyone else is living
in.  She daydreams about ways to kill
herself, and has discovered that digging into her upper arms with her
fingernails is somehow relieving. 
Physical exam revealed rows of half-moon shaped marks on both her
forearms.

Table
1 here

 

III.            
Treatment of Borderline Personality Disorder

 

a.      
Brief review of symptoms in BPD

Borderline
Personality Disorder is a common mental health problem. Prevalence is estimated
at 1-5% in the general population and ~20% in mental health clinics 9,10 11 . The natural history of
the disorder is for symptoms to lessen over time, but functional recovery lags behind
symptom relief for many 12.  Many people afflicted by BPD suffer chronic
suicidality 13
and make repeated suicide attempts 14
12. Five to ten percent of
people with BPD ultimately complete suicide 12,14 – that is nearly 50-fold the suicide rate of people in
the general US population 15.

Symptoms that
may suggest BPD should prompt further investigation: symptoms and relevant
questions are reviewed in Table 1.
Affective instability (mood fluctuations across minutes to hours rather than
over weekly or months as in primary mood disorders) is a highly sensitive
single-item screener for BPD: negative predictive value is 99% in a large
community outpatient mental health sample 16.
For further investigation of positive screens, standardized scales can be
helpful, such as the Diagnostic Interview for Borderline Personality Disorder,
a semi-structured interview, 17, the SCID-2 self-report questionnaire (15
yes/no BPD questions) 18,19, and the Borderline Symptom List (23 BPD questions scored on a 5
point likert scale)  20, among
others. To distinguish BPD from syndromes that share similar experiences, it
may be especially helpful to identify symptom fluctuations that occur in
response to interpersonal problems, such as affective changes as discussed
above and psychotic symptoms of brief duration (sometimes termed
“micro-psychotic” episodes”) 21 22
23 24.

Jackie fulfills several criteria for a diagnosis of BPD (Table 1);
She experiences mood instability, anger, dissociative episodes and often
demonstrates impulsivity, interpersonal problems and suicidal or self-injurious
behavior.

b.     
Treatment approaches for BPD

Standard of
care for the treatment of BPD is psychotherapy. 
For many patients, BPD-informed generalist mental health treatment is
sufficient – these principles are reviewed in the Good Psychiatric Management
manual 25. For more
complicated patients, several different manualized therapies have been
delivered in group and individual formats to good effect including Dialectical
Behavioral Therapy, Mentalization Based Therapy, and Transference Focused
Psychotherapy 26,27.  Inpatient psychiatric
hospital can be helpful for stabilization of acutely suicidal patients, but is
generally considered to be an approach of last resort, and there is concern
that it can lead to symptom exacerbation. No treatment for BPD targets a
specific biological mechanism.  Though
there is no pharmacologic approach to treating the disorder itself, medications
can be helpful for symptom management. 

Table 2 here

c.      
Role of medications in BPD

Current
guidelines recommend minimal medication use in BPD  28
29 Cochrane reviews have
examined the evidence for benefit of medication in BPD, and their evolving
conclusions reflect the recently expanding evidence base in the field.  In 2006, they were unable to recommend any
medication 26. By 2010, they
found some benefit for core symptoms, in particular for mood stabilizers
(topiramate, lamotrigine, and valproic acid) and second-generation
anti-psychotics (aripiprazole and olanzapine) 30. Meta-analyses by Vita et
al. (2011) and Stoffers (2015 review of data from 2009-2014) concur
(specific data reviewed in Table 2) 31,32. 
All
in all, the database is growing and further evidence is accumulating that BPD
is a condition that can be effectively treated by a combination of
psychotherapy and symptom-targeted pharmacotherapy.

 

d.     
Prescribing patterns in BPD

Review of prescribing
patterns suggests that patients with BPD are often taking complex regimens that
do not reflect the available evidence about efficacy 33. A 2010 review found that BPD patients received an
average of 2.7 drugs; only 6% were drug-free; 56% were taking >=3 drugs and
30% >=4 drugs. Over the past 8 years, prescription of antidepressants has
remained stable; there has been a significant reduction in prescription of
benzodiazepines and an increase in the use of mood stabilizers and atypical
antipsychotics. Comorbidity with Axis I disorders was the main factor
associated with drug prescription. Drug prescription and polypharmacy are
common in the management of BPD in clinical practice (Pascual et al.,
2010).  This is similar to prescription
patterns reported in a 2015 review of prescribing practices for people with BPD
in the UK: 82% were taking at least one psychotropic medication 34. 
More than 60 % were on an anti-depressant, >50% on an anti-psychotic,
> 25% on a benzodiazepine, > 15% on a z-hypnotic, and ~ 20% on a mood
stabilizer. Bridler et al. reported on prescribing patterns in Europe, finding
that 70% of all BPD patients were prescribed antipsychotics or antidepressants,
33% anticonvulsants, 30% benzodiazepines. 
Also, more than half the patients were prescribed more than 3
psychotropic medications 35.
Zanarini et al. reported on 16 year follow-up of a US sample 36, and about prn use 37) . 
Knappich et al.  have also
reported on a survey of medication management in private practices 38.

Based on these data, there is a
discrepancy between the recommendation for focused, minimal prescribing and
real-world practice.  Several different
factors may contribute to the over-use of medication in the treatment of BPD.

Jackie’s
medication regime demonstrates some of the problems that plague the real-world
pharmacological management of BPD – polypharmacy and attempts at treating a
symptom that very likely cannot be treated with medication, with medication.

       

IV.             
 Factors that perpetuate polypharmacy in
borderline personality disorder:

1.     
Under-diagnosis, and reluctance to disclose diagnosis

If people who have BPD are not diagnosed, or if diagnosis
is not disclosed, the mystery of their highly distressing often
treatment-resistant symptoms can lead to ever-intensifying efforts to subdue
symptoms with medication.

 

Clinicians are reluctant to diagnose BPD in part because
they are often more experienced diagnosing primary mood disorders and psychotic
disorders (the “Axis I” disorders of DSM-IV). 
However, as we have described above, a quick clarification of the
frequency and triggers of symptom fluctuations is an effective screening method,
and standardized scales can help to distinguish commonly confused disorders
such as treatment-resistant depression and Bipolar disorder.  While some patients with BPD may have
co-morbid bipolar disorder, major depression, and/or psychotic illness, many
others are misdiagnosed when the BPD diagnosis is not considered.

 

Clinicians may also be reluctant to diagnose BPD because
they suspect that treatment doesn’t help, or that patients may feel
insulted.  In fact, recent data suggest
that many patients feel relieved upon receiving psychoeducation about BPD, and
clinicians who are trained to diagnose and disclose BPD feel more comfortable
working with BPD patients. 

 

Open discussion of the BPD diagnosis holds promise for more
effective use of medications, and a way of understanding the situations when
they may be more or less helpful.

 

            Although it is clear to us that Jackie
suffers from BPD, it is possible that her providers have not communicated this
diagnosis to her, hence her frantic efforts to medicate her distress. A
conversation about diagnosis will lead to discussion about what treatments can
really help Jackie in the long-term.

 

2.     
Attempt to treat all the (many) symptoms and (common)
co-morbidities with medication

BPD can vary widely in the specific symptoms that they
experience: only five of the nine DSM criteria are needed to make the
diagnosis, so many different combinations can occur.  This can augment the perception that this is
a unique or mysterious clinical situation rather than an understandable one in
the form of BPD.  Also, because people
with BPD can be quite sensitive to medication side-effects, additional symptoms
can arise that may tempt providers and patients to consider additional
medications.

 

Patient and prescriber can practice tolerating symptoms
when they have a shared language for this: BPD is primarily treated by
psychotherapy, strong emotions are expected and can be talked-about,
medications are adjunctive. This stands in contrast to the idea that some
patients and even some prescribers have that psychiatric stability is
achieved largely or solely through medications: The “therapeutic illusion” or the “illusion of control” has been
defined as a situation where physicians believe that their actions or tools are
more effective than they actually are and is based on the tendency of human
beings to overestimate the effect of their actions 39,40. This can easily lead to the perpetuation of the idea
that withdrawal or change in a medication will destabilize a patient.
This in turn causes both the prescriber and the patient to remain in favor of
keeping the medication unchanged, often at the risk of exposure to side
effects.   two conscious heuristics can help counteract
the therapeutic illusion. The first might be formulated as “Before you conclude
that a treatment was effective, look for other explanations.” The second
heuristic might be “If you see evidence of success, look for evidence of
failure.” 39

 

            It
appears that Jackie may be unnerved by her hospitalization and is attempting to
gain control of her life by taking as many different medications as possible.
Although her inpatient doctor may have resisted the pressure to prescribe more
medication in addition to valproate and quetiapine this time, this may change
with repeated hospitalization. Further, the outpatient doctor may err on the
side of ‘safety’ and keep the valproate and quetiapine unchanged to keep Jackie
out of the hospital.

 

3.     
Symptom fluctuations and temporary exacerbations

As we consider the effect of BPD symptom profile on
prescribing patterns, we should reflect on the relationship between symptoms
and environmental stressors. This can be a useful therapeutic technique – a way
to rehearse the idea that symptoms in BPD arise from understandable
circumstances, and that we should try to get in the habit of identifying these
circumstances (often interpersonal difficulties).

           

            Jackie’s attempt at self-harm and subsequent
hospitalization were a result of her argument with her long-distance husband.
The addition of a medication, an antidepressant for instance, may not resolve
the central reason that led to the hospitalization in the first place. Further,
it is very possible that by the time that the antidepressant begins to exert
its effect, Jackie may have made up with her husband.

 

4.      Comorbid substance use

Co-morbid alcohol and other drug use disorders is common in
BPD 41 and can cause
medication non-adherence without the prescriber being aware and/or blunting of
the effects of psychotropic medication, leading to escalating doses and the
addition of more medications.

 

5.      Patient requests for medication

People with BPD can seem demanding because of impulsive
anger and because of alternating idealization and devaluation.  Frantic fears of abandonment can be activated
by usual clinical schedules (the lack of provider availability over a weekend)
or by proposed changes in care plan (decreased session frequency, decreased
medication dosing) These strong displays of emotion and obvious distress can
lead to prescriptions aimed at calming the patient and de-escalating a
difficult interpersonal encounter.

 

            Jackie has just transitioned from an
inpatient unit to the outpatient setting. In addition to having to deal with
the original problem that led to the hospitalization, Jackie also has to deal
with the loss of the constant support that the inpatient service provides. This
may be a part of why she is requesting more medications.

 

6.     
Counter-transference prescribing:

A hallmark of
countertransference prescribing is its focus on managing the experience of the
prescriber rather than the experience of the patient 42. Psychiatrists
are not immune from countertransference responses, even if their task is solely
to prescribe medication. They may find it difficult to process their feelings
and prescribe in a desire to ‘rescue’ a patient or in a vain attempt to ‘do
something’. In treating BPD, the lure of action can be very compelling and may
be driven by a delusion of therapeutic precision and the ‘mind-brain’ barrier 43. Further,
countertransference prescribing may occur in the context of issues related to
turf and power, the therapist/prescriber’s rescuer fantasies and using
medication as a distancing mechanism 44.
For instance, in a study of clinician’s experiences in combining medication and
psychotherapy for borderline patients. Waldinger and Frank (1989) found that
medications were prescribed when therapists felt pessimistic about the
patient’s ability to benefit from psychotherapy 45. These reactions may account for the high number of
medications that patients with borderline personality disorder take over time,
even though polypharmacy is rarely recommended.

Depending on the prescriber’s vulnerability,
they may respond to Jackie’s plea for help by prescribing all the medications
that she asks for (which may fulfill their rescuer fantasies or distance them
from Jackie) or firmly refuse to prescribe any other medication (as they do not
want to be told what to do).

Risks of medication use in BPD

Medications can interact with one another as well as with
substances of abuse. For instance, the use of alcohol or opioids with prescribed
benzodiazepines can put a patient at serious risk of respiratory depression.
Patients who are at a high risk for self-harm may find the means in large
numbers of prescribed pills. This is especially concerning with medications
that have a narrow therapeutic index such as lithium and tricyclic
antidepressants. Further, given the high levels of sensitivity to both
interpersonal and somatic experience, people with BPD may be more likely to
experience both side effects as well as withdrawal symptoms of psychotropic
medications.  Medications can, because of
time spent discussing them, divert attention and energy from psychotherapy.

V. Strategies to reduce polypharmacy and promote quality
prescribing for people with BPD

a.      
Principles of quality prescribing in borderline PD

Standard
guidelines such as the APA guidelines for the management of BPD emphasize that
medications target specific and time-limited symptoms and that flexibility is
essential 28. Dimeff et al 46 offer a mnemonic for medication
management of BPD in the context of ongoing DBT – The five Ss – Safe, simple,
scientific, specific, superfast. These and other principles are explained in
more detail in table 3 using the example of Jackie.

 

Table 3 here

b.     
Deprescribing as a conceptual framework for streamlining
medication regimes in BPD

An intervention originally described in geriatric and palliative
care medicine, deprescribing is now being adapted to psychiatry. It has been
emphasized that deprescribing is not the withdrawal of care but a positive
intervention aimed at the effective and parsimonious use of medications.
Deprescribing involves appropriate timing, careful assessment of the patient’s
medical and psychiatric history, development of psychosocial supports and a
plan for tapering and finally, ongoing monitoring and support 7. In table 4 we adapt the process of
deprescribing for use in patients suffering from BPD, paying special attention
to the rapid and often dramatic changes in clinical presentation, sensitivity
to withdrawal effects and the psychological meaning of the medication to the
patient.  Table 4 here

c.      
Increasing the use of as-needed medications: Although, there is evidence
that PRN medications for psychiatric disorders may be associated with increased
risks of morbidity, side effects, drug interactions and addiction 47 they may have a place in the
management of acute crisis in BPD, especially if the use of the PRN medication
can offset the need for continuous antipsychotic regimens. A follow-up study of
use of PRN medications by BPD patients found that such patients were three
times as likely to use PRN medications, use declined over time, recovery was
associated with a very low PRN use and most PRNs were used to treat agitation 37. 
For an acute mental health setting, Baker,
Lovell 48 recommend a clear focus on the purpose of the PRN
medication, ideally making the prescription time-limited, limiting the number
of PRN medications used, specifying the maximum daily doses and documenting the
response clearly.  All these
recommendations are highly relevant to the outpatient setting as well.

 

d.       Higher sensitivity to the
meaning of the medication to the patient: In the
psychopharmacological management of the person with BPD, pills may serve as transitional
objects 49. To a patient, a medication
can be imbued with intentionality and influence and can exist in a dynamic
object world with action and agency 50.
 In attending to the meaning of the medication
while prescribing, Mintz and Flynn 42
recommend that the prescriber avoid mind-body split, attend to ambivalence
about loss of symptoms, cultivate the therapeutic alliance. and attend to
counter-therapeutic uses of medications. An exploration and awareness of these
issues is likely to increase the success of a deprescribing intervention.

Table 5 here

VII.         
Conclusions: Evidence for
psychopharmacological management of BPD is limited to short-term use of second
generation antipsychotic medications for affective instability, psychotic
symptoms and impulsivity. Any medication for BPD needs to be initiated for
short-term use and hence, the prescriber must be mindful of the psychodynamics
of  prescribing and be able to plan for
deprescribing. Further research is needed on the prevalence, safety and
efficacy of as-needed (PRN) medications in BPD.

 

I.                  
Introduction

Prescribing
psychotropic medications for persons with Borderline Personality Disorder (BPD)
can be complicated by both medical and psychological concerns.  BPD is commonly co-morbid with other
psychiatric disorders such as depression and post-traumatic stress disorder
that are commonly addressed with psychotropic medications in addition to other
non-psychiatric medical problems 1
2 3 4.  Also, people with BPD may
be more sensitive to medication side-effects and to the interpersonal dynamics
with the medical professional prescribing their medication. We propose that
alongside the current best evidence for prescribing in BPD, an awareness of the
aforementioned issues can inform a flexible approach to work with BPD patients,
and is most likely to yield positive outcomes.

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            People suffering from Borderline Personality Disorder (BPD) are
often prescribed a large number of psychotropic medications as a result of
intense affective and psychotic symptoms, concerns over self-harm  and impulsive behavior or even a sense of
helplessness in the prescribing provider 5
. Although mood stabilizers, antipsychotic medications and antidepressants can
reduce the intensity of symptoms, their benefits need to evaluated frequently
due to the transient nature of these symptoms and due to the exquisite
stress-sensitivity of persons with BPD 5.
Further, medications may be less safe in the context of impulsive substance use
and/or self-harm. Hence, for people with BPD the risk-benefit ratio of
medications may fluctuate significantly in a short period of time.

            Prescribers may hesitate to reduce
psychotropic medications due to lack of time for conducting these discussions
with the patient, inadequate training, a ‘fear of rocking the boat’ and often
due to the absence of a framework for implementing this process. In this paper,
we attempt to fill this void by using the framework of deprescribing to parse
medication regimes to the minimum helpful treatment. Deprescribing is an
intervention originally described in geriatric medicine and involves the
reduction and/or cessation of medications whose current or potential risks may
outweigh their current or potential benefit keeping in consideration the
patient’s medical and functional status as well as values and preferences 6. The process of deprescribing has
recently been expanded for use in psychiatry 7 and strong arguments have been made for its utility in
children and adolescents on psychotropic medications 8. Using a case example in this paper, we
demonstrate how deprescribing may be further modified for use in the patient
with BPD.

 

II.               
Case history

We begin with
an example of a case developed based on a series of patients we have worked
with.

Jackie,
a 27-year-old single woman, presents to your clinic after discharge from the
psychiatric hospital.  She is a slightly
overweight, casually dressed young woman. 
She is glad you were willing to see her so quickly and asserts that she needs
her medications sorted out as the inpatient doctors did not pay attention to
what she was saying.  She asks to be
restarted on dextroamphetamine, clonazepam, and fluoxetine in addition to the
valproate and quetiapine that she is already taking. She adds that you seem
like the kind of doctor who will really listen.

 

Records
indicate that Jackie was admitted for a possible suicide attempt.  She had taken 4mg of clonazepam together with
four shots of vodka after an upsetting phone call with her long-distance
husband.    She endorsed feelings of
emptiness and worthlessness that worsen with relationship problems, and feeling
desperate to communicate her strong feelings to the people she loves.  Though people initially seem to understand,
they often leave her feeling alone and betrayed.  In those situations, she finds herself
feeling odd, as though she’s not part of the world everyone else is living
in.  She daydreams about ways to kill
herself, and has discovered that digging into her upper arms with her
fingernails is somehow relieving. 
Physical exam revealed rows of half-moon shaped marks on both her
forearms.

Table
1 here

 

III.            
Treatment of Borderline Personality Disorder

 

a.      
Brief review of symptoms in BPD

Borderline
Personality Disorder is a common mental health problem. Prevalence is estimated
at 1-5% in the general population and ~20% in mental health clinics 9,10 11 . The natural history of
the disorder is for symptoms to lessen over time, but functional recovery lags behind
symptom relief for many 12.  Many people afflicted by BPD suffer chronic
suicidality 13
and make repeated suicide attempts 14
12. Five to ten percent of
people with BPD ultimately complete suicide 12,14 – that is nearly 50-fold the suicide rate of people in
the general US population 15.

Symptoms that
may suggest BPD should prompt further investigation: symptoms and relevant
questions are reviewed in Table 1.
Affective instability (mood fluctuations across minutes to hours rather than
over weekly or months as in primary mood disorders) is a highly sensitive
single-item screener for BPD: negative predictive value is 99% in a large
community outpatient mental health sample 16.
For further investigation of positive screens, standardized scales can be
helpful, such as the Diagnostic Interview for Borderline Personality Disorder,
a semi-structured interview, 17, the SCID-2 self-report questionnaire (15
yes/no BPD questions) 18,19, and the Borderline Symptom List (23 BPD questions scored on a 5
point likert scale)  20, among
others. To distinguish BPD from syndromes that share similar experiences, it
may be especially helpful to identify symptom fluctuations that occur in
response to interpersonal problems, such as affective changes as discussed
above and psychotic symptoms of brief duration (sometimes termed
“micro-psychotic” episodes”) 21 22
23 24.

Jackie fulfills several criteria for a diagnosis of BPD (Table 1);
She experiences mood instability, anger, dissociative episodes and often
demonstrates impulsivity, interpersonal problems and suicidal or self-injurious
behavior.

b.     
Treatment approaches for BPD

Standard of
care for the treatment of BPD is psychotherapy. 
For many patients, BPD-informed generalist mental health treatment is
sufficient – these principles are reviewed in the Good Psychiatric Management
manual 25. For more
complicated patients, several different manualized therapies have been
delivered in group and individual formats to good effect including Dialectical
Behavioral Therapy, Mentalization Based Therapy, and Transference Focused
Psychotherapy 26,27.  Inpatient psychiatric
hospital can be helpful for stabilization of acutely suicidal patients, but is
generally considered to be an approach of last resort, and there is concern
that it can lead to symptom exacerbation. No treatment for BPD targets a
specific biological mechanism.  Though
there is no pharmacologic approach to treating the disorder itself, medications
can be helpful for symptom management. 

Table 2 here

c.      
Role of medications in BPD

Current
guidelines recommend minimal medication use in BPD  28
29 Cochrane reviews have
examined the evidence for benefit of medication in BPD, and their evolving
conclusions reflect the recently expanding evidence base in the field.  In 2006, they were unable to recommend any
medication 26. By 2010, they
found some benefit for core symptoms, in particular for mood stabilizers
(topiramate, lamotrigine, and valproic acid) and second-generation
anti-psychotics (aripiprazole and olanzapine) 30. Meta-analyses by Vita et
al. (2011) and Stoffers (2015 review of data from 2009-2014) concur
(specific data reviewed in Table 2) 31,32. 
All
in all, the database is growing and further evidence is accumulating that BPD
is a condition that can be effectively treated by a combination of
psychotherapy and symptom-targeted pharmacotherapy.

 

d.     
Prescribing patterns in BPD

Review of prescribing
patterns suggests that patients with BPD are often taking complex regimens that
do not reflect the available evidence about efficacy 33. A 2010 review found that BPD patients received an
average of 2.7 drugs; only 6% were drug-free; 56% were taking >=3 drugs and
30% >=4 drugs. Over the past 8 years, prescription of antidepressants has
remained stable; there has been a significant reduction in prescription of
benzodiazepines and an increase in the use of mood stabilizers and atypical
antipsychotics. Comorbidity with Axis I disorders was the main factor
associated with drug prescription. Drug prescription and polypharmacy are
common in the management of BPD in clinical practice (Pascual et al.,
2010).  This is similar to prescription
patterns reported in a 2015 review of prescribing practices for people with BPD
in the UK: 82% were taking at least one psychotropic medication 34. 
More than 60 % were on an anti-depressant, >50% on an anti-psychotic,
> 25% on a benzodiazepine, > 15% on a z-hypnotic, and ~ 20% on a mood
stabilizer. Bridler et al. reported on prescribing patterns in Europe, finding
that 70% of all BPD patients were prescribed antipsychotics or antidepressants,
33% anticonvulsants, 30% benzodiazepines. 
Also, more than half the patients were prescribed more than 3
psychotropic medications 35.
Zanarini et al. reported on 16 year follow-up of a US sample 36, and about prn use 37) . 
Knappich et al.  have also
reported on a survey of medication management in private practices 38.

Based on these data, there is a
discrepancy between the recommendation for focused, minimal prescribing and
real-world practice.  Several different
factors may contribute to the over-use of medication in the treatment of BPD.

Jackie’s
medication regime demonstrates some of the problems that plague the real-world
pharmacological management of BPD – polypharmacy and attempts at treating a
symptom that very likely cannot be treated with medication, with medication.

       

IV.             
 Factors that perpetuate polypharmacy in
borderline personality disorder:

1.     
Under-diagnosis, and reluctance to disclose diagnosis

If people who have BPD are not diagnosed, or if diagnosis
is not disclosed, the mystery of their highly distressing often
treatment-resistant symptoms can lead to ever-intensifying efforts to subdue
symptoms with medication.

 

Clinicians are reluctant to diagnose BPD in part because
they are often more experienced diagnosing primary mood disorders and psychotic
disorders (the “Axis I” disorders of DSM-IV). 
However, as we have described above, a quick clarification of the
frequency and triggers of symptom fluctuations is an effective screening method,
and standardized scales can help to distinguish commonly confused disorders
such as treatment-resistant depression and Bipolar disorder.  While some patients with BPD may have
co-morbid bipolar disorder, major depression, and/or psychotic illness, many
others are misdiagnosed when the BPD diagnosis is not considered.

 

Clinicians may also be reluctant to diagnose BPD because
they suspect that treatment doesn’t help, or that patients may feel
insulted.  In fact, recent data suggest
that many patients feel relieved upon receiving psychoeducation about BPD, and
clinicians who are trained to diagnose and disclose BPD feel more comfortable
working with BPD patients. 

 

Open discussion of the BPD diagnosis holds promise for more
effective use of medications, and a way of understanding the situations when
they may be more or less helpful.

 

            Although it is clear to us that Jackie
suffers from BPD, it is possible that her providers have not communicated this
diagnosis to her, hence her frantic efforts to medicate her distress. A
conversation about diagnosis will lead to discussion about what treatments can
really help Jackie in the long-term.

 

2.     
Attempt to treat all the (many) symptoms and (common)
co-morbidities with medication

BPD can vary widely in the specific symptoms that they
experience: only five of the nine DSM criteria are needed to make the
diagnosis, so many different combinations can occur.  This can augment the perception that this is
a unique or mysterious clinical situation rather than an understandable one in
the form of BPD.  Also, because people
with BPD can be quite sensitive to medication side-effects, additional symptoms
can arise that may tempt providers and patients to consider additional
medications.

 

Patient and prescriber can practice tolerating symptoms
when they have a shared language for this: BPD is primarily treated by
psychotherapy, strong emotions are expected and can be talked-about,
medications are adjunctive. This stands in contrast to the idea that some
patients and even some prescribers have that psychiatric stability is
achieved largely or solely through medications: The “therapeutic illusion” or the “illusion of control” has been
defined as a situation where physicians believe that their actions or tools are
more effective than they actually are and is based on the tendency of human
beings to overestimate the effect of their actions 39,40. This can easily lead to the perpetuation of the idea
that withdrawal or change in a medication will destabilize a patient.
This in turn causes both the prescriber and the patient to remain in favor of
keeping the medication unchanged, often at the risk of exposure to side
effects.   two conscious heuristics can help counteract
the therapeutic illusion. The first might be formulated as “Before you conclude
that a treatment was effective, look for other explanations.” The second
heuristic might be “If you see evidence of success, look for evidence of
failure.” 39

 

            It
appears that Jackie may be unnerved by her hospitalization and is attempting to
gain control of her life by taking as many different medications as possible.
Although her inpatient doctor may have resisted the pressure to prescribe more
medication in addition to valproate and quetiapine this time, this may change
with repeated hospitalization. Further, the outpatient doctor may err on the
side of ‘safety’ and keep the valproate and quetiapine unchanged to keep Jackie
out of the hospital.

 

3.     
Symptom fluctuations and temporary exacerbations

As we consider the effect of BPD symptom profile on
prescribing patterns, we should reflect on the relationship between symptoms
and environmental stressors. This can be a useful therapeutic technique – a way
to rehearse the idea that symptoms in BPD arise from understandable
circumstances, and that we should try to get in the habit of identifying these
circumstances (often interpersonal difficulties).

           

            Jackie’s attempt at self-harm and subsequent
hospitalization were a result of her argument with her long-distance husband.
The addition of a medication, an antidepressant for instance, may not resolve
the central reason that led to the hospitalization in the first place. Further,
it is very possible that by the time that the antidepressant begins to exert
its effect, Jackie may have made up with her husband.

 

4.      Comorbid substance use

Co-morbid alcohol and other drug use disorders is common in
BPD 41 and can cause
medication non-adherence without the prescriber being aware and/or blunting of
the effects of psychotropic medication, leading to escalating doses and the
addition of more medications.

 

5.      Patient requests for medication

People with BPD can seem demanding because of impulsive
anger and because of alternating idealization and devaluation.  Frantic fears of abandonment can be activated
by usual clinical schedules (the lack of provider availability over a weekend)
or by proposed changes in care plan (decreased session frequency, decreased
medication dosing) These strong displays of emotion and obvious distress can
lead to prescriptions aimed at calming the patient and de-escalating a
difficult interpersonal encounter.

 

            Jackie has just transitioned from an
inpatient unit to the outpatient setting. In addition to having to deal with
the original problem that led to the hospitalization, Jackie also has to deal
with the loss of the constant support that the inpatient service provides. This
may be a part of why she is requesting more medications.

 

6.     
Counter-transference prescribing:

A hallmark of
countertransference prescribing is its focus on managing the experience of the
prescriber rather than the experience of the patient 42. Psychiatrists
are not immune from countertransference responses, even if their task is solely
to prescribe medication. They may find it difficult to process their feelings
and prescribe in a desire to ‘rescue’ a patient or in a vain attempt to ‘do
something’. In treating BPD, the lure of action can be very compelling and may
be driven by a delusion of therapeutic precision and the ‘mind-brain’ barrier 43. Further,
countertransference prescribing may occur in the context of issues related to
turf and power, the therapist/prescriber’s rescuer fantasies and using
medication as a distancing mechanism 44.
For instance, in a study of clinician’s experiences in combining medication and
psychotherapy for borderline patients. Waldinger and Frank (1989) found that
medications were prescribed when therapists felt pessimistic about the
patient’s ability to benefit from psychotherapy 45. These reactions may account for the high number of
medications that patients with borderline personality disorder take over time,
even though polypharmacy is rarely recommended.

Depending on the prescriber’s vulnerability,
they may respond to Jackie’s plea for help by prescribing all the medications
that she asks for (which may fulfill their rescuer fantasies or distance them
from Jackie) or firmly refuse to prescribe any other medication (as they do not
want to be told what to do).

Risks of medication use in BPD

Medications can interact with one another as well as with
substances of abuse. For instance, the use of alcohol or opioids with prescribed
benzodiazepines can put a patient at serious risk of respiratory depression.
Patients who are at a high risk for self-harm may find the means in large
numbers of prescribed pills. This is especially concerning with medications
that have a narrow therapeutic index such as lithium and tricyclic
antidepressants. Further, given the high levels of sensitivity to both
interpersonal and somatic experience, people with BPD may be more likely to
experience both side effects as well as withdrawal symptoms of psychotropic
medications.  Medications can, because of
time spent discussing them, divert attention and energy from psychotherapy.

V. Strategies to reduce polypharmacy and promote quality
prescribing for people with BPD

a.      
Principles of quality prescribing in borderline PD

Standard
guidelines such as the APA guidelines for the management of BPD emphasize that
medications target specific and time-limited symptoms and that flexibility is
essential 28. Dimeff et al 46 offer a mnemonic for medication
management of BPD in the context of ongoing DBT – The five Ss – Safe, simple,
scientific, specific, superfast. These and other principles are explained in
more detail in table 3 using the example of Jackie.

 

Table 3 here

b.     
Deprescribing as a conceptual framework for streamlining
medication regimes in BPD

An intervention originally described in geriatric and palliative
care medicine, deprescribing is now being adapted to psychiatry. It has been
emphasized that deprescribing is not the withdrawal of care but a positive
intervention aimed at the effective and parsimonious use of medications.
Deprescribing involves appropriate timing, careful assessment of the patient’s
medical and psychiatric history, development of psychosocial supports and a
plan for tapering and finally, ongoing monitoring and support 7. In table 4 we adapt the process of
deprescribing for use in patients suffering from BPD, paying special attention
to the rapid and often dramatic changes in clinical presentation, sensitivity
to withdrawal effects and the psychological meaning of the medication to the
patient.  Table 4 here

c.      
Increasing the use of as-needed medications: Although, there is evidence
that PRN medications for psychiatric disorders may be associated with increased
risks of morbidity, side effects, drug interactions and addiction 47 they may have a place in the
management of acute crisis in BPD, especially if the use of the PRN medication
can offset the need for continuous antipsychotic regimens. A follow-up study of
use of PRN medications by BPD patients found that such patients were three
times as likely to use PRN medications, use declined over time, recovery was
associated with a very low PRN use and most PRNs were used to treat agitation 37. 
For an acute mental health setting, Baker,
Lovell 48 recommend a clear focus on the purpose of the PRN
medication, ideally making the prescription time-limited, limiting the number
of PRN medications used, specifying the maximum daily doses and documenting the
response clearly.  All these
recommendations are highly relevant to the outpatient setting as well.

 

d.       Higher sensitivity to the
meaning of the medication to the patient: In the
psychopharmacological management of the person with BPD, pills may serve as transitional
objects 49. To a patient, a medication
can be imbued with intentionality and influence and can exist in a dynamic
object world with action and agency 50.
 In attending to the meaning of the medication
while prescribing, Mintz and Flynn 42
recommend that the prescriber avoid mind-body split, attend to ambivalence
about loss of symptoms, cultivate the therapeutic alliance. and attend to
counter-therapeutic uses of medications. An exploration and awareness of these
issues is likely to increase the success of a deprescribing intervention.

Table 5 here

VII.         
Conclusions: Evidence for
psychopharmacological management of BPD is limited to short-term use of second
generation antipsychotic medications for affective instability, psychotic
symptoms and impulsivity. Any medication for BPD needs to be initiated for
short-term use and hence, the prescriber must be mindful of the psychodynamics
of  prescribing and be able to plan for
deprescribing. Further research is needed on the prevalence, safety and
efficacy of as-needed (PRN) medications in BPD.

 

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