A recent review of the
literature on the use of medications in cases of people with borderline
personality (BPD) disorder (“Pharmacological Treatments for Borderline
Personality Disorder: A Systematic Review and Meta-Analysis.” CNS Drugs. 35(10):1053-1067, 2021 10)
concluded that “Despite the common use of pharmacotherapies for patients with
BPD, the available evidence does not support the efficacy of pharmacotherapies alone to reduce the severity
of BPD.” Additionally, “Second-generation antipsychotics, anticonvulsants, and
antidepressants were not able to consistently
reduce the severity of BPD.”
Well, duh. This is
hardly surprising in light of the fact that personality disorders are primarily
disorders of relationships and their subsequent effect on the mental state of
participants in problematic interactions. Last I checked, medications do not
fix relationships.
So are medications not
indicated at all for people with this relatively common disorder? Well that’s
nonsense as well, because sufferers often have other co-existing anxiety and
mood syndromes (comorbid disorders)
for which meds are most useful. The most common one in this population is panic
disorder. One study showed that 40% of these people experienced panic attacks,
but I think it’s much higher than that, at least in the patients who came to a
psychiatrist like me for psychotherapy. It’s also true that rage attacks—another
symptom of the disorder—are physiologically identical to panic attacks. You
know, fight or flight.
I found out relatively early on that self injurious behavior like self-cutting or burning or bulimia often occurred when a patient found themselves in a hopeless bind in their families in which they felt it was imperative to do something to “fix” the situation but they felt helpless to do so. I discovered this the hard way.
A patient would
call me, often late at night, asking me what to do about something when they
knew very well that I did not yet know enough about their situation to make any
suggestions which would actually be helpful. If I dared to offer most anything,
they immediately would know that I was full of crap. Talk about a sense of
helplessness. I later figured out the best response in this situation was to
say, “You don’t have to do anything right now. From what you’ve told me, this
crisis will soon pass and be replaced by another crisis in short order.”
Patients found this comment had a calming effect.
So what medications can
reduce the chances of self injurious behavior by lowering the frequency of
panic attacks? Oddly, when I first started private practice way back in 1979, a
psychoanalyst (of all people) told me the secret: a combination of an antidepressant drug
called an MAO inhibitor (this was before there were any Prozac-like drugs,
which also fill the bill) with a long acting benzodiazepine like Clonazepam.
Prescribing these worked far more quickly for reducing or even stopping self injurious behavior episodes than months of dialectical behavior
therapy, and was quite effective.
Naturally, I was
criticized for prescribing this combination. With MAOI’s, the patient would
have to avoid certain foods and drugs which interact with these medications and
cause an attack of severe high blood pressure. (Luckily with the Prozac-like SSRI’s,
this is no longer an issue). “You mean you trusted these people to keep to the
diet?!? I was asked. My answer, “Yes I do if they tell me they will stick to
the diet.” Yes, and if they told me that, lo and behold, they did! I had only
one patient take a proscribed medication, ending up in the ER, and I took him
off the MAOI immediately.
“And benzo’s can be
abused!” was the next attack. Yes, so can pretty much anything. Once again, if
the patient agreed to take the meds as prescribed, and I prescribed an adequate
dose (patients who were given sub-therapeutic doses tended to raise the dose on
their own), seemed not to abuse them. I received further confirmation of this
belief when states started to produce a data base of prescriptions for drugs of
abuse, and I saw that my patients were only rarely getting them from another
doc (in which case I immediately tapered them off the drug). Luckily, with the
exception of Xanax and in methadone treatment centers, there is no large street
market offering my patients benzo’s.
So are there studies that prove this
combination is effective in the way I say? Well I’ve been on the lookout for
such studies for decades, and there literally aren’t any! The closest that come
are those that study SSRI’s by themselves in this population without the
necessary augmentation. They show some very small effects on self-injury, but
nothing substantial. Oddly, I asked the guy who did most of these studies if he
ever considered doing the add-on one, and he looked at me as if he didn’t understand
what I was talking about. He later gave a talk on BPD and chemicals (neurotransmitters) that help brain cells
communicate, and he discussed several of them. Except one —GABA—which is the
most important one in anxiety and the target of benzo drugs.
