Drug Studies in B.P.

D 1

 Ganislow & McGlachlan reviewed 28 studies

 19 out of 28 on B.P.D

 Treatment Strategies

– Antidepressants for mood stabilisation

– Lithium and CBZ for mood stabliisation
– transient psychotic symptoms - neuroleptics
– impulsivity with CBZ and SSRI’s

 Most of studies small and poor design

 Short duration and short follow-up

 Guidelines for Management

 Think of BD not BPD

 Regard the emotional dysregulation and dyscontrol

behaviours as both biological and learned
components

 Stick with it but don’t overdo it

 Look for change at about ten years

 Treat mood disturbance as actively as you can

 Use brief hospital admissions don’t strive not to admit

 Watch out for increasing social isolation as borderline

symptoms subside

 Have all acute ward staff learn some basic

DBT techniques

 Use Carbamazepine !
Borderline Personality Disorder ?

The concept / diagnostic boundaries

The natural history

Drug treatment

Other treatment studies

Guidelines for Management

Stability of diagnosis / natural history

 Early studies show poor prognosis / outcome

 Borderline syndrome and organisation

 Follow up for 5 years or less

 Pre DSM III

 Prevailing psychoanalytic zeitgeist

 Often defined by treatment failure

 Perjorative Labelling “borderline”

 Werble B. Archives Gen. Psych. 1970

 Grinker RR, Werble B and Dryce 1968

The Borderline Syndrome : Basic Books

 N = 51

 Follow up 3 - 5 years

 Prospective, inpatient

 No improvement, low functioning, 1/3 re-admitted

 Paris J Brown, R Nowlis 1987

 Comprehensive Psychiatry 1987 Vol 28

1988 Vol 29

 All D.I.B Borderline Personality Disorder

 N = 322

 15 year follow up

 Less impulsivity with time

 23% re-admitted mainly due to unstable

social functioning

 Limited pleasurable activities

 Drug Studies in B.P.D 2

 Soloff - low dose haloperidol

 Gaolberg - low dose thiothixine

 Cowdry - alprazalem
- carbamazepine
- trifluperazine
- tranylcypromine

 Frankenburg - clozapine

 Salzman - fluoxetine
 Stability of diagnosis / natural history

 2nd generation studies

 Used Gunderson’s D.I.B. / DSM III

 Tighter less subjective research designs

 Longer follow up 15 years +

McGlachlan T.H. Bardenstein KK : Archives 1986

 Chestnut lodge study N = 89

 Long term outcome of borderline personality

Arch. Gen. Psych. 1986

 Mean follow up 15 years

 Good outcome increased with time

 Good work functioning

 Suicide rate 3%

 Personal stability by avoiding intimacy

Drug Studies

Soloff PH. Et al (1993) Efficacy of phenelzine

and haloperidol in borderline personality
disorder

Arch. Gen Psych. 1993 50 : 377 - 85

Cornelius JR et al (1990) Fluoxetine trial in

borderline personality disorder

Psychopharm. Bull 1990

26 : 151 - 64

Cowdry RW et al (1988) Pharmacotherapy of

borderline personality disorder

Arch. Gen Psych. 45 : 111 - 9

 Stone et al : The PI 500

 New York State Psychiatric Institute Studies

 N = 550 personality dis. 205 Borderline PD

 Follow up 10 - 23 years

 Improvement in functioning after 5 - 10 years

not before

 Journal of Personality Disorders 1987

 Drug Studies : BPD 3


Low dose neuroleptics benefit those who have
ideas of reference, paranoid ideation or
dissociative reactions to stress

 Alprazolam increases behavioural dyscontrol

 Equivocal or negative results from

amitriptyline on mood symptoms / increased dyscontrol

 Better results from MAOI’s but high

non - tolerance rate

 Carbamazepine
decreased behavioural dyscontrol
improved mood
better able to tolerate negative
affect without acting out

 Equivocal results from Fluoxetine

 Delivery of Acute Care

 Tyrer et al 1994 Psychol. Medicine

 Compared Early Intervention Service (EIS)

with standard hospital treatment

 EIS Group did better

1.2 days inpatient treatment EIS

9.3 days standard hospital treatment

 50% patients had personality disorder

 Personality Disorder patients did better with

standard hospital care

- greater improvement in depressive symptoms

- greater improvement in social functioning

 Linehan’s studies fit in here

 POPMACT study underway

Outpatient Treatment

 Perry et al metanalysis of psychotherapy studies

for personality disorder

Effect size 1.04 self report

Effect size 1.13 observer rating

 Require longer courses of psychotherapy

improvement occurs around 50 + sessions

 Patients with least disturbance do best

particularly with traditional forms of psychotherapy

(Paris 1996)

 Suicidal behaviour increases in 1st year

of psychotherapy (Waldinger 1987)
decreases in years 2 - 5
Day patient treatment

 Piper et al 1993 hospital and community psychiatry

– Time limited dynamic group orientated

– 42% drop out rate

– only 14% had Borderline Personality Disorder

 Bateman (In press)

Assertive Community Treatment ACT

 In vivo assistance and training of patients

 ACT workers provide care not just broker it

 Staff teamwork emphasis

 High staff patient ratio (caseload N = 10)

 ACT lowers treatment costs for non

schizophrenic psychosis

 Cost for Schizophrenia same

 Costs for Personality Disorders doubled

- no clear benefit

 Stein & Test (Archives 1980)

 Borderline Personality Disorder

Borderline Personality Disorder 1994

The Psychiatric Clinics of North America

Share I.A. Ed W B Saunders, Philadelphia

Kernbeg O.F. (1994)

Chapter I in above. Aggression, Trauma and

Hatred in the treatment of Borderline patients
pp 701 - 7014

Van der Kolk et al (1994)

Chapter 2 in above. Trauma and the

development of Borderline Personality
Disorder pp 715 - 730
Borderline Disorder not B.D.P.

 Symptoms and behaviours define it

 No different to severe OCD, Anorexia Nervosa

 Is this the same disorder as complex PTSD

or Disorder of Extreme Stress ? (DES)

 Not trait based changes with time

 Borderline Personality Disorder

75% female

2% general population

10% psychiatric outpatients

30 - 60% psychiatric inpatients with

personality disorder
 Borderline Personality Disorder DSM IV

A pattern of instability in personal relationships,

self image and affects, and marked impulsivity which
begins by early adulthood

 Fear of abandonment

 Unstable interpersonal relationships

 Disturbance of self identity

 Impulsivity

 Recurrent self harm

 Labile affect

 Chronic feelings of emptiness

 Uncontrollable anger

 Stress related paranoia or dissociation

Emotionally unstable personality disorder
I.C.D. 10

Impulsive type

3 of 5 criteria

borderline type

3 of impulsive criteria
and 2 from borderline
Borderline Personality Disorder : Diagnosis

 Validity and reliability of most DSM IV

Axis II diagnoses close to zero

 Gunderson BPD has higher validity and

reliability if structured interview used

 BPD’s meet criteria for between 4 - 6

Other Axis II labels

 Why is BPD not in Axis I