Medication for Symptoms of Borderline Personality Disorder

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.

Verrrrry interrrresssssting.

Keeping the Customer Satisfied



Recently, a Dr. S. Brown wrote in Medscape:

"A while ago, a patient called me to say he couldn't believe I charged him $50 to tell him he didn’t need a chest X-ray. He was a was a 30-something male patient who had had a cough for a few weeks. He had a short visit, wherein I took a brief history of his illness, did his vital signs, listened to his lungs and told him he probably had a viral bronchitis but didn’t need antibiotics or a chest X-ray; his condition would improve with time. He felt he had been overcharged.

I find it increasingly frustrating to do the right things for patients who feel they are being shortchanged if they don’t leave with either a prescription or a requisition. I attempted to explain to him that I make my living mainly by giving professional advice, not by pushing drugs or ordering tests "

The fact that patients seem to demand a prescription when they go to the doctor has led to such things as the overuse of antibiotics. Viruses, which cause a significant percentage of infections, do not respond to them; only bacteria do. Doctors want to keep patients happy, so often will prescribe them even when they know the patient has a viral infection which will clear up all by itself.  The over-prescription of antibiotics, in turn, has led to the emergence of highly antibiotic-resistant bacteria.

Psychiatrists have taken a lot of heat in some quarters for being overly quick with a prescription pad.  If you go to a psychiatrist, you are in fact very likely to leave with a prescription whether you need one or not.  However, some of this situation is accounted for by patients who demand a medication to solve every problem.  It is not due just to psychiatrists being overly enthusiastic about the wonders of modern medicine.

Not that wilting in the face of a patients' demandingness is a legitimate excuse for the doctor to prescribe drugs for everyday problems in living.  Doctors should be prepared to give patients their honest opinion, whether the patient likes it or not.  If the patient gets upset because the doctor says they need individual or family therapy - or perhaps even no treatment at all - then so be it.  If the patients go away angry and see someone else to get a different opinion, that is their perogative.  There is enough legitimate business to keep psychiatrists busy.

Nontheless, what happens if such a patient goes on some website and gives the doctor a bad review, or creates some other kind of negative publicity?  The government has even discussed the use of patient satisfaction surveys for evaluating a physician's "performance."

What if an insurance company demands a diagnosis or refuses to pay for the doctor's negative evaluation?  I do not know for sure if any managed care company has tried to pull that trick, but I have heard tell about it. 

If that happened to me, I would call the insurance company and demand payment, and immediately resign from that insurance company's provider panel if turned down, because I have to spend time doing an evaluation to find out whether or not a patient needs treatment.  I deserve to be paid for my time.

I can nonetheless appreciate how some doctors can succumb to the temptation to take the easy way out and give patients and insurance companies what they seem to want.  Medicine is a business, and alienating potential "customers" can be a poor way to stay in business.

The medicalization of behavior problems has may causes, and the demands of patients for quick and easy solutions to every problem has to be counted among them.

Antidepressants and Suicide Redux

On my post of July 19, Do Antidepressants Cause Suicide, I listed several reasons why antidepressants might increase suicidal ideation in some adult patients.  (I was not talking about children or adolescents since clinical trials in those populations have taken place only rarely). 

Now comes a huge study of adults and antidepressants out of Germany (Stubner, S et. al, "Suicidality as Rare Adverse Event of Antidepressant Medication," Journal of Clinical Psychiatry 71:10, p.1293).  The dataset from the European drug surveillance program was reviewed for patients on inpatient psychiatric units.  142,090 of these patients had taken antidpressants.

Of this ginormous sample, only 33 incidents of suicidality were documented.  12 of these consisted of suicidal ideas only, 18 were actual suicide attempts, and 3 people successfully completed the act.  14 of the 33 cases seemed to be probably, and 19 definitely, related to the medication.  Consistent with my earlier blog post, fully 23 of these 33 of these cases were associated with restlessness.  This is most probably a side effect of antidepressants, and it is one which is completely and very easily treatable.

The authors concluded that antidepressants rarely trigger suicidality, although even this conclusion is hard to be sure of since the attempters were not assessesed at all for psychological, social, or environmental events which might have contributed to their suidality.

Even assuming that a drug was the only cause of the suicide attempts, just 10 patients in this large sample made attempts that were seemingly unrelated to a common and treatable side effect.  10 out of 142,090.  This was in hospitalized patients, who in general tend to be have more serious symptoms and have far more suicidal ideation than comparable outpatients.

The risk therefore is .007 percent in this population.  And that's a maybe.  That is roughly one third of the minimum estimate of the risk of death from having liposuction for cosmetic surgery.

Polypharmically Incorrect

I continue to be amazed by the bizzaro combination drug cocktails that have been prescribed to patients coming to see me for the first time, either in my private practice or in the residents' clinic, who had previously seen another psychiatrist.  These chemical stews make no sense pharmacologically, let alone diagnostically.  To paraphrase an old song, "Uppers in the morning, downers in the evening, sugar at suppertime..." 

I'm not just talking about an occasional patient, by the way.  I'm talking about a big percentage here.

I have been having some interesting conversations with people who, after being harmed by inappropriate psychiatric medications, go on the warpath.  They start websites that bash psychiatric drugs in general (http://www.ssristories.com/; http://discoverandrecover.wordpress.com/).  They talk to a lot of other people who claim to have had horrible experiences with psychiatric drugs, which no doubt many of them have.

The website webmasters tend to think that all psych drugs are evil in all cases, and I can't say that I blame them, although clearly I do not agree with them.  However, my guess is that they are talking to a biased sample of people.

Some of the people they talk to are the people who have had a bad reaction to one specific drug, a certain number of which would be expected with any medication (one can indeed bleed to death after taking an aspirin), or a bad withdrawal reaction.

Others had been victimized by psychiatrists who did not appropriately follow their patients for side effects and then take the patient off the medication if necessary.  This sort of thing happens all the time in the case of "atypical" antipsychotics, which can cause huge weight gain, cholesterol problems and diabetes. 

Still others are probably those who have been inappropriately diagnosed with bogus disorders such as "bipolar II" and "adult ADHD" and actually have personality problems, or who are misdiagnosed dysthymics who need therapy and not just medication.  And the vast majority of the people diagnosed with the bogus disorders generally do not even met DSM diagnostic criteria for the bogus disorders!

Most importantly, a high percentage of these people probably have been placed on the aforementioned bizarre drug combinations. Often the patients I see had been prescribed several different drugs from the same class at the same time, or drugs that have opposite effects on the brain.  Many are patients with mild symptoms that probably would not have responded to medications anyway, yet are put on more medications precisely because they did not respond.

Now I hear tell of a study that seems to validate my perceptions of what is going on in the field.  Truely objective psychiatric dissidents like Dan Carlat have been called anti-psychiatry for pointing out stuff like this, but it is the psychiatrists who are practicing bad psychiatry who are giving psychiatrists a black eye, not the critics (and I like to consider myself as one of the dissidents).

A study of antidepressant and antipsychotic treatment effects showed there is an emphasis on "polypharmacy" in clinical practice, without much evidence of benefit and an increase in adverse effects. Swiss investigators reported these findings at the 23rd European College of Neuropsychopharmacology Congress (23rd European College of Neuropsychopharmacology (ECNP) Congress: Abstract P.2.c.019. Presented August 31, 2010).

"In our study, we found no advantages for 'complex' treatment approaches over conventional monotherapeutic approaches," said senior investigator Hans H. Stassen, PhD, of University Hospital of Psychiatry in Zurich, Switzerland. "There appear to be no controlled studies showing the superiority of combinations of drugs over [a single drug (monotherapy)]. We looked at this because we have observed in clinical practice that response rates are less and side effects are greater." (reported by Medscape).

Treatment with antidepressants and antipsychotics was often non-specific in a number of ways, according to the study authors. Yet polypharmaceutical approaches have gained favor in recent years. Today' treatment regimens rely on various combinations of antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, analgesics, and antiparkinson drugs.

Aggressive treatment of "mild" cases has rarely been shown to be superior to placebo, the investigators noted. This may explain why response rates have continuously decreased in recent years, whereas the proportion of incomplete responders has increased.

After two weeks in the study,  26% of patients followed were treated with a combination of 2 or more antidepressants, and 32.6% with a combination of antidepressants and antipsychotics. During the observation period of 6 weeks, the polypharmacy patients received an average of 8.3 different drugs, with a maximum number of 20.  Twenty!!!

"The observed polypharmaceutical treatment patterns appeared to be primarily associated with the psychiatrist in charge and much less with the patients' severity at baseline," an investigator noted.

In a comparison of monotherapy, polypharmaceutic treatment regimens, and placebo mean change in Hamilton Depression score (a symptom checklist) among patients matched for severity at baseline was −16 (higher minus numbers mean fewer and less severe symptoms) with monotherapy and −8 with both the combination approach and placebo.

In addition, during the 6-week study, the percentage of patients with cardiovascular problems increased from 8.8% to 30.7%.

Yikes.

Babies and Bathwater - I Must Be Doing Something Right.

Note: this will be the last post for the next couple of weeks, but I will be back, so don't go away.

Where is Goldilocks when we need her? I am always amazed at how people, even professionals who should know better, can take extreme positions and then argue vehemently for them (usually with a healthy dose of debate tricks and logical fallacies). Middle ground does not seem to exist for them. I must be doing something right, because I am now catching flack from both sides.

When I began writing this blog, I expected to be attacked by those folks who think that child abuse and dysfunctional family interactions are a figment of the imagination of a bunch of whining liars, and that the problem with modern psychiatry is that we are just not prescribing near enough drugs. I was waiting with baited breath to hear the phrase, "Parent Bashing." It actually took a while for me to hear from these folks, but it finally happened. Susan Resko, Executive Director of the Child & Adolescent Bipolar Foundation, naturally took exception to my post of May 3, 2010, Preying on Human Misery, which was highly critical of the way her organization's web site was being used and abused by the pharmaceutical companies. She accused me of posting misinformation, which I had in fact taken from other websites that I find to be reliable. In response to an e-mail, I asked her to let me know which things I had wrong, and told her that she could post an unedited rebuttal on my blog, to which I would of course respond. In a blistering e-mail back, she declined my offer.

I am also getting a few negative e-mails from folks at the other extreme: those people who believe that all mental illness is a myth and a hoax, and that any doctor who prescribes psychiatric medications for any reason is destroying the lives of their patients. And these people are not even Scientologists (whom I think have not yet come across my blog). This point of view is equally absurd in my opinion.

I have even been accused of trying to hawk my upcoming book. Ya think? Why shouldn't I? It's very informative and I think people will find it entertaining. However, just for the record, I am in fact not promoting my book, which is called HOW DYSFUNCTIONAL FAMILIES SPUR MENTAL DISORDERS: A BALANCED APPROACH TO RESOLVE PROBLEMS AND RECONCILE RELATIONSHIPS, which should be available this summer from either Praeger Publishers or one of their imprints. Again, to be very clear, the book that I am NOT promoting is called HOW DYSFUNCTIONAL FAMILIES SPUR MENTAL DISORDERS. Available soon!

Psychiatric Drugs

Some people who read my blog may get the wrong idea about where I stand on the issue of the use of psychiatric medications, so I want to make something perfectly clear: I am an advocate of the proper use of psychiatric medications, and I think that when used correctly, they are highly effective. I prescribe them to almost all of the patients I treat, including my psychotherapy patients. If fact, my patients who exhibit signs and symptoms of borderline personality disorder would not be able to engage in the type of therapy I do if their high emotional reactivity were not partially controlled on meds.

I even prescribe atypical antipsychotics, even though they can have toxic side effects. I monitor my psychotic patients' for the emergence of metabolic syndrome by checking their blood sugar, cholesterol, and triglycerides (fat). I watch them closely for the emergence of tardive dyskinesia, a neurological side effect that may emerge after long-term treatment with antipsychotic medications. (If you saw the movie "The Dark Knight," Heath Ledger's Joker character's mouth movements look a lot like this syndrome).

Without antipsychotics, many more patients would be living out on the street in cardboard boxes. Additionally, sometimes the atypicals are the only medications that stop certain patients with borderline personality disorder from severely mutilating themselves. They are not my first choice for that, but they are sometimes necessary.

On the basis of my obvious disgust with pharmaceutical companies' disease mongering and the sloppy use of diagnostic terms by many psychiatrists, I hope no one lumps me together in the same camp as Peter Breggin or Robert Whitaker, who grossly exaggerate the dangers of psychiatric medication and distort the studies in a fashion precisely opposite to the way the drug companies do. Nor I am a fan of Tom Ssazz or R.D. Liang, who think that there is no such thing as a psychiatric disease.

BTW, Dan Carlat posted on his blog an excellent description of PhARMA disease mongering by Adriane Fugh-Berman, available at http://bostonreview.net/BR35.3/fugh-berman.php.

One of the drug company strategies that is not described in this article is to label their critics as members of Scientology. Just so you know for certain, I think the idea that mental illness is caused by a volcano god (Xenu) and space aliens (body thetans) is just a wee bit ludicrous, and that Scientology is a dangerous cult. I remember when I was a resident receiving a mailing from them asking me to come and confess my sins. Clever.

I find that doctors who buy into disease mongering are usually well-meaning but incompetent. Some, however, are predators. On an earlier post, I mentioned something called sensory integration dysfunction. I said it was a "mysterious illness" which might have caused confusion to some readers. This "dysfunction" is not recognized as a disorder by the DSM or the International Classification of Diseases, and its descriptions in the literature are highly dubious. There are no adults who are diagnosed with it. Even if it does exist as a syndrome, it is could easily be something that is due to other factors like anxiety. Yet there are doctors who prescribe expensive "treatments" for it to the children of unsuspecting and naive parents. This is shameful.