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
