21
Paul S. Links, Philippe Boursiquot, and Madison Links
Introduction
Case Example
Ms. A., a 28-year-old separated woman with panic disorder and borderline personality disorder, had been exposed over her years of treatment to multiple medications including sertraline, aripiprazole, valproic acid, gabapentin, paroxetine, venlafaxine, risperidone, fluoxetine, citalopram, topiramate, and desvenlafaxine. In spite of her multiple exposures and general experience that medications had not been useful, the patient still attended the consult to request a new medication that might be helpful for her symptoms.
This case example illustrates that patients with borderline personality disorder will request and are often prescribed multiple medications over the course of their disorder. However, the use of medication in the management of borderline personality disorder and other personality disorders is highly controversial. The United Kingdom National Institute for Healthcare and Excellence (NICE, 2015) states that medications are “not to be used” in the management of borderline personality disorder; although they could be utilized to treat comorbid psychiatric disorders. The NICE treatment guidelines are known to be stringent and directly contrast with the American Psychiatric Association guidelines that recommend a symptom targeted approach to the pharmacologic management of patients with borderline personality disorder (APA, 2001). The Australian guidelines from 2012 do not recommend medications as primary interventions but suggest time-limited use for specific symptoms and as adjuncts to psychological therapies (National Health and Medical Research Council, 2012). In spite of the controversy and the need for further research, medication can play a role in the management of symptoms and in improving the functioning of patients with borderline personality disorder and other personality disorders.
Regardless of clinical guidelines, prescribing combinations and high doses of medication are endemic in clinical practice. Zanarini and colleagues (Zanarini, Frankenberg, Hennen, & Silk, 2004) empirically demonstrated that poly-pharmacy was very common and found that over six years of follow-up, 40 percent of patients with borderline personality disorder had been taking three or more concurrent psychotropic medications, 20 percent had been taking four or more, and 10 percent had been taking five or more medications. As a preliminary test of the efficacy and safety of poly-pharmacy, Zanarini and colleagues (Zanarini, Frankenberg, & Parachini, 2004) compared fluoxetine, olanzapine, and the combination of the two medications in 45 women with borderline personality disorder without current major depressive disorder. The study demonstrated that olanzapine was more effective than either fluoxetine alone or their combination for impulsive aggressiveness and dysphoria, and suggested that the support for poly-pharmacy “was limited.” Based on a survey of the use of psychotropic medication in patients cared for in the United Kingdom mental health services, Paton and colleagues (Paton, Crawford, Bhatti, Patel, & Barnes, 2015) reported that 82 percent of patients with personality disorders alone were prescribed at least one psychotropic medication, as were 94 percent of patients with personality disorders and at least one comorbid psychiatric diagnosis. The Emotionally Unstable Personality Disorder (EUPD), the ICD-10 equivalent of borderline personality disorder, was the most common personality disorder diagnosis and in spite of the NICE guidelines, 87 percent of patients with EUPD alone were prescribed at least one psychotropic medication and two-thirds were receiving at least two different classes of psychotropic medication. Crawford et al. (2011) in a separate survey had found evidence that patients cared for by a specialist personality disorder service were less likely to be prescribed psychotropic medication than patients seen within a general adult psychiatric service. However, even in psychosocial randomized controlled clinical trials involving patients with borderline personality disorder that tried to set up ideal conditions, patients were still exposed to two different medications on average (McMain et al., 2009) over the course of treatment.
In this chapter, recent research evidence is reviewed regarding the use of medication for patients with personality disorders. The bulk of the research has been done with patients with borderline personality disorder and this research will be discussed by each drug type. For other personality disorders, less empirical research exists but the evidence again is reviewed by drug type. The review will also make mention of some novel approaches that require further research. These novel approaches highlight possible neuropathological mechanisms underlying personality disorders and may open up new avenues for managing these patients. We will conclude by discussing the limitations of the current research and summarize the principles of our pharmacologic approach.
Review Methodology
A literature search was conducted using the McMaster University Health Sciences Library online catalogue search tool. Parameters of the literature search involved sources limited to peer-reviewed journal articles published between January 1, 2008 and November 19, 2017. In addition, the Health Sciences Library website has a health related article database that was used to find sources. The databases used to search for articles included: OVID, Pubmed, Clinical Key, Cochrane Library, DynaMed Plus, and PsychINFO. The keywords and phrases used for the literature search included the following: personality disorders, borderline personality disorder, pharmacology, pharmacotherapy, drugs, medications, anti-depressants, anti-convulsants, anti-psychotics, anxiolytics, and emotionally unstable personality disorder. The reference lists of sources found via the initial search were scanned to find the titles of additional articles. Fifty-two references were identified by our search methods and the authors in preparing this chapter reviewed all of these articles. Updating the search as of December 31, 2017, six additional articles were identified and reviewed.
Borderline Personality Disorder
Antipsychotic Medications
Based on the major meta-analytic studies and recent reviews done since 2009 (Hancock-Johnson, Griffiths, & Picchioni, 2017; Ingenhoven, Lafay, Rinne, Passchier, & Duivenvoorden, 2010; Lieb, Völlm, Rücker, Timmer, & Stoffers, 2010; Mercer, Douglass, & Links, 2009; Nose, Cipriani, Biancosino, Grassi, & Barbui, 2006; Stoffers & Lieb, 2015), antipsychotic medications are superior to placebo in managing certain symptoms in patients with borderline personality disorder. Antipsychotic medications seem useful in lessening anger, impulsivity, aggression, and the cognitive perceptual disturbances found in patients with borderline personality disorder. Many of the second and third generation antipsychotics have been used with patients with borderline personality disorder; however, all of the studies utilized small samples and were of short duration. The one exception is the study by Zanarini and colleagues (Zanarini et al., 2011) that tested olanzapine versus placebo in a large randomized controlled trial involving 451 outpatients. In this study, 5–10 mg of olanzapine was superior to placebo in lessening borderline personality symptoms. During an open label extension study, the placebo participants improved in a fashion similar to the patients previously treated with olanzapine once active drug was started (Zanarini et al., 2012). Although benefits were evident, the adverse effects of olanzapine were found to be considerable, including somnolence, fatigue, and increased appetite and weight.
Another major study compared quetiapine ER versus placebo in an eight-week randomized controlled trial involving 95 participants. This research compared quetiapine ER 300 mg per day to quetiapine ER 150 mg per day to placebo. Black et al. (2014) found a large effect size for the low-dose quetiapine ER versus placebo on borderline symptoms (d = ‒0.79). The moderate dose versus placebo comparison was not significant, and there were no significant differences between the quetiapine groups. On secondary outcomes including verbal and physical aggression, both quetiapine doses were superior to placebo. However, side effects were common particularly with the moderate dose quetiapine ER. The side effects such as sedation predicted participants’ discontinuation of the study. This study had fairly stringent exclusion criteria for comorbid disorders so further studies are clearly indicated to generalize the findings to the majority of patients with borderline personality disorder who present with multiple comorbid disorders.
Rohde and colleagues (Rohde, Polcwiartek, Correll, & Nielsen, 2017) studied the effects of exposure to clozapine on naturalistic outcomes in patients with borderline personality disorder using Danish national registries and a two-year mirror-image model. Within the sample of 25,916 patients with borderline personality disorder, 4.27 percent (1107) received at least one clozapine prescription. The mean dose of clozapine was 286 mg (95% CI [244,327]) and the mean follow-up was 529.67 days. After adjusting for secular trends and removing patients with comorbid schizophrenia, schizoaffective, or bipolar disorder, treatment with clozapine was associated with a significant decrease in admissions and significant reductions in psychiatric bed-days in patients with “specific” borderline personality disorder. There was no evidence that exposure was associated with an increase in serious adverse side effects such as agranulocytosis, cardiomyopathy, myocarditis, and neuroleptic malignant syndrome. Among all patients with borderline personality disorder, clozapine treatment was related to a significant reduction in the number of patients performing self-harm or overdosing. These observational data are consistent with earlier case series that suggested benefits of clozapine treatment on psychotic symptoms, self-harm behaviors, suicidal ideation, impulsivity, use of restraints, and overall functioning in patients with borderline personality disorder (Beri & Boydell, 2014).
In summary, antipsychotic medications appear to have some usefulness for symptoms of borderline personality disorder such as anger, impulsive aggression, and the cognitive perceptual features. The Cochrane review raised one potential concern suggesting that olanzapine had a clear tendency to cause more suicidal ideation and self-harm in comparative trials. However, this finding does not appear to be a consistent observation but a caution worth noting that needs further study. Overall, antipsychotic medication at low doses can have some value but the risks versus the benefits have to be carefully weighed. Tolerability continues to be a major issue in using antipsychotic medications among patients with borderline personality disorder.
Mood Stabilizers
Mood stabilizers have shown particular promise in treating patients with borderline personality disorder. These medications have been found to have benefits for anger, impulsivity, and perhaps also for affective instability symptoms of borderline personality disorder (Hancock-Johnson et al., 2017; Ingenhoven et al., 2010; Lieb et al., 2010; Mercer et al., 2009; Nose et al., 2006; Stoffers & Lieb, 2015) Various mood stabilizers have been utilized including valproic acid, lamotrigine, and topiramate. Lamotrigine seems to be effective for reducing anger, impulsivity, and perhaps also depression. Reich and colleagues (Reich, Zanarini, & Bieri, 2009), for example, carried out a 12-week randomized controlled trial of flexible dose lamotrigine versus placebo in patients with borderline personality disorder. These patients were chosen for having evidence of severe affective instability and the study’s primary outcomes were related to measures of affective instability. The lamotrigine group (n = 15) versus the placebo group (n = 13) demonstrated significant reductions in affective instability and impulsivity. However, two caveats to note related to this research were that the mean dose of lamotrigine was only 106.7 mg per day and that 3/15 (20 percent) of the lamotrigine participants developed rashes. In practice, this medication is generally well tolerated, but because of the dangers of the Stevens-Johnson syndrome, the medication has to be slowly titrated over weeks to the therapeutic dose range. Therefore, lamotrigine would not be an appropriate medication to use to try to stabilize a patient with borderline personality disorder in crisis. Omega-3 fatty acids (eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA]) have also been evaluated in patients with borderline personality disorder and they may have modest benefit on mood symptoms usually focusing on EPA plus DHA in the range of 1–2 g per day (Hancock-Johnson et al., 2017; Stoffers & Lieb, 2015).
In summary, mood stabilizers can be useful for some with borderline personality disorder and there is evidence to support their use. Most of the trials have been of short duration, although there is a recent investigation of the long-term effectiveness of lamotrigine in patients with borderline personality disorder. Crawford et al. (2018) undertaking a multi-site randomized controlled trial of lamotrigine (up to 200 mg per day) versus placebo in a sample of 252 patients with 3, 6, and 12-month follow-up and found no benefits. The outcome measures were extensive and covered symptoms, self-harm, quality of life, and cost-effectiveness. The results of this study are highly compelling, and are discussed in chapter 21c. Again, mood stabilizers have significant side effects (particularly for women in the childbearing years) and the risks versus benefits must be carefully evaluated.
Antidepressants
The meta-analytic and systematic reviews of pharmacologic treatment in patients with borderline personality disorder suggest that antidepressants have a limited role in the management of these patients (Hancock-Johnson et al., 2017; Ingenhoven et al., 2010; Lieb et al., 2010; Mercer et al., 2009; Nose et al., 2006; Stoffers & Lieb, 2015). There is some evidence that anger, depression, and perhaps affective instability can be symptom targets when using these medications. For example, a recent pilot study of duloxetine in patients with borderline personality disorder suggested that impulsivity, anger, and affective instability were improved (Bellino, Paradiso, Bozzatello, & Bogetto, 2010). However, there is no robust evidence supporting the efficacy of antidepressants in treating borderline personality disorder. Most often, antidepressants are used to treat comorbid depression or anxiety disorders. The use of antidepressants for comorbid disorders is justified; however, the patient has to be realistic about the expected outcomes. For example, we know that the longitudinal course of comorbid depression in patients with borderline personality disorder is more influenced by having the underlying borderline personality disorder resolved than focusing on the comorbid depression (Gunderson & Links, 2014).
Methylphenidate
Attention deficit disorder is often found to be comorbid with borderline personality disorder and this raises the question about prescribing stimulants such as methylphenidate for patients with borderline personality disorder. No randomized controlled trial evidence examining the use of methylphenidate in patients with borderline personality disorder was found for this review; however, there are two studies that are of relevance to this question. An open label prospective study in 14 adolescent females with borderline personality disorder and attention deficit hyperactivity disorder (ADHD) examined several outcomes related to prescribing up to 60 mg per day of methylphenidate (Golubchik, Sever, Zalsman, & Weizman, 2008). The study excluded adolescents with psychosis or substance abuse diagnoses. The findings indicated that ADHD and aggressive symptoms were improved; however, interestingly, in three of the patients, self-harming behaviors were eliminated after exposure to methylphenidate (Golubchik et al., 2008). There was no worsening of the borderline personality symptoms and no development of psychoses. The study requires replication but suggests that, for certain patients, aggressive and self-harming behavior may be helped by methylphenidate. A second prospective naturalistic study compared patients with borderline personality disorder with and without ADHD on methylphenidate to patients with borderline personality disorder and ADHD not on methylphenidate (Prada et al., 2015). All of these patients were going through an intensive Dialectical Behavior Therapy (DBT) program during the course of the investigation. Patients with borderline personality disorder and ADHD on methylphenidate showed significant improvement compared to patients with borderline personality disorder and ADHD not on methylphenidate on motor impulsiveness, overall impulsiveness, ADHD severity, state anger, and depression severity. In addition, the study suggested that patients who had their ADHD symptoms treated with methylphenidate were more available and able to benefit from the DBT program. Again, the study suggests that methylphenidate may have a role in making patients with borderline personality disorder and ADHD better able to participate in psychosocial interventions. This research illustrates that the outcomes of pharmacological interventions should include changes in functioning beyond just symptom improvement.
In summary, methylphenidate prescribed in slowly released preparations may prove useful in patients with borderline personality disorder and comorbid ADHD. When diagnosing ADHD in patients with borderline personality disorder, the clinician should try to confirm the ADHD diagnosis in childhood using collateral and/or school records. Stimulant medications prescribed for adult patients with borderline personality disorder and comorbid ADHD can be helpful, and the benefits should be particularly apparent through improvements in functioning in their treatment programs, school, or work settings.
Novel Approaches
Opioid antagonists such as naltrexone have been tested in female patients with borderline personality disorder in terms of their impact on dissociative symptoms; however, the research showed non-significant effects of naltrexone on dissociative symptoms. The role of naltrexone in modifying dissociation and self-injurious behavior in patients with borderline personality disorder remains controversial but deserves further study (Moghaddas, Dianatkhah, Ghaffari, & Ghaeli, 2017). Clonidine has been used to decrease inner tension and hyperarousal and may be useful in patients with borderline personality disorder and comorbid posttraumatic stress disorder (PTSD; Hancock-Johnson et al., 2017; Stoffers & Lieb, 2015). Doxazosin, a long-acting alpha-1-antagonist that produces fewer orthostatic side effects than prazosin, was studied using a retrospective chart review in inpatients admitted with borderline personality disorder and/or PTSD (Roepke et al., 2017). The results demonstrated that doxazosin reduced nightmares in patients who took the medication over a 12-week period with a medium pre-post effect size (d = 0.78). The authors concluded that doxazosin appears to be a viable option to prazosin in treating trauma-associated nightmares. However, further randomized controlled trials are clearly needed to clarify the role of these medications in patients with borderline personality disorder and comorbid PTSD.
As patients with borderline personality disorder demonstrate dysfunctional interpersonal relationships, several medications have been advanced as possible approaches to improve prosocial behavior. Oxytocin in normal participants has been shown to promote group trust and cooperation and improve social cognitive abilities such as emotional recognition (Amad, Thomas, & Perez-Rodriguez, 2015). Therefore, oxytocin was believed to have possible benefits for improving deficits in mentalizing and the bias to negatively-valenced social stimuli that are found in patients with borderline personality disorder. At this point, there are no clinical trials of oxytocin in patients with borderline personality disorder and most of the studies that have been done have examined laboratory outcomes related to prosocial behavior (Amad et al., 2015). These studies showed a mixture of results in patients with borderline personality disorder, with some evidence that oxytocin can improve hypersensitivity to social threats but contradictory findings that oxytocin may lessen trust and cooperative behaviors in certain social dilemmas. These mixed results may be explained by the social salience hypothesis (Shamay-Tsoory et al., 2009), which suggests that oxytocin may modulate the salience to both positive- and negative-valenced social emotions and, therefore, in certain contexts may lead to contradictory outcomes. Although interest remains in studying the role of oxytocin in patients with borderline personality disorder, all of these findings come from laboratory studies and this research has not controlled for various confounders such as gender differences, menstrual cycle effects, and medication interactions.
Research is underway to determine whether medication could modify the social pain patients with borderline personality disorder experience with actual or perceived social rejection. A recent randomized controlled trial tested the efficacy of exogenous opioids to reduce separation distress and the risk of suicide in adult severely suicidal patients (Yovell et al., 2016). This study tested buprenorphine up to 0.8 mg versus placebo in severely suicidal adult patients without substance abuse to determine whether the medication would reduce suicide ideation and the probability of suicide risk. These patients were not selected for having borderline personality disorder; however, more than half of the participants met criteria for the disorder. Over the four-week trial, buprenorphine versus placebo led to significant reductions in suicidal ideation and in the suicide probability scale. The study also found a reduction in depressive symptoms, but this reduction was smaller than the impacts on suicide risk. Based on these results, the mechanism of action was felt to be through reducing social pain associated with rejection and abandonment versus impacting and reducing depressive symptoms. The study was limited by a high dropout rate, short duration of follow-up, and a need to further study the safety of buprenorphine. However, this research indicates a unique line of inquiry to determine whether modifying social pain can reduce suicidal crises in patients with borderline personality disorder.
Other medications that have been implicated in modifying social pain include acetaminophen and marijuana (Deckman, DeWall, Way, Gilman, & Richman, 2014; DeWall et al., 2010). Roberts and colleagues (Roberts, Krajbich, Cheavens, Campo, & Way, 2018) carried out a randomized controlled trial in undergraduates to determine whether acetaminophen would increase trust behavior in students high in borderline personality disorder features. Participants received an acute dose of 1000 mg of acetaminophen or placebo and then completed an economic trust game. The findings demonstrated that participants with high borderline personality disorder features evidenced less trusting behaviors than participants with low borderline personality disorder features; however, the acute administration of acetaminophen reduced the behavioral distrust of the participants with high borderline personality disorder features. The authors speculated that acetaminophen increased trust in participants with high borderline personality disorder features by reducing negative affect about the possibility of social rejection regardless of expectations. Deckman et al. (2014) used data from cross-sectional, longitudinal, and experimental study designs to test whether marijuana reduced the pain of social exclusion. Based on four separate studies, the authors concluded that marijuana – similar to acetaminophen – activated cannabinoid 1 receptors and could buffer both social and physical pain.
Transcranial magnetic stimulation has been studied in patients with borderline personality disorder through several case reports. A few case reports utilizing a focus in the dorsal lateral prefrontal cortex have suggested that transcranial magnetic stimulation may have an impact on borderline symptoms such as anger and affective instability (Arbabi, Hafizi, Ansari, Oghabian, & Hasani, 2013; Cailhol et al., 2014). Feffer and colleagues (Feffer, Peters, Bhui, Downar, & Giacobbe, 2017) used a focus on the dorsal medial prefrontal cortex and documented improvement in depressive rather than borderline symptoms in three cases of patients with borderline personality disorder. Transcranial magnetic stimulation deserves further study in patients with borderline personality disorder, particularly with regard to its impact on mood and affective instability.
Pharmacotherapy in Other Personality Disorders
Compared to borderline personality disorder, there is a relative dearth of evidence-based directives with respect to pharmacological interventions for other personality disorders (Ripoll, Triebwasser, & Siever, 2011). The available literature provides guidance for mainly two additional personality disorders: schizotypal and avoidant. Also, contrary to borderline personality disorder, much less evidence supports the use of mood stabilizers for other personality disorders.
Antipsychotic Medications
Both typical and atypical antipsychotics have been studied – and found beneficial – in schizotypal personality disorder (Bateman, Gunderson, & Mulder, 2015; Herpertz et al., 2007; Mazza, Marano, & Janiri, 2016; Roepke et al., 2008). This stems mostly from small, open-label studies (Bateman et al., 2015). Koenigsberg et al. (2003) reported one of the few randomized controlled trials in patients with schizotypal personality disorder. Koenigsberg et al. hypothesized that risperidone would be useful for both the positive and negative symptoms of the disorder. Twenty-one schizotypal patients were involved in the randomized controlled trial. They were treated with risperidone up to a maximum dose of 2 mg per day. Results of the study revealed significant effects on both positive and negative psychotic symptoms. Using a 30 percent change in scores as a response rate, four of seven patients exposed to risperidone were considered responders versus none in the placebo arm. Overall, the benefits of antipsychotic medication pertained to modifying the psychotic-like symptoms, but also the cognitive deficits that are mostly associated with schizotypal personality disorder.
Antidepressants
Herpertz et al. (2007), on the basis of the clinical resemblance and continuum between social phobia and avoidant personality disorder, suggested extrapolating the findings pertaining to the pharmacological interventions for social phobia to treatment options for avoidant personality disorder. As such, on the basis of randomized controlled trials conducted in patients with social phobia, selective serotonin reuptake inhibitors, as well as the selective norepinephrine reuptake inhibitor venlafaxine, can be first-line pharmacological agents for the treatment of avoidant personality disorder. There is also a role for phenelzine, although the side effect profile makes this a less appealing choice. The presence of avoidant personality disorder was noted in some of these studies (4 of 26), with similar or even greater benefit from moclobemide (3 studies) and sertraline (1 randomized controlled trial) in samples with the two conditions rather than social phobia alone. Unfortunately, pharmacological treatment suggestions related specifically to avoidant personality disorder are based on case series rather than randomized controlled trials (Deltito & Stam, 1989).
Novel Approaches
A randomized placebo-controlled double-blind trial (McClure et al., 2010) showed that pergolide, a D1 and D2 dopamine agonist, reduced several cognitive deficits in patients with schizotypal personality disorder. The domains that improved during the trial were visuo-spatial working memory, executive functioning, verbal learning, and memory. Although pergolide has since been removed from the market due to concerns around induction of valvular heart disease, future research in this domain may identify agents with similar properties and benefits.
Intranasal oxytocin has also been tested in patients with antisocial personality disorder (Alcorn, Rathnayaka, Swann, Moeller, & Lane, 2015). In this small study (n = 6), male participants received intranasal oxytocin, and human aggression was monitored with the point subtraction aggression paradigm. The results were not conclusive, but this new approach, along with some more robust findings in borderline personality disorder, may suggest the utility of further study in other personality disorders.
Limitations
Although there is research evidence supporting the value of medication over placebo for certain symptom targets in patients with borderline personality disorder, this research has many limitations. Most of the studies have samples with an overrepresentation of women, and the number of men with borderline personality disorder involved in these studies is limited. Overall, the sample sizes in the studies are small, trial durations are short, and often there have been extensive exclusions of participants with clinical or non-personality disorder psychiatric comorbidities that make the generalizing of findings problematic. The quality of the studies is often questionable, creating a risk of biases. The study of personality disorders has been severely hampered by the limits of the measures of the psychopathology characteristic of these disorders. It may well be that impulsive aggressiveness is the best-measured aspect of personality disorder pathology and we have been able to demonstrate change in this because of its measurable behavioral component. There is a lack of definition of the affective and cognitive aspects of personality disorders. Not only do we have to refine the definition of the various aspects of psychopathology, but we also need to develop responsive measurements that can capture change through pharmacological interventions. These measurement issues need to be addressed so that we may demonstrate beyond behavior that we are able to effect changes in affect and cognition.
Finally, as patients with borderline personality disorder are often exposed to medication, there has been insufficient attention given to the side effects and reasons for withdrawal in previous pharmacologic trials. An important outcome of pharmacological trials should be an improvement in work, family, and other aspects of role performance. In the future, pharmacological trials should include indicators of quality of life so they can be used as measures of effectiveness of pharmacological interventions and provide a broader assessment of the impact of pharmacological interventions beyond symptom reduction and side effects. Certainly more research on the psychopharmacologic management of patients with personality disorder is warranted and needs to be supported.
Patients’ Experience of Medication
Clinicians, besides considering the research evidence for using medication, must understand patients’ experience of being prescribed medication. Rogers and Acton (2012) used qualitative methods and thematic analysis to capture the experiences of seven patients with a diagnosis of a personality disorder treated within a specialist service. The patients spoke about their recovery pathways and how they often felt that they were not involved in treatment decisions, including whether they wanted medication to be a part of their recovery plans. Some patients felt that medication was not necessary for their recovery, whereas others saw medication as important to their recovery. The patients reported more opportunity to have input in their treatment when they were treated by a specialty service (Rogers & Acton, 2012).
The clinician needs to ask about the patient’s perceptions of medication treatment particularly because most of the medications are associated with adverse effects. As many young people are diagnosed with personality disorders, their exposure to medications can lead to an increased risk of obesity and the development of metabolic syndromes that can impact their lifetime morbidity, mortality, and quality of life. All personality disorder clusters have been shown to have a robust relationship with obesity, and in the McLean Study of Adult Development, the rate of obesity rose among patients with borderline personality disorder from 17 percent at baseline to 28 percent at six-year follow-up (Dixon-Gordon, Conkey, & Whalen, 2018)
In addition to taking time to understand patients’ perceptions of the role of medications in their recovery, the clinician must understand the psychodynamic and interpersonal exchanges associated with the pharmacotherapy relationship. Kenneth Silk (1996, p. 124) cautioned “understanding what medication means to the patient is crucial because whenever medication is introduced into any therapy, it has repercussions on the transference process.” Perhaps this is nowhere truer than when prescribing for the patient with borderline personality disorder. Pills and prescriptions can be loaded with meanings, affected by the patient’s attachment history, and affected by how the patient regards him- or herself in illness and as a receiver of care. Understanding what purpose and meaning medication holds – not only for the patient but also for the involved clinician(s) – can help to minimize and make use of transference/relationship feelings, direct psychoeducation about personality disorders and the role of medication, and assess clearly the impact of any one medication change. The clinician’s self-worth and anxieties regarding being competent and/or in control can become magnified in the context of a therapeutic relationship with the borderline personality disorder patient who feels helpless, hopeless, out of control or too controlled, and acts out these meanings – in part – via their expectations of and adherence to medication.
In structuring our thinking of how to examine the meanings and dynamics of the pharmacotherapy relationship alongside the effect of a medication adjustment, Gunderson (2001) identified the need to assess what positive and negative attributions the patient has towards medication and towards the prescribing clinician. Building upon this notion, two dimensions or axes can be addressed (Table 21.1). The first axis tracks the “outcome” or treatment response. The second axis examines the transference/relationship issues and quality of the therapeutic relationship. Using this model assumes two things: (1) the patient is basically compliant with medication and (2) the therapist’s expectations regarding the effectiveness of the medication are in accordance with existing evidence.
Table 21.1Therapeutic outcomes and pitfalls
|
Attributions |
|||
|
Negative Relationship |
Positive Relationship |
||
|
Treatment Response |
Negative |
Feeling controlled, persecuted, thwarted |
Won’t stop ineffective medication; may abuse them. |
|
Positive |
All improvement attributed to medication. Therapy is dismissed, and possibly avoided. Patient potential to improve only half accessed. |
Therapist &/or medications idealized short term. |
|
Where there is a negative rapport and apparent negative response to medication both subjectively and objectively, the patient – and clinician – may begin to attach several negative meanings to the medication and therapy. The patient who experiences difficult side effects or gets no relief may feel they are being “experimented upon” and question the genuineness of the clinician’s concern. Many patients with borderline personality disorder will feel paranoid and persecuted at times, and may view medication as the clinician’s covert means of trying to control them. Increased non-adherence of the patient to the regime may be a warning sign. At the same time, some clinicians, particularly those who feel rushed or pressed for time, may respond with feeling thwarted and that their effort has been deliberately sabotaged; in other words, they too feel as persecuted as the patient. Warning signs of this reaction might include avoidance of the patient, cutting time, changing or cancelling appointments, or being increasingly inflexible. These efforts by the clinician to try to gain more control are just what the patient fears. The patient’s complaints may then be inadequately assessed and misattributed solely to their “personality.” Other negative attributions or meanings that may be attached to the medication and therapy include being untreatable, helpless, dependent, and/or viewed as incompetent.
In another scenario, the patient may have a negative treatment response but still maintain a basically positive rapport with the pharmacotherapist. In some circumstances, the patient may not want to stop a medication even though it appears to be causing disconcerting side effects or is of questionable benefit. In such circumstances, the medication regime may have some positive meaning or association, perhaps to a previous soothing or valued therapist. Such a patient could possibly resort to abusing these medications in seeking the soothing memory of the old therapist, perhaps misattributing treatment failure as their own “incurability” and hopelessness. Additionally, a patient may think that compliance is essential, even though there is subjectively and objectively little benefit, in order to maintain the current clinician’s approval. Another possible outcome in this scenario is the patient’s secret non-compliance and stockpiling of medication. The patient will need careful coaching to have them evaluate if their need is actually being met through such behaviors.
In a third scenario, one might have a positive treatment response yet the rapport remains negative. Whereas symptom relief will usually enhance the patient–clinician relationship, medication and therapy can continue to hold a great deal of negative meaning that can be projected into the relationship. Feelings and perceptions of being mentally ill or “disordered,” vulnerable, or controlled can remain at play. The patient may accept that medication has some value but downplay the relationship, taking on the stance of “You’re not such a great doctor but I’m hanging in there just for the meds.” The clinician who consequently feels rejected and helpless may, once again, want to avoid the patient with the consequence being that the therapeutic relationship is left to dwindle; dynamic issues do not get addressed and the patient’s distress related to interpersonal issues remains.
In a fourth and final scenario, the response to medication is positive and the therapeutic rapport is also positive. Even in this circumstance, pitfalls exist. The meanings the patient – and clinician – attribute to medication need to be understood. A primary pitfall is that the clinician and/or medication may become idealized and this may be short-lived. Without a clear understanding of what change medication has effected alongside the therapy relationship, life stressors, and the patient’s acquisition and use of new coping skills, these positive gains may be incorrectly attributed to medication. A downturn in the patient’s mood that becomes attributed solely to the medication “not working anymore” might result in the once idealized clinician making greater and greater efforts to eliminate the symptom. Symptom chasing, polypharmacy, over-involvement, and therapy exhaustion are all possible consequences.
Clinical Approach
To ensure that pharmacotherapy does more good than harm, we suggest that clinicians adopt the following approach when prescribing medications to patients with personality disorders. When treating a patient with a personality disorder, the clinician is often clear when aggressive treatment is needed and when to first prescribe pharmacotherapy. The difficulty according to Soloff (2000) is when to settle for “modest gains” and then maintain and eventually stop the current regime. As a result, clinical outcomes should be measurable and related to the patients’ functioning. When medications are to be considered, the clinician should create a partnership with the patient in choosing the medication, discussing the options, and then monitoring and evaluating the outcome. Encourage patients to investigate the medications using appropriate online resources or reading materials. Often, patients can be directly engaged in deciding how best to measure the outcomes of interest. In addition, symptoms that might be possible side effects of the medication should be monitored at baseline and over the course of the medication trial.
Some useful principles to follow when managing patients with personality disorders are avoiding polypharmacy, regularly reviewing the value of long-term medications, treating comorbid clinical or non-personality psychiatric disorders as a priority (especially if they interfere with functioning or participation in psychosocial treatment), and eschewing medication changes during crisis episodes. Crisis management skills ultimately will be much more useful in crisis episodes versus a possible placebo response to a new medication. If the patient fails to respond to a medication, the agreement should be to taper and stop the first medication before beginning another medication (unless a cross-taper is feasible). If the patient has negative attitudes towards the medications or their use, as indicated above, these feelings need to explored and understood. Whenever medications are to be considered, the patient and clinician must evaluate and monitor the risks versus the benefits. Finally, the patient must understand that medications are adjunctive agents, whereas psychosocial interventions appear to be the primary approach to treatment.
Summary
Good psychiatric care of patients with personality disorders still supports the use of medication for specific symptoms and to foster certain outcomes in patients with personality disorders (see Table 21.2; Gunderson & Links, 2014). Unfortunately, most of the trials involve patients with borderline personality disorder and, thus, we know much less about how to use medications for other personality disorders or how effective medication would be for specific pathological personality traits regardless of diagnosis. Pharmacotherapy should still be considered as an adjunct to evidence-based psychosocial interventions, and the clinician must carefully weigh the risks versus benefits of prescribing psychotropic medication. Certainly more research and pharmacological trials are indicated and several novel approaches suggest that new neuropathological mechanisms are worthy of further study. In the future, collaborative networks of researchers should be established that would allow the testing of pharmacological agents in larger, representative samples using state-of-the-art clinical trials. In addition, specific protocols could test an algorithm approach to the treatment of personality disorders based on systemized protocols.
Table 21.2Pharmacological summary
|
Drug type |
Summary |
Example |
|
Mood stabilizers |
Broadest effectiveness, but only modest effectiveness for depression/mood stabilization. More useful for anger/impulsivity |
Lamotrigine |
|
Antipsychotics |
Second broadest effectiveness. Side effects encourage time-limited trials |
Quetiapine |
|
Antidepressants |
Uncertain value, used for comorbid disorders especially for depression/anxiety |
Fluoxetine |
|
Anti-anxiety |
Benzodiazepines: habit forming, sometimes disinhibiting. Relatively contraindicated; trauma-related anxiety – clonidine; prazosin |
Prazosin |
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