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.

Cognitve Behavioral Therapy "Evidence-Base" Grossly Exaggerated

In my post on my Psychology Today blog on November 21, 2011, I discussed how the purveyors of today’s most predominant psychotherapy methodology, cognitive behavioral therapy, grossly exaggerate the strength of their research evidence base in the psychotherapy outcome literature.

My opinion was recently confirmed in a review of meta-analyses of the CBT literature in the Journal of the American Medical Association, published online September 21, 2017 (“Cognitive Behavioral Therapy the Gold Standard for Psychotherapy:  The Need for Plurality in Treatment and Research” by Falk Leichsenring and Christiane Steinert).
 
They reported that a recent meta-analysis using criteria of the Cochrane risk of bias tool reported that only 17% (24 of 144) of randomized clinical trials of CBT for anxiety and depressive disorders were of high quality. The “allegiance factor”—study authors were CBT therapists themselves and often designed the studies to make their treatment look better than it was, and opposing treatments look worse that they were—was rarely controlled for.

Compared with "treatment as usual" —letting subjects get whatever other treatments outside of the study treatment that they chose to have, allowing good therapists and bad therapists, and good therapies and bad therapies, to essentially cancel each other out—the sizes of treatment effects were only small to moderate and might eventually even be found to be due to the allegiance effects.

In panic disorder, CBT was not more effective than treatment as usual but only to being on a waiting list.

Even with these amazing biases, for depressive disorders, response rates of about 50% were reported. This was true for anxiety disorders as well. “Response” just meant there was some significant improvement in symptoms, not that the symptoms of the disorders actually went away. Rates for actual remission from the disorders were even smaller. Conclusion: a considerable proportion of patients do not sufficiently benefit from CBT.

Last but certainly not least, there was no clear evidence that CBT was more effective than other psychotherapies, either for depressive disorders, anxiety disorders, personality disorders or specific eating disorders.

Personally, my biggest beef with CBT and other psychotherapy outcome studies has less to do with symptom relief than with actually changing maladaptive interpersonal behavior. The latter is almost never even looked at, let alone measured in these studies.

CBT’ers seem to think anxiety, depression, and self-destructive behavior are all due to screwed up thinking by individuals rather than being normal reactions to stress-inducing environments. In experimental psychology circles, this is known as the fundamental attribution error. Telling people with these particular symptoms that their problems are basically “all in their heads” in this manner is very invalidating for them.  Ironically, an ‘invalidating environment” is one of the two primary factors these very same therapists cite as the main causes for borderline personality disorder.

Cognitive Behaviorists and Big Pharma Demonize Tranquilizers for PTSD

A medical society called the International Society for Traumatic Stress Studies (ISTSS) publishes a set of guidelines for treating those people suffering from post traumatic stress disorder (PTSD), such as soldiers returning from war zones or victims of natural disasters.

Treatments for PTSD generally involve both psychotherapy and psychiatric medications. No psychiatric medication controls two of the primary symptoms of post traumatic stress disorder:  re-experiencing the trauma as flashbacks, and becoming episodically numb or zoned out.  We do, however,  have a medicine that effectively controls the nightmares, believe it or not – an old blood pressure medication called prazocin. I will talk more about medication a little later in the post, but first let me discuss the psychotherapy of PTSD. 

Many types of psychotherapy have been employed for PTSD, with widely varying results. 

In my clinical experience, many chronic PTSD patients have been given group therapy, in which they meet with other PTSD sufferers who have had similar experiences. I have found that this sort of treatment has been next to worthless for a significant percentage of such patients, particularly those patients who have been severely disabled by their disorder and who have been unable to work for years or even decades.

In patients with chronic PTSD (who do not also have severe personality disorders or majorly dysfunctional families), it is generally believed that the most effective type of psychotherapy is something called prolonged exposure therapy (PE), which is an intense form of what cognitive behavioral therapists (CBT) refer to as systematic  desensitization.  

It is a difficult process in which - and I am grossly simplifying it in order to be brief (and since I do not do this sort of work myself) -  the traumatic experiences suffered by the patient are relived under controlled conditions so that the anxiety and other symptoms generated by the memories can gradually be extinguished.  I have read that doctors have even experimented with recreating the traumatic events using virtual reality through computers, projected images, and earphones, to enhance the desensitization process.

In a PTSD treatment facility I know of, I was told that if a patient were taking a benzodiazepine tranquilizer like Klonopin or Xanax, then they would not be a candidate for PE and would therefore be referred to the aforementioned group therapy.  I was told this was the case because, CBT folks believed, that tranquilizers somehow affect the learning process so that the PE therapy was not effective if the patient were on the meds.  I had heard this idea before from other CBT therapists. 

However, since people who take benzodiazepines are almost never intoxicated, I had always thought this idea a bit strange. So I asked the head of the clinic for a reference. He did not know of one.  Interesting, I thought.  So I did my own literature search. 

Well guess what?  I found exactly one study that showed that benzodiazepines might affect learning in rats.  But in people?  All of the studies showed they had absolutely no effect whatsoever. 

Yet another urban CBT psychotherapy myth.

But then things got even stranger. I was also told that I should check out the treatment guidelines from ISSTS, which said that benzo’s were not indicated for the treatment of PTSD, and that  this clinic followed ISSTS guidelines.  On advice from the clinic leader, I looked up said treatment guidelines, which turned out to be pretty amazing.

Here’s what they said:

 “Although [benzos] are effective anxiolytics [anti-anxiety] and anti-panic agents, they are contraindicated [italics mine] for PTSD treatment.  They don’t reduce re-experiencing or avoiding/numbing behavior.  They should not be prescribed in patients with past or present alcohol/drug abuse or dependence.  Finally, they may produce psychomotor slowing or exacerbate depression. [Benzo’s] do not have any advantage over other classes of medications; therefore they cannot be recommended as monotherapy [again, my italics] in PTSD at this time.”

Being the cynical critic that I am, I should not have been shocked how a supposedly scientific document could be filled with so many half truths. (I’ll enumerate them shortly). But I was. And then I remembered that the pharmaceutical companies had been demonizing benzo’s ever since they all went generic and therefore became far less profitable for the companies (See my earlier post). 

The Cognitive Behavioral Mafia folks also has a vested interest in demonizing benzodiazepines, it seems to me, since the drugs are so effective for some symptoms. This leads to a situation in which  patients would rather just take drugs than go to a CBT therapist to go through systematic desensitization, which can be a long, involved process that is sometimes itself quite traumatic in the short run. 

This preference is unfortunately common even though it is probably better to treat chronic anxiety with psychotherapy than with medication alone, because when the therapy is successful, the patient might be  more or less cured. Not so with the medication.  If you stop them, the symptoms often return.  (And no, not because the medications cause the symptoms, but because they stop but do not cure the symptoms).

Of course, it is also a perfectly good idea to treat anxiety issues with medicine for the quick relief and therapy for the eventual cure. You might then be able to stop the drugs after therapy is completed.  Remember, there is no evidence that medications interfere with systematic desensitization. Still, the CBT folks (and many psychiatrists as well) seem to think of drugs versus therapy as some sort of competition or zero sum game, so their prejudices just happen to coincide with the interests of drug companies: demonizing benzodiazepines. 

It is well documented by several news organizations that drug companies have insinuated themselves into scientific committees that draw up treatment  guidelines to make sure that their interest in making higher profits from their brand-named medication is advanced.  I do not have any proof, of course, but might this have been what happened with the ISSTS treatment guidelines for PTSD?

So let us return to the subject of the half truths in the ISSTS guidelines.  Most of the misleading ideas in the paragraph reproduced above have to do with the misconception implied in the guidelines that PTSD generally exists in some sort of psychiatric vacuum in which PTSD patients show no other symptoms of any other psychiatric disorders as well (Comorbid conditions). In fact, comorbidity is the rule rather than the exception.

For patients suffering from PTSD, I find clinically that the most important common co-morbid condition is panic disorder. In this disorder, sufferers experience severe anxiety attacks with physical symptoms that mimic those of a heart attack.  People who have been traumatized are especially vulnerable to developing panic attacks. 

I found it difficult to find information about exactly what percentage of chronic PTSD sufferers also have panic attacks, but in one study it was 35% and in those patients who sought treatment, 49%! (Cougle et. al., Anxiety Disorders 24(2), p. 183, 2010.)  In another study  (Falsetti & Resnick, Journal of Traumatic Stress 10, p. 683, 1997) the percentage was 69%. More than two thirds!

Yet another study (MacFarlane and Papay, Journal of Nervous and Mental Disorders 180 (8) p.498, 1992) showed that comorbid panic disorder is an important predictor of PTSD turning in to a chronic disorder.

People who have panic disorder also often develop agoraphobia - the fear of being out in crowded places.  Agorophobia is particularly likely to develop in combat veterans who have comorbid PTSD and panic disorder because of another symptom of PTSD: hyper-vigilence. It is as if these veterans have to remain constantly on guard for enemy soldiers, rocket propelled grenades, and improvised explosive devices – even though they are now back home in a safe environment. Being hyperalert in a crowd will often bring on panic attacks. 

This is probably one reason why patients with chronic PTSD and panic disorder may do not do well in group therapy. They are deathly afraid of groups.

Supposedly the first line treatment for panic disorder is an SSRI antidepressants like Paxil or Zoloft, but in my clinical experience benzodiazepines tend to be far more effective. The SSRI’s often only decrease the frequency and severity of panic attacks, but do not stop them completely as certain benzo’s often do. In fact, many victims of PTSD are already on SSRI’s when I first see them, and their panic symptoms and agoraphobia are not under any semblance of control whatsoever. 

So I add a benzo. The combination of an SSRI and a benzo is probably the most effective pharmacologic treatment of panic attacks of all, but you will never find a study that shows that.  In fact, you will never find a study using them in combination for the treatment of any disorder. The drug companies won’t fund such studies, because they don’t want doctors to think that benzo’s are good drugs.

Interestingly, the clinic I have been discussing allows patients who are on SSRI’s to get PE, whereas not so for those on benzo’s or the combination.

Back to the ISSTS guidelines.  They correctly point out that benzo’s do not help the PTSD symptoms of flashbacks and numbing - but no one has said that they do.  I agree that they should not be used as monotherapy for PTSD, as the guidelines say, for that very reason. But why would they be contraindicated (which means they should never ever be used under any condition)? The guidelines themselves start out by admitting that they are very effective for panic disorder, which as I have shown is highly comorbid with PTSD.

Well, maybe it’s because, “They should not be prescribed in patients with past or present alcohol/drug abuse or dependence. Finally, they may produce psychomotor slowing or exacerbate depression.” 

Well first of all, the first statement is not at all true for all patients, particularly those patients who have been sober for a significant period of time. Two different studies have shown that ex-alcoholics do not abuse benzo’s at a higher rate than anyone else. Also, some alcoholics are drinking only because they are, in fact, medicating themselves with alcohol for their panic attacks. They often STOP drinking when put on a benzo.

And even if a chronic PTSD sufferer becomes dependent on benzo’s, so what?  Is that somehow worse that being nearly housebound and completely disabled from work because of panic disorder with agoraphobia?  I think not. And the drugs have almost no side effects. The worst thing about being addicted to a benzo is that you are addicted to a benzo.

Ironically, a lot of the PTSD patients I see are never taken off SSRI’s. Essentially, they are dependent on them. But somehow that’s different. How?  Beats me.

What about benzo’s causing depression?  They sometimes do.  Rarely. The studies that led to FDA approval of the various benzo’s show that this happens in the range of 2-6% of cases. Not much different than placebo!  Sometimes one benzo will have this side effect on a given patient, while another will not. And if they all do in a given patient, they can be discontinued. Or an SSRI can be added for the very effective combination therapy, which prevents this side effect as well as the panic attacks.

The treatment guidelines do not say that SSRI’s are contraindicated because some people might develop side effects, so why should benzo’s be? This is particularly nonsensical in light of the fact that one common side effect of SSRI medication is increased agitation. PTSD is an anxiety disorder!!  (This side effect can also be treated with – you guessed it – a benzo).

Do Panic Attacks Really Come "Out of the Blue?"

 

Panic disorder (PD) can be a severe, highly disabling and debilitating psychiatric condition. Thankfully, it is usually easily treatable with a combination of medication and a cognitive-behavioral technique known as cognitive restructuring, which I will not describe here.

 

Panic attacks are basically attacks of extreme anxiety accompanied by a variety of physical symptoms which I will describe in a moment. People experiencing them for the first time often think they are having a heart attack, because the symptoms of panic attacks mimic those of a myocardial infarction. They often go the emergency room multiple times. When they get there, the doctors do an EKG and blood tests that would be evidence that the patient was indeed having a heart attack, and lo and behold, all the tests would come back completely normal.

 

In the days before ER docs became familiar with the disorder, patients would be basically told that their symptoms were all in their head and sent home. The patient would be flumoxed. The physical symptoms are of such intensity and acuity that patients would come to the correct conclusion that something physical must have happened.

 

Panic attack symptoms include palpitations (pounding heartbeat), increased heart rate, sweating, tremulousness, shortness of breath, choking, chest pain, dizzyness or lightheadedness, nausea and abdominal distress, a sense that everything is unreal, fear of losing control or going crazy, fear of dying, numbness, tingling, chills, and hot flushes. Symptoms can last for a few minutes or for a few hours.

 

Hyperventilation, or breathing too fast, may trigger many of these symptoms, but not all panic attack sufferers hyperventilate. They still get a lot of the same symptoms. Nothing physical going on? What claptrap!!

 

When people have recurring panic attacks, they are said to have panic disorder, and are at high risk of developing a psychological reaction called agorophobia. This byproduct of panics is more common in women with the disorder than men for unknown reasons. In any event, people with agorophobia become fearful of being trapped and avoid crowds (malls, supermarkets, theaters, sporting events and even church), elevators and other tight spaces, lines, and driving, especially distances or over bridges. Sometimes sufferers become fearful of going outside the house alone, and in severe cases they become completely housebound.

The diagnostic criteria for panic disorder is defined in the DSM-IV-TR are:

Recurrent unexpected panic attacks and:

• The attacks are not due to the direct physiological effects of a substance (such as drug of abuse or a medication), or another general medical condition.

•The attacks are not better accounted for by another mental disorder, such as social phobia (such as occurring on exposure to feared social situations), specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder or separation anxiety disorder.

I italicized the "unexpected" criteria because that is the main subject of this post. But first, I would like to point out that all of the listed physical panic symptoms can also be experienced as part of a rage reaction. Rage attacks are most often seen in patients with borderline personality disorder, a high percentage of whom also have panic attacks.

In fact, the physiology and symptoms of a rage attack are identical to those of a panic attack. The individual's cognitive processes (thoughts and evaluation of the symptoms and what may have triggered them) during an attack may be the only phenomena which distinguish them.

That this should be the case is not surprising. Both panic and rage attacks are a manifestation of the primitive fight, flight, or freeze response in all animals. A fight response would lead to rage, and a flight or freeze response might result from panic. Indeed, it seems that people who have panic disorder have a disturbance of this fight, flight or freeze mechanism that causes it to go off and keep going off even after any threatening stimulus is no longer present. An important, self-protective physiological phenomenon may have gone haywire.

In humans, the ability to think might help an individual to decide whether to run or to fight in the presence of a potentially dangerous or threatening stimulus.

To make a diagnosis of panic disorder, the DSM requires that the individual with panic attacks experience them as unexpected, spontaneous, and uncued. That is, there does not seem to be an environmental event that triggers the attacks.

Rage attacks, on the other hand, are usually thought to be triggered by specific environmental events. If an individual has recurrent rage attacks which seem to be unexpected, spontaneous, and uncued, then a completely different diagnostic label is usually applied to them by psychiatrists: intermittent explosive disorder. I have never seen a case in over 30 years that could not be better explained by another diagnosis.

To summarize, for panic disorder, as opposed to the occasional panic attack, the conventional psychiatric wisdom is that they occur “out of the blue” rather than as responses to environmental threats. If they only occur in the presence of one or more specific environmental threats, say snakes, then the person is diagnosed with a specific phobia instead of panic disorder - a snake phobia in this case.

One caveat is that the idea of panic attacks being "unexpected" refers to the absence of a specific stimulus, not to whether or not the presence of a feared stimulus is expected to be present. If, for example, a snake phobic "unexpectedly" comes across a snake on a hike and has an attack, this would not qualify under the "unexpected" rubric of panic disorder.

Panic disorder might be considered a prime example of something that would pit "biological" psychiatrists against psychotherapists. In people who suffer from panic disorder, the attacks do seem to come out of nowhere. They can be sitting quietly in their house doing almost nothing when one comes on. They can even be jolted awake from them in the middle of the night, without having had a nightmare. A tendency to have panic attacks tends to run in families, so clearly some people are more genetically prone to get them than others.

So does this mean that panic disorder is purely and entirely a brain disease? Is its classification as an anxiety disorder incorrect? Does it have nothing to do with chronic stressors?

In my opinion, the answer to all three questions is a resounding no. People who are prone to the disorder do indeed seem to have to have a problem with the internal regulation of their flight or flight mechanism, to be sure, but environmental factors do, in my clinical experience, determine whether such a person has an occasional attack or has a lot of them.

But if attacks happen without a fearful stimulus being present, how is this possible? My theory is thatpeople who are genetically prone to them will start to have them when they are chronically anxious. Whenever they are on guard, on edge, walking on eggshells, or disturbed about something, they then can have a panic at any time during the whole period they feel that way. Why they happen at any particular time remains a mystery.

Now comes a study which adds a lot of credence to the opinion I have formed over the years (Ethan Moitra et al, Journal of Affective Disorders, in press). The study results show that, instead of an immediate reaction, stressful life events (SLEs) in patients with PD can cause a gradual, but steady, increase in panic symptoms over time.

The investigators note they expected to find that panic symptoms would spike immediately after a stressful event and then taper off, but this was not the case. In analysis of more than 400 patients with PD from the Harvard/Brown Anxiety Research Program (HARP) study, panic symptoms worsened progressively over 3 months after participants experienced specific SLEs, including serious family discord or being fired.

What this study tells clinicians is that they need to be aware that, although people may have an immediate reaction, be vigilant in keeping track of how patients are doing over the next few months after the event, and perhaps even longer," according to lead author Dr. Moitra quoted in a Medscape article.

So most patients with panic disorder, even if the symptoms are extremely well controlled with medications as they often are, should also be offered psychotherapy to learn better coping skills to handle the stressors they are experiencing. Otherwise, they will most likely never be able to get off the medication. Not offering or referring for therapy in these cases is disgraceful.

I almost always find that anyone who seems to be experiencing any long term, ongoing anxiety symptoms and/or unhappiness is usually in the middle of ongoing repetitive dysfunctional family interactions. If the doctor does not specifically ask about them, the patients is unlikely to bring them up.