Treating Borderline Personality Disorder in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 02/11/2016

Disclosures and Learning Objectives
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– Be able to name three evidence-based therapies for BPD
– Be able to list the three basic tenets of
Relationship Management
– Know 7 ways to improve outcomes in
Borderline Personality Disorders
– Appreciate the role of hope in the treatment of BPD
Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

Assessing Borderline Personality Disorder
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Borderline Personality Disorder, DSM-IV TR
A pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following 9 criteria:
• Frantic efforts to avoid abandonment, imagined or real
• A pattern of unstable, intense relationships
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• Identity disturbance; unstable self-image or sense of self
Impulsivity in at least two potentially damaging areas
Recurrent suicidal behaviors, gestures, threats, self harm
Affective instability due to market reactivity of mood
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Chronic feelings of emptiness
Inappropriate intense anger or difficulty controlling anger
Transient paranoia or severe dissociative symptoms http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_per sonalidad_psicosis/material/dsm.pdf

Borderline Personality Disorder
• 1-4% of the general population
• 6% of a primary care clinic population
– 50% had no mental health treatment that year
– 43% not recognized by PCP has having any emotional or mental health problems.
• http://archinte.jamanetwork.com/article.aspx?articleID=210746
Higher rates of common health problems, perhaps due to medication-induced obesity
– Diabetes, Hypertension
– Chronic Back Pain
– Arthritis, Fibromyalgia http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

Borderline Personality Disorder and Health
• Medically self-sabotaging behavior
• Increased perceptions of illness
• Pain syndromes (BPD in 50% of chronic pain patients)
• Prescription misuse and abuse
• HIV
• Skin picking or excoriation (1 in 4 have BPD)
• Factitious illness
• Plastic Surgery (more surgeries, less satisfaction)
• Rheumatoid Arthritis (40% have BPD?)
• Disability (3 times more likely) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3012616/pdf/PE_1_2_19.pdf

Treating BPD - Pharmacology
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– Fluvoxamine, Sertraline, Fluoxetine
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– Valproate may be helpful for rage
– Lamotrigine and Topiramate may help
– Omega-3 Fatty Acids (one small study)
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– Aripiprazole, Olanzapine
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http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd-guide.pdf
http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.160.1.167
http://emedicine.medscape.com/article/913575-medication; http://www.bpddemystified.com/treatments/medication/

Treating BPD - Pharmacology
General study limitations:
• Outpatients, not severely ill (excluded if expressing acute suicidality).
• Small sample sizes
• Short duration (≤ 3 months); longer trials had high drop-out rates
• RCTs prone to high placebo response rate
APA practice guideline recommendation: Symptomtargeted approach.
• Opens door for polypharmacy, but there is little evidence regarding its effectiveness.
• Using as few medications as possible to target central areas of clinical dysfunction, together with evidence-based psychotherapy, is usually the optimal treatment strategy.

Treating BPD - Pharmacology
Antidepressants
• Disturbances of serotonin has been associated with BPD, impulsive aggression, self-harm, and suicidality.
• Early research with TCAs
• Amitriptyline has been associated with paradoxical increases in suicidality, paranoia, and behavioral dysregulation. Medications with adverse cognitive effects, including anticholinergic side effects, may contribute to worsening impulsivity. Added risk with overdose potential.
TCA are discouraged in BPD.
• MAOIs
• Older studies have demonstrated benefit with phenelzine in the treatment of hostility, anxiety, and borderline symptoms. Many patients will not be able to tolerate adverse effects and associated restrictions.
Risk for toxicity in overdose.

Treating BPD - Pharmacology
• SSRIs
• Fluoxetine has been shown to reduce anger in BPD independent of any
ATD effect. Also may improve verbal and impulsive aggression, irritability and overall functioning. Limited added benefit when added to
DBT.
• Paroxetine has demonstrated efficacy in preventing recurrent suicidal behavior but no significant effect on depression, hopelessness, or anger.
• Fluvoxamine decreased affective lability, but not impulsivity or aggression
• Current evidence-based practice recommends use of SSRIs, due to potential benefits on impulsive aggression that may outweigh associated risks. There has been no evidence that ATDs alleviate the chronic emptiness, shameful self-concept, and intra-psychic pain in BPD.

Treating BPD - Pharmacology
Antipsychotics
• First Generation Antipsychotics
• A Cochrane review suggests haloperidol is efficacious in reducing anger in BPD. By contrast, evidence for efficacy of neuroleptics on affective symptoms, psychosis, and anxiety remains inconsistent. The dosage of antipsychotic medication for evidence-based treatment of BPD is usually lower than schizophrenia. High drop-out rates are noted, and risk of extrapyramidal symptoms may further limit their utility.
• Second Generation (Atypical) Antipsychotics
• Olanzapine has demonstrated effectiveness in treatment of BPD patients’ anxiety, anger, interpersonal sensitivity, and paranoia, but not depression. No difference when compared to haloperidol. Adding fluoxetine to olanzapine did not elicit further benefit. The addition to DBT reduced depression, anxiety, and impulsive aggression, but magnitude and timing of benefits related to DBT was difficult to determine.

Treating BPD - Pharmacology
• Second Generation (Atypical) Antipsychotics
• Aripiprazole effective in reducing aggression, anxiety, depression, psychosis, interpersonal symptoms, self-injurious behavior and subjective distress in non-suicidal BPD patients.
• Meta-analyses demonstrate that the class of antipsychotics have moderate effect in treating aggression, but no significant effect on depression. Best evidence may be with olanzapine and aripiprazole.

Treating BPD - Pharmacology
Mood Stabilizers
• Lithium
• Particularly beneficial in quieting affective instability
• Toxicity and/or adherence may be problematic
• Carbamazepine
• Has demonstrated reductions in behavioral dyscontrol, and improvements in global functioning, anxiety, anger, euphoria, impulsivity, and suicidality, but has been associated with worsening melancholic depression.
• Depakote
• Has reduced aggression, irritability, and overall disease severity in patients with Cluster B personality disorders and prominent impulsive aggression

Treating BPD - Pharmacology
Mood Stabilizers
• Lamotrigine
• Has been shown to reduce anger, reduce affective lability and impulsivity, but no change in other BPD symptoms. Dose should be titrated carefully.
• Topiramate
• Has been shown to reduce anger in BPD patients. Other benefits may include improvements in somatization, anxiety, health-related QOL, overall stress, interpersonal sensitivity, and hostility. Need to balance risk benefit of cognitive adverse effects.
• Overall
• May be effective in treating impulsivity and aggression, with moderate effect on depression in BPD. Little evidence of any effect on interpersonal dysfunction or disturbances of identity.

Treating BPD - Pharmacology
Other Medications
• Benzodiazepines
• Have been associated with disinhibition, worsening impulsivity, suicidal ideation, and behavioral dyscontrol in BPD. May interfere with progress in psychotherapy and adversely affect cognition.
• Omega-3 fatty acid (E-EPA)
• May decrease aggression and depression. May act by inhibiting protein kinase C (perhaps similar to lithium and valproic acid).
• Clonidine
• Study has shown reduction in tension, dissociative symptoms, selfinjurious urges, and suicidal ideation.

Treating BPD - Psychotherapy
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http://www.bpddemystified.com/treatments/psychotherapy/

BPD – Relationship Management
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– Patient is intelligent, responsible and in control
– PCP does not make decisions or give advice
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– Do no harm
– Reduce chaos and curtail the distorted relationship between patient and health care
– Consider therapy http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf
http://www.powells.com/biblio/62-9781138004993-1

Relationship Management, continued
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– Slowing down the interview
– Using fewer words
– Increasing the use of silence
– Responding with empathetic neutrality
– Assuming a position contrary to assigned attributes http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf

BPD – Office Management
• Structure, Structure, Structure
• Remain calm and go for the emotion
• Watch for splitting
• Notice your own feelings
• Open, honest discussions about the role of emotions and life stressors in medical concerns
• Partner up for physical exams
• Educate about BPD
• Know that Suicide and Self Harm will be issues http://www.ncbi.nlm.nih.gov/pubmed/17484331 http://www.learningace.com/doc/1139736/439fcb618548f7a4d233ad1696bca6de/borderline-presentation-4-16-09-printversion

BPD – The UK Approach
• People with BPD should not be excluded from healthcare
• Work in partnership to develop autonomy and promote choice
• Develop an optimistic and trusting relationship
– Many have experienced trauma
– Recovery is possible
– Be open, engaging, non-judgmental, reliable
• Anticipate the end of relationships and support transitions http://www.nice.org.uk/guidance/cg78/resources/guidance-borderline-personality-disorder-pdf

Summary
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– Avoiding harm
– Management of relationships
– Therapy
– Medications

The End!
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