Is there evidence-based psychopharmocology for BPD?

[futureapppsy2]

Psychologist here--I was taught--and teach my students--that DBT is the standard of care for BPD and genuinely pretty effective if implemented with good fidelity (which, admittedly, can be hard to find in many areas). I've always gotten the strong impression that common practice re: psychopharmocological tx for BPD is, unfortunately, kind of lobbing stuff at the wall to see if anything sticks, often to the point of dangerous polypharmacy. Is there actual evidence-based psychopharmocology for BPD? I did a very cursory lit search, but the review articles seemed to be old and basically promoting the "throw medications at the wall and see if anything sticks" approach I mentioned above.

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[Stagg737]

Psychologist here--I was taught--and teach my students--that DBT is the standard of care for BPD and genuinely pretty effective if implemented with good fidelity (which, admittedly, can be hard to find in many areas). I've always gotten the strong impression that common practice re: psychopharmocological tx for BPD is, unfortunately, kind of lobbing stuff at the wall to see if anything sticks, often to the point of dangerous polypharmacy. Is there actual evidence-based psychopharmocology for BPD? I did a very cursory lit search, but the review articles seemed to be old and basically promoting the "throw medications at the wall and see if anything sticks" approach I mentioned above.

Specifically for BPD? No, however BPD patients often have other co-morbidities or symptoms which can be treated well with medications. Lots of BPD patients note improvements after starting SSRI/SNRIs as their MDD/GAD exacerbates their personality problems. It can sometimes seem like just throwing meds at them (and unfortunately this actually happens too frequently), but I've found that most of the time it's because there's an incorrect diagnosis or the symptoms we think are related to depression/anxiety/whatever are actually a personality component that improve with therapy. If a patient is purely BPD with no other psychiatric co-morbidities (aka a unicorn) then it's therapy all the way.

 

[comp1]

There is not clear and good evidence for psychopharmacology in borderline personality disorder. You can of course find relatively weak studies supporting the use of pretty much any class of medications, but standard of care is not pharmacologic. Given how severe the disorder is and how often it is misdiagnosed as a primary mood or psychotic disorder compared to its demonstrated population prevalence, you will often see extreme polypharmacy in an attempt to get it under control. As a psychologist, any psychometric testing you can supply to prescribers to demonstrate the presence of borderline personality disorder and lack of conditions that would better explain the presenting symptoms, you could do a world of good and keep the patient off a polypharmacy merry-go-round.

 

[futureapppsy2]

Specifically for BPD? No, however BPD patients often have other co-morbidities or symptoms which can be treated well with medications. Lots of BPD patients note improvements after starting SSRI/SNRIs as their MDD/GAD exacerbates their personality problems. It can sometimes seem like just throwing meds at them (and unfortunately this actually happens too frequently), but I've found that most of the time it's because there's an incorrect diagnosis or the symptoms we think are related to depression/anxiety/whatever are actually a personality component that improve with therapy. If a patient is purely BPD with no other psychiatric co-morbidities (aka a unicorn) then it's therapy all the way.

Yeah, SSRIs/SNRIs to treat co-morbid MDD/GAD makes sense. I'm more thinking of the (seemingly not-uncommon) practice of prescribing mood stabilizers and/or atypical anti-psychotics to patients with BPD who have no real indication of psychotic or bipolar disorders.

 

[Sushirolls]

Last review I did several years ago was Lithium / Seroquel / Lamictal, for weak benefits. Then a review came out few years ago saying lamictal didn't really do anything.

I emphasis DBT DBT DBT, and any pharmacology trials I don't emphasize nor try to oversell for efficacy. Here and there I've had some symptom reduction with lamictal or lithium. I try to avoid antipsychotics in general.

Some patients simply don't want to enroll in a full time DBT program, and their therapists have no interest in doing DBT work book sessions, so some spinning of wheels happens with meds. But I've also found identifying and making the diagnosis and routinely openly discussing that, is therapeutic in its own way for folks who are more on a mild severity spectrum.

I once had one patient who spent 80% of the days of the year in a hospital, but after doing ECT with maintenance, patients days in hospital dropped to like less than 10% of the year.

Some of the folks I've seen you get lucky with low dose lamictal or lithium or whatever SSRI/SNRI, and that is enough quiet symptoms down to now they are more willing to seek out and engage in DBT.

 

[docksan]

I've heard Abilify has some promising data.

 

[FlowRate]

IMO decent evidence for lamotrigine and aripiprazole when balanced against how both typically have mild side-effect profiles. I've also had good anecdotal clinical experience with both. I used to have a table saved from an article on BPD pharmacology evidence base that I really liked but 20 minutes of googling and I can't find it. Here's a link to the last cochrane review on the subject.

I've read a little about Good Psychiatric Management (GPM, which is primarily a therapeutic approach) and worth looking into before assuming everyone needs full-fat DBT. Not sure how many places actually implement GPM as published though.

 

[theduderino]

I don't have the DBT lit at my fingertips, but from what I recall even DBT primarily only effects the self-harm/suicidality domains of BPD. Correct me if I'm wrong. GPM isn't as intensive as DBT for sure, but still assumes pretty frequent follow ups. One of the underlying treatment problems is the sheer variety of manifestations of BPD. This is from a CME review from a few years ago... my take is to limit polypharm and think carefully about what portion of BPD I'm trying to target.

 

[aim-agm]

Another challenge with pharmacotherapy in BPD is that in many patients EVERYTHING will work great...for a few weeks. Then they switch to (or add) another medication and the placebo effect works its magic until it doesn't. Repeat dozens of times.

I've had good experience with sympatholytics (alpha2-agonism in particular) to help control emotional reactivity and impulsivity as an adjunct to psychotherapy for patients engaging well in treatment.

 

[Taddy Mason]

We recently had a grand rounds that touched a fair amount on this topic by Kaz Nelson from the UofMN. The general takeaway was that data for psychopharm in BPD is very limited and should be aimed at targeting comorbid disorders that are clearly co-occurring and not just a product of character pathology. If meds are going to be used they should really be limited to one agent and really try to avoid benzos. I don’t remember if she had explicit data on this or if it was more anecdotal, but seemed to have some slight leanings towards lamotrigine in terms of its affective blunting without being really sedating/dulling.

 

[NickNaylor]

There's a Cochrane review about pharmacotherapy for bipolar disorder here: Pharmacological interventions for people with borderline personality disorder

 

[robellis]

There's a Cochrane review about pharmacotherapy for bipolar disorder here: Pharmacological interventions for people with borderline personality disorder

It’s not bipolar!!! 🤣

 

[Stagg737]

Yeah, SSRIs/SNRIs to treat co-morbid MDD/GAD makes sense. I'm more thinking of the (seemingly not-uncommon) practice of prescribing mood stabilizers and/or atypical anti-psychotics to patients with BPD who have no real indication of psychotic or bipolar disorders.

So imo it depends on how you're trying to treat the patient. Are you trying to treat the actual disorder or just manage a symptom? As others have said, BPD can present in many ways and the form of a patient's dysfunction can vary a lot. Do they keep getting fired for severe anger or violent outbursts? Do their mood swings prevent them from having appropriate interactions? Are they impulsive and using a lot of substances and are promiscuous? Do they struggle with trusting or interacting with others d/t paranoia or have illusions/hallucinations that bother them (the background whispering, seeing the walls "breathing", etc)? Is it some combination of the above? We know the variation is there, but we just lump all patients with a specific PD together and expect a universal treatment to be effective. I think this is partially d/t the stigma of mental health, even within the medical community, and does a disservice to our patients with PDs.

If I have a BPD patient who does well in most domains but has a specific symptom that causes problems, I usually address the specific symptom in addition to therapy. I agree with others that Abilify at low doses can be helpful for managing irritability and anger. I've found lamictal can also be helpful, but is more hit or miss and makes me wonder how much of it is just placebo. I know docs who will have BPD patients on antipsychotics for those with hallucinations/illusions/paranoia. I don't start patients on APs for psychotic symptoms unless the symptoms are severe, in which case I'm also monitoring for a primary psychotic disorder. However, I have inherited some BPD patients on solid doses of antipsychotics (most commonly latuda and abilify) who just do better with them. As long as they're not having side effects, I don't mess with their stability.


Might be doxxing myself a bit, but I'm actually going to start working with a new research project focusing on personality disorders from the alternative approach and looking at treatment efficacy for various symptoms domains. I'm particularly interested in developing better rating scales for severity of PDs to better guide treatment approaches and hopefully develop some outlines to identify which patients may actually benefit from meds vs. just therapy. I'll report back in 2-3 years when we've got the results, lol.

 

[clausewitz2]

GPM as intended is going to go about pharmacotherapy in very much the same way as many people are describing here. You identify specifically the symptom/symptom cluster you are hoping to affect with the medication, discuss this with the patient, be very careful to track response over time, and have a low threshold for discontinuing if it doesn't appear to be effective. I would say it is generally allergic to significant polypharmacy - if something isn't working to the point you are thinking about a second agent, it probably isn't working well enough to justify it in the first place.

The big naturalistic lamictal study that came out of the UK a couple years back was disheartening but had a major issue I haven't seen people mention much. For reasons that are a little mysterious to me the medication each group was assigned to (placebo v. lamotrigine) could not be sent by mail to a substantial proportion of participants, and so instead members of the research team paid weekly visits to these people to deliver the medications.

I kind of think there is a floor effect likely when you have a disorder that is often conceptualized as a problem with attachment runs into very regular visits for years with polite, curious people who are very interested in you personally and concretely demonstrating how much they care by bringing a medicine for a very important scientific study.

 

[NickNaylor]

It’s not bipolar!!!

Ha! My bad - I did link to the right paper though.

 

[DynamicDidactic]

Since all the PDs are so heterogenous (and overlapping), I think it is important to think about symptoms rather than a change of personality. This trial seems to show equivalence compared to DBT when dealing with suicidal clients and the psychiatrists are experts in that area.

Psychiatry Online

ajp.psychiatryonline.org

To me it seems more and more that avoiding hospitalizations (e.g., APA PsycNet) helps reduce suicidality. Seeminly, expert suicide psychiatrists are much more likely to avoid hospitalizations.

All the other stuff associated with BPD, 🤷‍♂️