Overcoming Barriers to Excellent Pharmacologic Treatment of Borderline Personality Disorder

Kara R. Wong, PharmD, BCPP
Senior Editor, Recertification Editorial Board

This session can be purchased in CPNP University

Borderline personality disorder (BPD) is an extremely heterogeneous disorder characterized by a pervasive pattern of unstable relationships, avoidance of abandonment, identity disturbance, impulsivity, recurrent suicidal behavior, affective instability, intense anger and stress-related paranoia. BPD impacts between two to six percent of the population and is commonly encountered in practice. Unfortunately, BPD is a highly stigmatized diagnosis and is significantly underrepresented in discussions about mental illness. In the opening session of CPNP’s 2019 Annual Meeting, Dr. Katharine "Kaz" Nelson shared her expertise in providing evidence-based care to those with BPD.

Dr. Nelson acknowledged that BPD has a reputation of being “untreatable.” However, she emphasized that BPD can improve over time with appropriate treatment. A comprehensive treatment plan for BPD should include non-pharmacologic interventions. There is no FDA approved medication for the treatment of BPD and medication is not an essential component of treatment. However, some medications have been shown to target specific symptom domains of BPD, and may be considered after the patient has been thoroughly educated about the risks and benefits, including off-label use. Co-morbid mental health disorders may dictate medication selection and meta-analyses provide guidance in medication selection based on BPD symptom domains.

The symptoms of BPD make it challenging for patients to feel heard by their providers. Certain communication strategies can assist with building a therapeutic relationship. Dr. Nelson stressed the importance of never minimizing a patient’s symptoms; it is essential to frequently repeat what is legitimate to the patient (i.e. pain, suffering, disappointment). Another strategy is to replace “but” with “and.” For example, “This medication feels helpful in the short term and makes things worse over time.” Lastly, frequent and regular appointments can assist with earning a patient’s trust.

Following Dr. Nelson’s session many members approached her for additional resources. She recommended the following tools to support further learning and clinical practice:

• The Mind Deconstructed Podcast (https://www.theminddeconstructed.org/)
• National Education Alliance for Borderline Personality Disorder (https://www.borderlinepersonalitydisorder.org/)
• Borderline Personality Disorder Demystified: An Essential Guide for Understanding and Living with BPD by Robert O'Friedel
• The High-Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, and Validation by Alan Fruzzetti and Marsha Linehan

Take Home Points

• BPD is a common mental health disorder that should be openly discussed with patients.
• BPD can improve with appropriate treatment.
• There are many non-pharmacologic evidence-based treatments available for BPD; BPD is not a disorder that requires medication. If pharmacotherapy is elected as part of a comprehensive treatment plan, then a medication should be selected through shared-decision making based on co-morbid mental health disorders and the BPD symptom domain posing the greatest impairment.
• Key strategies for cultivating a healthy treatment alliance include frequent and regular appointments, explanations using plain and clear concepts, and never minimizing a patient’s symptoms. 

References

1. Ingenhoven T, Lafay P, Rinne T, Passchier J, Duivenvoorden H. Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials. J Clin Psychiatry. 2010;71(1):14–25.
2. Lieb K, Völlm B, Rücker G, et al. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry. 2010;196(1):4–12.
3. Stoffers J, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K. Pharmacologic interventions for borderline personality disorder (review). Cochrane Database of Systematic Review. 2010;6:1–330.
4. Nelson KJ & Schulz SC. Treatment Advances in Borderline Personality Disorder. Psychiatric Ann. 2012; 42(2): 59–64.
5. Stoffers JM & Lieb K. Pharmacotherapy for Borderline Personality Disorder—Current Evidence and Recent Trends. Curr Psychiatry Rep. 2015;17:534.