Borderline personality disorder: what role for medication? Mike Crawford Imperial College London CNWL NHS Foundation Trust m.crawford@imperial.ac.uk
Licensed medication for PD
Jane, 34, moderately severe PD prominent negative emotionality, repeated self harm, self hatred, comorbid bulimia nervosa
Jane, 34, moderately severe PD prominent negative emotionality, repeated self harm, self hatred, comorbid bulimia nervosa Unemployed, abusive relationship Very disturbed family background social care/ father Referred by community team following recent admission to hospital: crisis, paranoia, hearing voices, self-cutting Medication: Quetiapine 400mg BD, Mirtazapine 30mg Diazepam 2mg TDS, Zopiclone nocte No record of BMI, glucose or lipids BMI = 34.3 (30> = obese), abnormal LFTs
Prescribing for people with borderline PD Evidence-base Guidelines Prescribing in practice Experience-based recommendations Research and future developments
DSM IV Borderline PD Affective Inappropriate intense anger or difficulty controlling anger Chronic feelings of emptiness Affective instability Cognitive Transient paranoid ideation Identity disturbance Behavioural Recurrent suicidal behaviour, threats, or self mutilating Impulsivity harmful acts other than suicidal behaviour Interpersonal Frantic efforts to avoid abandonment Unstable and intense interpersonal relationships
DSM IV Borderline PD Affective?depression - antidepressants Inappropriate intense anger or difficulty controlling anger Chronic feelings of emptiness Affective instability -?bipolarity mood stabilisers Cognitive Transient paranoid ideation -?antipsychotics Identity disturbance Behavioural Recurrent suicidal behaviour, threats, or self mutilating Impulsivity harmful acts other than suicidal behaviour Interpersonal Frantic efforts to avoid abandonment Unstable and intense interpersonal relationships
DSM IV Borderline PD Affective?depression - antidepressants Inappropriate intense anger or difficulty controlling anger Chronic feelings of emptiness Affective instability -?bipolarity mood stabilisers Cognitive Transient paranoid ideation -?antipsychotics Identity disturbance Behavioural Recurrent suicidal behaviour, threats, or self mutilating Impulsivity harmful acts other than suicidal behaviour Interpersonal Frantic efforts to avoid abandonment Unstable and intense interpersonal relationships
Evidence base
Antidepressants 7 trials (poor methodological quality) Findings 6 no evidence of beneficial effects, 1 trial of Amitriptyline reported reduction in depressive symptoms BUT 30% of people in contact with services meet criteria for depression Treatment of depression among those with coexisting personality disorder
Response to antidepressants (Newton-Howes, 2006)
Why? Symptoms do not have same neurobiological correlates as in depression Compliance Coexisting drug and alcohol use Alexithymia - No words for self reduced ability to identify and describe one s emotions Qualitative exploration of patient s experience of self ascribed depression among borderline PD and major depression (Westen et al. 1992) diffuse negative feelings..emptiness, loneliness, shame
Antipsychotics 13 trials (2) Haloperidol, (4) Olanzapine, (1) Aripiprazole, (1) Ziprasidone. Some evidence of reductions in hostility, anger and impulsivity. BUT Short term: 1-3 months High attrition rate (35 to 50% not followed up) Side effects: e.g. 2kg increase in weight with Olanzapine.clozapine
Clozapine (case series) Frankenburg & Zanarini 1993 M&F outpatient (n = 15) after mean of 4m reduced symptoms and improved functioning Bendetti et al. 1998 IP Women with BPD 16 weeks (n = 12) reduction in impulsive behaviour and in affect-related symptoms Chengappa et al. 1999 IP Women with BPD & psychosis (n = 7) decreased aggression and self harming behaviour Frogley et al. 2013 Forensic IP Women with BPD (n = 22) 18m FU: evidence for a beneficial effect of clozapine on symptom severity, reduced use enhanced observations, fewer aggressive incidents in period after initiating clozapine. Greatest within the first 6 months. Significant increase in weight.
Mood stabilisers 9 trials: (1) Carbamazepine, (3) Valproate, (3) Topiramate, (2) Lamotigine. Findings evidence that they lead to reductions in anger, depression and impulsivity. BUT Small (<50) Poor methodological quality
Methodological limitations Funding: GlaxoSmithKline Sample: websites and TV adverts Severity: Mean GAF = 55 Outcomes: Subscales on ZAN-PD but not on total score
Never had another manic episode
Interpreting the evidence NICE (2009) Do not use drug treatment specifically for borderline personality disorder or for the individual symptoms or behaviour associated with it. Cochrane review (Lieb et al 2010) Mood stabilisers and second-generation antipsychotics may be effective in treating symptoms associated with borderline PD...WHY?
Interpretative bias Differences of opinion Methodological quality Cost/ benefits weight gain, teratogenesis (IQ and valproate) Difference between clinical and research populations Compliance Overdose Polypharmacy
Prescribing in practice Examine the use of psychotropic medication in people with borderline PD in contact with secondary care mental health services Which drugs are being prescribed, and why Approved by local audit departments Electronic search of records for F60.3, NO psychotic disorder 1 in 10 sample of records (Spring 2010) Three mental health Trusts in London: CNWL, Oxleas and West London
Results 1755 patients Sample of 175 26 excluded as clinical diagnosis if psychosis, 4 sets of notes unobtainable data from 144 Aged 17 to 79 (mean = 38). 108 (75%) female 105 (73%) white British 75% had one or more co-morbid mental disorders Depression - 60 (42%) Substance misuse - 46 (32%)
Results Total of 258 medications 123 patients (85%) prescribed one or more medication 78 (54%) prescribed two or more Half of those on antidepressant had no record of depression Lower levels of medication among those treated by specialist PD services Number of drugs N % 0 21 15 1 45 31 2 36 25 3 31 21 4 7 5 5 4 3
People with which type of PD were most likely to be receiving a prescription?
Specific PDs
Reasons for prescribing Of the 107 taking an anti-depressant, 53 (50%) had diagnosis of depression recorded in their notes
Duration Duration: 95 (37%) of 258 for more than three years
POMH-UK 12a All current IPs and all OPs seen in last 8 weeks 2600 from 61 Trusts (mean age 39, 59% female) Among those with borderline PD 33% more than one antipsychotic, 13% - three or more in last 12 months Those who did NOT have a coexisting axis one disorder recorded were LESS likely to have documented evidence that side effects were checked
Implications Support for concerns raised in NICE guidelines: polypharmacy, half on long term use of antipsychotics Life expectancy reduced by 19 years main cause cardiovascular disease (Fok et al. 2011) Cost: 107 patients = 37,000 (Baker-Glen et al. 2010)
Why are levels of prescribing so high and what might be done to reduce this? So.
Why are levels of prescribing so high and what might be done to reduce this? So.
Why? Patient factors Don t trust words only actions - something must be done! Dependence (fear of abandonment) Clinician factors Counter-transference (McIntyre & Schwartz, 1998) Hostility and anger, frustration/ manipulation, doing harm Feeling that you are not doing enough - decreases with years of experience
Principles of management Avoiding extremes e.g. dismissing-taking over, excusing-demonising Active participation in working out what to do (what helped in the past?) Being consistent as a service (reflective practice) Knowing your limits and boundaries (while avoiding extremes)
Principles of management Acknowledge distress Containing anxiety FU appointment, text, email NHS/ voluntary sector helplines Being explicit Provide information (McMain et al, 2009)
Information for patients NICE http://publications.nice.org.uk/borderline-personality-disorder-ifp78 Scottish Personality Disorder Network http://www.scottishpersonalitydisorder.org/
Experience-based practice Stopping is hard think twice before starting Doing something promethazine BNZP - avoid Antidepressants rarely help (even when people are depressed ) Patients generally recognise this. Monitor response to them and, if helpful, in treating comorbid depression/ anxiety document this Antipsychotics can help at times of crisis but usually do not seem to reduce symptoms in long-term explain prior to prescribing that it will be short term stop (1-2 weeks)
Future developments
LABILE trial http://www.labile.org NIHR: Health Technology Assessment Lamotrigine vs placebo 260 participants over next 12 months Change in core BPD problems over one year 50 randomised to date, variable adherence Inconsistent use, always knew I would get the sugar pill stopping medication to get at staff, taking five to see if it was the real treatment Impact on engagement in psychological therapy (>50% don t)
Conclusions Try to deliver consistent structured clinical management Active involvement of the patient Check what depression means for the patient Short-term use of antipsychotics.?role of mood stabilisers Australian Government, 2012: Doctors should not choose medicines as a person s main treatment, because medicines can only make small improvements in some symptoms of BPD, but do not improve BPD itself
Jane Not self harmed for last 12 months Off antipsychotic Feeling more suspicious (end of group-based treatment) still taking Mirtazapine and sometimes her friends diazepam