borderline personality and medication

[Suedehead]

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so.... I know the standard of treatment for BPD is DBT for the moment.

I know an attending who describes the 'three arms of love' for very brittle borderlines - meaning an SSRI, a mood stabilizer, and a neuroleptic.

How, if at all, are you treating persons with BPD psychopharmacologically. I know the research is pretty thin, I'm just really wondering what you all are actually doing or seeing. I mean, these poor people are very ill. what's helping them?

 

[billypilgrim37]

so.... I know the standard of treatment for BPD is DBT for the moment.

I know an attending who describes the 'three arms of love' for very brittle borderlines - meaning an SSRI, a mood stabilizer, and a neuroleptic.

How, if at all, are you treating persons with BPD psychopharmacologically. I know the research is pretty thin, I'm just really wondering what you all are actually doing or seeing. I mean, these poor people are very ill. what's helping them?

Well, by giving them Seroquel, you do address their perceived lack of endogenous quetiapine production.

 

[whopper]

If patients with borderline get better with a psychotropic, you have to highly question that they were misdiagnosed, or had a comorbid condition.

I do have several borderline patients on psychotropics despite my rants that too many psychiatrists are too willing to give them out to borderline patients. Why? The above. E.g. I got a patient with borderline PD and bipolar disorder. The bipolar was stabilized with Lamictal (e.g. now she can sleep, she has several hours straight of manic-free symptoms, but she still splits, she still cuts herself, she still has chronic feelings of emptiness--all are nto symptoms of bipolar disorder). The person is still borderline and I will not continue to add on more medications in a futile attempt to treat borderline PD when meds do little with it.

I told this patient that I felt she got maximum medical benefit and that her symptoms of borderline PD had to be treated with DBT that I am not qualified to give. I have several therapists I know of that provide it and I referred the patient to one of them.

If a doctor gives out psychotropics for borderline PD, are they at least referring or doing DBT no the patient? IMHO to not do DBT while giving out psychotropics is getting too close to malpractice. If the doctor is at least referring for DBT, one could argue that the meds could at least provide some small benefit at best and could be justified because DBT could take several weeks before a benefit is seen.

If I ever prescribed a medication for a patient with only borderline PD, I'd do the following 1) give out a med with very few side effects and without a need for labs..e.g. Citalopram, Lamictal. 2) give something cheap. 3) only give out something more heavy duty as a PRN. E.g. a low dose antipsychotic if the person has micro-psychotic episodes. 4) The person HAS TO GET DBT or you have to document that you are trying to get the person DBT but are having problems finding a therapist to do it and that you are doing the next best thing you can think of.

Why? The data for psychotropic use on borderline PD is poor, why start something heavy duty that will cause several side effects such as weight gain and cost the system thousands of dollars per year in labs and med costs?

 

[Suedehead]

If patients with borderline get better with a psychotropic, you have to highly question that they were misdiagnosed, or had a comorbid condition.

very much agreed. but... i have yet to meet a pt with BPD that does not qualify for GAD, MDD, or dysthymia, or even all of them (kind of like the old dsm III diagnosis of Neurotic Depression). they endorse these symptoms. The self perceptions and the behaviors associated with BPD need DBT. but the low moods, the anxiety - are those symptoms responding to psychopharm?

E.g. I got a patient with borderline PD and bipolar disorder.

I'm still a rookie and I trust Whopper with MY LIFE (not kidding), but I'll eat my hat if this pt has BPD and BMD. both are so rare and to have them together.... AND while the pts may endorse the sx of mania, bipolar disorder is a different animal.

If I ever prescribed a medication for a patient with only borderline PD, I'd do the following 1) give out a med with very few side effects and without a need for labs..e.g. Citalopram, Lamictal. 2) give something cheap. 3) only give out something more heavy duty as a PRN. E.g. a low dose antipsychotic if the person has micro-psychotic episodes. 4) The person HAS TO GET DBT or you have to document that you are trying to get the person DBT but are having problems finding a therapist to do it and that you are doing the next best thing you can think of.

This I love. I just have not met a pt that has ONLY BPD. and it makes sense - how are they so disordered without feeling chronically depressed or anxious?

Why? The data for psychotropic use on borderline PD is poor, why start something heavy duty that will cause several side effects such as weight gain and cost the system thousands of dollars per year in labs and med costs?

Yes. One of the reasons I'm asking is that I'm moonlighting in a VERY rural part of California. Lots of axis II, lots of drug dependence. these pts are miserable, and they have very few resources and no DBT. I push therapy like crazy. just wish I had more tools for these people.

and my one attending uses psychotropics to treat BPD symptomatically - ssri for low mood; mood stabilizer for anger, impulsivity, mood reactivity; neuroleptic for mood control, anxiety, depression adjunct, and for psychotic and obsessive thinking.

not sure if this attending is using the drugs correctly (with a drug centered model) or if he's shooting in the dark.

 

[whopper]

I'm still a rookie and I trust Whopper with MY LIFE (not kidding),

Don't do that. I do think I'm a good psychiatrist but only because I do what I think I'm supposed to do vs. doing a terrible job. To treat someone who is depressed with an antidepressant, with one of the least amount of side effects that is $4 a month (that any psychiatrist with almost a decade of training ought to know) vs. an idiot that gives out Xanax for that depression without warning that it is addictive is not deserving of big kudos. To me that's like deciding to take a plate of Kobe beef at medium rare prepared by Marco Pierre White along with a fine red wine vs a plate of cow dung and choosing the Kobe beef.

I will say that I find it shocking to see how many doctors pick the cow dung. From anectdotal experience it's a significant minority. (E.g. the person has easily idenfitiable panic disorder and the doctor prescribed Wellbutrin and Haldol!) If only the doctor had to eat the dung, but usually it's the patient that ends up eating it. (Actually I just answered my own question...that's why so many doctors do it).

I do need to make some clarifications. If you prescribe meds, my recommendations were for borderline PD only. If, of course, the person has a comorbid condition where heavy duty meds are needed, then give it out. E.g. if the person has schizophrenia and borderline PD, of course give out an antipsychotic.

Comorbid conditions are actually not rare in those with borderline PD. If someone suffers from borderline PD, from my experience, they likely have PTSD. (A disorder that is too underdiagnosed IMHO in those with borderline PD). Think about it. If a young woman cuts herself to help her deal with the chronic feelings of emptiness caused by being repeatedly raped by her father, shouldn't PTSD be on the radar?

Every single patient I have with borderline, I screen them for PTSD. That should be required just like many psychiatrists believe that anyone with depression should be screened for bipolar disorder. That was something no one in residency taught me. I learned that from people who know how to utilize DBT.

Of course if someone had borderline PD and PTSD, the PTSD should be considered for treatment with an SSRI.

and my one attending uses psychotropics to treat BPD symptomatically - ssri for low mood; mood stabilizer for anger, impulsivity, mood reactivity; neuroleptic for mood control, anxiety, depression adjunct, and for psychotic and obsessive thinking.

The problem here is that according to theory with a heck of a lot of data backing it up, borderline is not so much a hardware problem as it is a software problem. ECT, for example, doesn't help borderline PD. Meds in studies don't do much Again, the person may have a comorbid condition that might benefit from psychotropic treatment.

If someone chooses to treat someone pharmacologically for BPD, that person must make an effort to get their patient DBT. Do not, repeat, do not get into the all to common problem of giving out the borderline patient a pharmacy full of meds unless you are seeing specific benefits from it and the patient is well aware of risk/benefit ratio that meds are not the recommended treatment for borderline PD. Do not, repeat, DO NOT give a borderline substances of abuse to treat their disorder.

I'm moonlighting in a VERY rural part of California. Lots of axis II, lots of drug dependence. these pts are miserable, and they have very few resources and no DBT.

I finally figured out why there is so much DBT in Cincinnati. There were specific key figures that brought it to the area. There is a Ph.D. Counseling program at U. of Cincinnati and some of the graduates, as their thesis project, started DBT teams in several localities. The head of one of the mental health community agencies in the area is one of those rare doctors that does not care about how much money she makes and is in the job purely to make a difference. She incorporated DBT into the agency and started DBT programs. One of the country's top psychiatric hospitals (the Lindner Center) is in the area and plenty of the patients there have borderline PD. The institution hired several highly respected people in treating DBT.

These were things I never saw in residency. There, Borderlines were treated like pathetic instigators of trouble. I very much believe that in an inpatient setting, you have to set limits, and often times push borderline patients out, even in a not-so-caring manner, but these people never got appropriate treatment once in the community because no one offered DBT in almost all of South Jersey (or for that hardly anyone in the entire state).

At your moonlighting gig, there are things you can do if you need to get your patients DBT but have no one available who is trained for it. You can start learning it on your own if your residency is not providing training you in it (and they are likely not). Pick up one of Linehan's books. Refer patients to www.dbtselfhelp.com. Also familiarize yourself with that website. Document that you want to provide your patients with DBT and you are only doing the best you can under the circumstances, that you are not trained in DBT, and that is it not the standard for psychiatrists to be trained in it.

I too was in a rural setting filled with lot's of Axis II issues during fellowship as a moonlighting gig. I started using several of the things my wife taught me about DBT and I was making progress with some of the borderline patients I had there. I still do not think I have enough experience and knowledge to consider myself well enough to be a competent DBT therapist. I may have gotten some of those patients better than they were before vs the other 10 psychiatrists that treated these patients with polypharmacy but like my Kobe vs dung example, the bar was set so low that I do not deserve praise. Discovering a cure to a disease deserves praise. Simply giving out the right treatment for a disorder that is commonly known as the right treatment should be considered MINIMAL COMPETENCY. Again MINIMAL.

(Yet so many doctors do less than the minimal.....)

If you have to do a 4th year project like a grand rounds, learning about DBT, trying it, and sharing your experiences could be a good project.

 

[masterofmonkeys]

I think that, provided they have/are developing some coping skills, medications can be helpful in borderline PD beyond just sedating or neurolepsing the crap out of them.

The effects of various psychotropics on both mood reactivity as well as impulsivity have been well studied. A drug that can decrease either one would of course result in some benefit to a borderline. Of course if the patient has no insight or coping skills, they will quickly overcome the medication benefit and look just as bad as before.

Lamictal has a lot of open-label and a couple of RCTs showing pretty promising benefit for depressive, anxiety, and anger symptoms.

Of course, I don't think of these drugs as treatment of borderline PD but rather symptomatic mgmt. The treatment is anything that improves self-mastery. DBT, MBCT, ACT, psychodynamic, whatever.

 

[whopper]

I've seen some cases where people claim that a psychotropic may take the "edge off."

In such cases, one has to speculate that the person may have had a comorbid condition. Even if not, the psychotropic may have provided some benefit if at least due to placebo effect. It may have even provided a benefit that was beyond placebo effect.

In any case, if the person truly has borderline PD, the meds will only provide, at best, small improvements in treating that disorder and the borderline patient will still suffer from it in a manner that could better be treated otherwise. For a psychiatrist to still not provide DBT or refer to someone who can offer it and still only provide meds if the patient has diagnosable borderline PD should violate the standard of care.

It, however, likely does not violate the standard. Why? Because I've seen too many areas where too many idiot psychiatrists only give out meds to treat this disorder. Remember the standard of care is based on the average practice standards doctors in the area perform. If every surgeon in the area rubbed cow dung on their patient before surgery, then that is the standard. It may not be the right standard, and one would have to seriously question why so many surgeons are doing the wrong thing, and demand why so many professionals as a whole are all committing such an egregious error, and someone needs to call out this problem and try to have this standard stopped, but nonetheless, it is the standard.

I understand that in several areas there are no DBT therapists. In that case, the psychiatrist that does not know how to administer DBT (and as we know that is the overwhelming majority) is trapped. In that type of case, the psychiatrist could at least inform the patient that he/she is doing the best he/she can given the circumstance with psychotropics, the doctor can try to learn DBT (and there are several conferences available), and people in public health positions need to be alerted on creating incentives and programs to increase DBT therapists in the locality. The APA, hospital and community health administrators, psychiatric departments in hospitals all have in their power the ability to push such a plan forward.

 

[masterofmonkeys]

Whopper I agree with you on the importance of DBT. I'm lucky enough that one of our faculty members is pretty big in DBT and I'll get a chance to work with her.

As for psychotropics working by placebo or due to comorbid Axis I condition, I'm going to have to disagree.

Our meds target neurotransmitters, receptors, and pathways that are present in all of us. We call them 'antipsychotics' and 'antidepressants' and 'mood stabilizers' but this ignores the fact that mechanistically, these meds are in fact 'membrane ion channel stabilizers', 'glutamatergic signalling pathway modifiers' 'dopamine receptor antagonists or 'serotonin reuptake inhibitors'.

An SSRI may be used to decrease impulsivity in a non-depressed TBI pt by virtue of increasing the available serotonin in 5HT-2 pathways in the forebrain, in effect inhibiting activity. LTG makes synapses less likely to fire, period. And thus may provide an inhibitory or at least modulating effect on all sorts of pathways, that may be more sensitive to firing in individuals, and thus reduce rapid changes in activity in all sorts of pathways. Antipsychotics were once called neuroleptics. I still call them that. Neurolepsis is a state of reduced overall brain activity, including less motor fxn, less anxiety, and indifference.

Almost everyone gets a cognitive enhancement effect from methylphenidate. Almost everyone gets stronger on anabolic steroids. It doesn't mean we have ADHD or testosterone deficiency.

Psychopharm can of course modify impulsivity, mood reactivity, and other aspects of brain fxn and behavior through its effects on the brain pathways and synapses present in all of us, regardless of whether or not we have a diagnosable Axis I disorder.

I happen to believe that without therapy, any improvements in fxn through psychopharmacology in borderlines or others with Axis II pathology will be transient, or at the very least require dose escalation. For the simple reason that this is an issue of personality style and thus ingrained behavior and neural weights.

You know me, I'm a died in the wool psychotherapy guy, but I'm on board with psychopharm for adjunctive and/or symptomatic tx. I believe it can be done in a scientifically-informed way that augments a patient's response to therapy and their ability to use the skills therein.

 

[kugel]

There is an APA Guideline "Treatment of Patients With Borderline Personality Disorder"

http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=BPD_05-15-06

 

[whopper]

As for psychotropics working by placebo or due to comorbid Axis I condition, I'm going to have to disagree.

I don't think there's much of a disagreement if any.

As I've written, there are cases where borderlines get some benefit from a psychotropic. The benefit may have been due to placebo effect, it may have not. In any case psychotropics usually aren't the best treatment for borderline PD but can cause some benefit.

My bigger point is that psychiatrists often rely on psychotropics as a first-line treatment, then put the borderline PD patient on an expensive and often metabolically risky array of polypharmacy, usually with the patient not getting any better but getting a much higher weight, cholesterol, and BP, yet the psychiatrist continues this treatment regimen and there's no attempt at initiation of DBT whatsoever.

If you have a borderline patient and you give them a psychotropic and there is a noticeable improvement, it is a step-forward, and from there you have to re-evaluate what's going on. E.g. if the person no longer shows traits of borderline PD, then I'd seriously question that perhaps the borderline PD dx was not correct or it was treating a comorbid disorder. It could however be a case where the psychotropic does cause some marginal improvement in the severity of the borderline PD symptoms but the borderline PD remains. In any case, if there is improvement, document it and keep with that medication unless you find reason to stop it.

Comorbidity with Axis I symptoms is not out of the ordinary. Depression, PTSD, and bipolar disorder have comorbidities with borderline PD.

You know me, I'm a died in the wool psychotherapy guy, but I'm on board with psychopharm for adjunctive and/or symptomatic tx. I believe it can be done in a scientifically-informed way that augments a patient's response to therapy and their ability to use the skills therein.

No disagreement there. Having a borderline patient where "Lamictal takes off the edge" or "I added an SSRI because she has some PTSD-like symptoms" IMHO is not bad treatment so long as there's a good psychotherapy regimen and there is noticeable improvement from the medication. A borderline pt on Zyprexa, Depakote, Lithium, Paxil, Klonopin, and Ritalin all at once and there's little improvement and no psychotherapy, or the treatment team all believe the person has borderline PD but the psychiatrist has the patient diagnosed as psychosis NOS and is giving large amounts of Thorazine because the patient not acting out is considered a treatment success (in reality the patient is zonked 24/7), and no one is giving psychotherapy without even an attempt, that's the problem I'm talking about that I anectdotally I'm finding all too common.

 

[MiesVanDerMom]

I'm still a rookie and I trust Whopper with MY LIFE (not kidding), but I'll eat my hat if this pt has BPD and BMD. both are so rare and to have them together.... AND while the pts may endorse the sx of mania, bipolar disorder is a different animal. .

My best friend has both Bipolar and Borderline. And it's no misdiagnosis.

While both are rare, it's easy to see that a patient with Bipolar could likely be more predisposed to develop Borderline for several reasons. Both conditions are more common in those who have a family history of various mental illnesses (not just BPD or Borderline specifically). Someone with untreated Bipolar in their childhood/adolescence would be more vulnerable to developing maladaptive coping skills. In their manic phase, they're more likely to engage in risky behavior which could increase their risk of trauma (hypersexual behavior leading to rape etc.) In their depressed phase, they would lack the energy and motivation to utilize healthy coping mechanisms. Also, since mental illness is more common in those with Bipolar, they are more likely to have been raised in a home with possibly untreated parents which would be more likely to have the neglect/poor parenting/abuse seen with Borderline patients.

 

[whopper]

My best friend has both Bipolar and Borderline. And it's no misdiagnosis.

Not surprising actually. Someone with borderline PD will likely have more stressors and those stressors could initiate the start of bipolar disorder. Studies show a comorbidity with both disorders.

When I wrote what I wrote, it was purely in reference to borderline PD. Of course if someone has bipolar disorder and borderline PD that bipolar disorder needs to be treated with psychotropic medication.

But of course, if the person truly has both, do not expect the bipolar medications to do much with the borderline PD. In this case psychotropic medication in addition to psychotherapy for the borderline PD should be given.

 

[Suedehead]

Not surprising actually. Someone with borderline PD will likely have more stressors and those stressors could initiate the start of bipolar disorder. Studies show a comorbidity with both disorders.

this is one of the things that drives me nuts about bipolar disorder.

Bipolar 1 is the easiest diagnosis to make on earth. True mania that leads to hospitalization - we've seen it on our inpatient units.

The idea that someone can be a 'little bit bipolar' is very new, starting in about the 1970s - episodic irritability, decreased sleep, etc. Such NON SPECIFIC symptoms we have classified under bipolar type II. And while bipolar type II may very well be a reality, our current tools for distinguishing these NON SPECIFIC symptoms from other disorders is poor poor poor.

the statistical comorbidity between bipolar disorder and borderline personality is almost invariably a problem of nosology.

Now, MiesVanDerMom's friend may very well have both, but we need to know what we're talking about. Does the patient have bipolar type I (episodic mania lasting WEEKS with rambling speech, grandiosity to the point of psychosis, ie special powers, healing abilities, and WEEKS of 1-2 hours of sleep per night with little fatigue) and borderline personality? OR does the patient have bipolar type II (poor sleep, irritability, increased energy/impulsivity lasting days here and there) and borderline personality? the former would a fascinating case. the latter is a gaping hole of nosologic confusion.

 

[whopper]

Nosologic confusion?

Exactly.

The comorbidity I'm sure to some degree has to do with the fact that both look similar. I best some of the people in the comorbidity studies were misdiagnosed.

Add to the confusion Cyclothymia, where one has symptoms of bipolar but not enough to meet enough criteria of bipolar mania or a major depressive episode.

Several similar symptoms: The age where the person does behavior that could be considered dangerous start around the same time where it is reasonable for a diagnosis of either bipolar disorder or borderline PD. Both are characterized by impulsivity, emotional dysregulation in borderline can look like irritability in bipolar disordorder, grandiosity could look like black and white thinking seen with borderline.

How do I try to differentiate the two?

Look at both disorders and try to parse out the differences.
1) Bipolar disorder is episodic where the manic/hypomanic episodes will last at least days. Compared to borderline where it's pretty much there all the time.
2) Lack of sleep. Yes it can happen in both, but if the person sleeps soundly even during periods where they show irritability, impulsivity etc., that leans towards borderline PD. (And yes, one can still be manic or hypomanic and still sleep fine though it's rare)
3) Self-mutilation especially in order to decrease the degree of emotional pain strongly pulls this to borderline PD.
4) Increased goal directed activity pushes this more so on the order of bipolar disorder.
5) A strong history of invalidation, abuse, lack of a supportife environment as a child, and good parenting moderately leans on borderline PD.
6) Impulsivity on the order of extreme grandiosity (e.g. I had a patient that opened up a gym all on credit card payments, invited all his friends and family and had them brought there in stretch limos, and had spotlights and a paid a tv celebirty to host the opening of the gym...and no the gym was not expected to rake in that much money) strongly hints of bipolar DO.
7) Psychological testing could help. An MMPI, YMRS, etc.
8) Get as much history as you can. Hospitalizations would be very important because the person may have been full-blown manic during the hospitalization and if records support this, that would strongly support bipolar disorder.

There is a spectrum where several disorders can look like each other.

A person with poor sleep, easy distractibility, faltering relationsihps, "racing thoughts" can be bipolar disorder, generalized anxiety disorder, borderline PD, and/or ADHD. Heck it could be ALL OF THEM (though that would be rare). What psychiatrists call racing thoughts is not what patients know to call racing thoughts. Someone with excessive anxiety could call it "racing thoughts." Remember, they don't have the training you and I have. Someone who diagnoses a patient as bipolar disorder simply on the mention of "racing thoughts" is in my opinion not too bright and is trying to cut corners. (That and the classic "Do you hear voices?" "Yeah I hear your voice." "Oh then you have schizophrenia." I kid you not a resident in my program did that all the time and no attending was willing to correct him. He ended up diagnosing everyone with psychosis.)

If someone says they have racing thoughts, try to further parse what they really mean. Ask open-endedly what they mean by racing thoughts. If they can't give you the information you need from that question, ask them the following: "When you say you have racing thoughts, do you mean you feel anxiety, like as if you're scared?" (suggests anxiety not bipolar disorder) "When you say you racing thoughts, do you mean you feel as if your thoughts are going so fast to the point where it seems uncomfortable?" (suggests bipolar disorder) "By racing thoughts, do you mean you have problems sitting still and if you don't move around you might feel like you're trapped?" (suggests ADHD).

Borderline PD may also describe their problems as racing thoughts but from experience it seems to be more so from a frantic fear of abandonment, problems controlling anger, and intrapsychich splitting.

Cases:A 30 year old Caucasian male with marriage problems including accusing his wife of cheating on him. He never experienced a manic episode but frequently feels that she is cheating on him, poor sleep, and irritability. He meets the chronicity pattern of cyclothymia.
There is no history of abuse, he came from a stable family (parents did not divorce, they are well educated, he is close with his parents).
Turned out that Lamictal 50 mg Q daily stabilized all his symptoms within 3 weeks of treatment (takes 2 weeks to get to 50 mg Qdaily!). Dx: Cyclothymia.
Problems: because he never met the criteria for bipolar disorder, for years psychiatrists and psychologists all told him this was not an Axis I disorder and he went through over 2 years of psychotherapy with little to no benefit.
Remember: cyclothymia exists!

Case: 32 year old Caucasian female with a history of self mutilation (but she no longer does this thanks to DBT), has 5 children, gets no child support, excessive irritability, poor sleep, poor anger management, impulsivity (would stand on cars while they were in motion because it was fun), and complains of racing thoughts.
I parsed out the chronicity pattern of her behaviors. IMHO she had both. She always had emotional dysregulation, the self-mutilation strongly suggests she had borderline PD, but she also had patterns where poor sleep, increased energy, impulsivity, and goal directed activity got worse and lasted weeks.
DX: Bipolar I disorder, most recent episode manic without psychotic features and borderline PD.
Tx: Lamcital 200 mg Q daily. Now there are only symptoms of borderline PD. No episodes of poor sleep, increased energy, and increased goal directed activity. She occasionally does impulsive behavior but not on the extreme it used to occur. She is getting DBT.

I mentioned before that trying to figure out what disorders someone has can be like trying to figure out what's in a dish of food.
Some cases are easy. A bowl of oatmeal with cinnamon. Easy. Pizza with mushrooms on it. Easy
What about a dish where there's meat that could pass for veal or marinated pork? What about the sauce? Figuring out what's in a sauce or gravy can be tough. What kind of cheese is sprinkled on it that's already drown in the sauce?

Diagnosing someone with multiple disorders can become like the latter example. With time, experience, and a true desire to diagnose for real and not cut corners, you can get there.

Start the video at 4 minutes.
http://www.youtube.com/watch?v=y--WVBbElPM&feature=fvw