Psychiatry & Psychotherapy Podcast - Understanding Borderline Personality Disorder (BPD) Medications & Treatment

Episode Date: October 9, 2024

Borderline Personality Disorder (BPD) is known for its complexity, but how should clinicians approach treatment? In this episode, Dr. Michael Cummings joins us to explore the role of medications in managing BPD, when to use them, and why psychotherapy remains the cornerstone of treatment. From pharmacotherapy to alternative approaches like exercise and omega-3s, we break down the latest evidence and offer practical insights for clinicians. Don't miss this deep dive into managing one of psychiatry's most challenging disorders. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Okay, welcome back to the podcast. I am joined today with Dr. Michael Cummings. He is a psychopharmacologist. He is someone who's been on the podcast many times at this point. Hello. I'm happy to be back. Today we're going to be talking about borderline personality disorder and medications and what we know, what we don't know, what is helpful, what is not so helpful. So maybe we can start out and you could just kind of define, how do you define borderline personality disorder? Okay. This is a disorder, which I'll start with a disclaimer at the beginning. I don't like the present name of the disorder in the DSM. It's a holdover from psychoanalytic theory in 1938, which saw this disorder as being in a borderland that was between psychosis and neurosis. These individuals were thought to be bordering on psychosis. is due to recurring dissociation or minor episodes of psychosis related to affective distress. But in many ways, the term is far out of date. I think a term that I've seen that I like better is emotionally unstable personality disorder, because over time it's become clear, at least to a number of authors, write about personality disorders, that the heart of this disorder is an inability to modulate often very intense affective states. For example, Marshall Linnahann, one of the major workers in this

area, has described people with this disorder as where an ordinary person might experience annoyance, these people experience rage. Where a typical person might experience sadness, these people will experience despair and hopelessness. I think the DSM criteria are fairly accurate in their description, that is, these people are prone to intense emotional states. they often are engaged in frantic efforts to avoid what they perceive as emotional abandonment. They're also very prone to black and white thinking, meaning they tend to view the world as either being ideal or terrible, and that includes interpersonal relationships in which they often either idealize the other person along the lines of, oh, you'll be perfect, which, of course, the other person never is,

which then sets them up to switch to, oh, you're terrible. So they alternate between idealization and devaluation. They often also feel an internal sense of emptiness, a lack of coherent self-identity, and often engage in very impulsive, often self-destructive behaviors in an attempt to escape from. what they find to be intolerable negative affective states. Yeah, so we've talked about this in episode 115,

which is one of our most popular episodes. We talk about the prevalence somewhere around 1.4%. There's about a 3 to 1 female-male ratio. Previously, we've also talked about temperament from birth And in a New York longitudinal study from 1956 to 1988, research has evaluated 138 infants and categorized them into three categories, easy, which was about 40% of them, which were generally cheerful, quickly established sleeping patterns, not much effective arousal to novel stimuli, and quickly adapted to new routines. So that was easy. There was about 15% that were slow to warm up. They had lower activity level withdrawal on first exposure to new stimuli.

And there were 10% that were categorized as difficult, which, quote, often irregular in feeding and sleeping, are slow to accept new foods and take a long term to adjust new routines or activities and tend to cry a great deal. And so of the 141 children, they followed, 42 had behavioral problems. The difficult children accounted for the largest proportion of these cases. About 70% of the difficult children developed behavioral problems. So in a previous time where we discussed this, you mentioned that this was probably temperamentally leading to some of the issues later on

that lead to borderline per size order. Yes, indeed. The data that's out there suggests that temperament plays a large role. and the evolution of borderline personality disorder. And indeed, although we don't know much about the genetics of the disorder, it is clear that having first-degree relatives who suffer with this disorder leads, those families have a higher overall prevalence of this disorder. This temperament, the temperament is thought of as then perhaps giving rise to some of the unstable social interaction. that may then worsen the person in the direction of developing borderline personality disorder.

Environmental things that have been associated with the development of this include things like physical and sexual abuse, neglect, unstable, chaotic family, lifestyle, which may then make more understandable how the person evolve some of the characteristics that we talk about. talked about in terms of having exaggerated fears of abandonment, seeking attachment that is sometimes idealized or devalued, being unable to regulate emotions, and having excessive, affective responses to environmental stimuli. There's still a lot we don't understand about the evolution of borderline personality disorder, or for that matter, any of the personality disorders. But I think it's clear that this is a case where perhaps innate temperament joins with childhood adversity to give rise to a pathologic personality disorder.

Yeah, and I'll just flesh out a couple of those things. You know, when I looked at the adverse childhood experiences studies, what popped out to me is that, you know, if you have one or two adverse childhood experiences, it might. double your risk for a lot of psychiatric issues. But if you have five or six, it really increases the rate of borderline per sali disorder. And there's a giant jump. And so when I looked at it, it was like complex PTSD and borderline per sali disorder were the biggest jumps when you get five or six adverse childhood experiences, so different types of childhood traumas that are going on simultaneously. At the same time, you know, when we're talking about the genetics, like why we don't know because it's so complex. There's so many genes. There's, you know, it's like probably

hundreds of genes that are contributing, not just one or two. And with the, the heritability estimates are around 46 percent. In one study, meaning if one, let's say you had one monosagotic twin with BPD, you would have a 7.4% chance of the other monosigotic twin also having BPD. this is in a study of 1.8 million individuals. And so, you know, if you think about heritability, 46%, what does that really mean? Well, height is somewhere around 90%, ADHD is around 71%, schizophrenia around 73%. So it's less heritable than some things, but it still impacts it, right?

So it's, yeah, I agree with you, Dr. Cummings, as always. Yeah. We're always in perfect agreement. Oh, indeed, this, you know, this follows a pattern that we've seen with a number of psychiatric illnesses that often there is a vulnerability that's imposed by genetics or by biology. That then is then that blossoms into a disorder when it meets the right environmental circumstances. and I tend to think of borderline personality disorders arising from that combination of difficult early temperament, promoted by repeated and often varied forms of childhood adversity.

As you point out in the adversity studies, when the person gets up to four, five, six, seven more adverse events, the rates of complex PTSD and borderline personality disorder just skyrocket. Okay, so now we're going to phase shift into talking about medications. So it was a 2015 study, Zanarini et al, 2015, which reported on a cohort of 190 inpatients with borderline personality disorder followed over 16 years. The average age was 26 at initiation. of the study, and they found that 80% were taking an antidepressant, 43% were taking a benzodiazepine, 38% were taking antipsychotics, 35% were on a mood stabilizer,

and so polypharmacy is very common. And so kind of starting it out with like, is this the best option, right? Yes, in that context, I would also say there have been a couple of meta-analyses, Cochran Reviews, basically looking at borderline personality disorder that concluded essentially that there is no convincing evidence that any medication is essentially curative for this disorder. Somehow that's not a surprise. We don't have medications that are very good at fixing

personality disorders of any kind. It's more the case that I think medications are given to target and hopefully ameliorate selected target symptoms that occur within the disorder. There has been a shift over time. Early on antipsychotics and benzodiazepines were common. That has shifted more to antidepressants and mood stabilizers over time. Again, though, I think this is a case where, while medications may play a role in ameliorating

specific target symptoms, the treatment of borderline personality for the most part is not based on pharmacotherapy. It's based on psychotherapy. In particular, the two categories of psychotherapy that have the most supportive evidence are dialectical behavioral therapy, a la Marsha Linnehan et al, and cognitive behavioral therapy. You know, this is a personality disorder that is frequently comorbid, most often with substance use disorders, very high rate of comorbidity, mood disorders, anxiety disorders, and eating disorders. Yeah, and I would also emphasize there are a couple other good therapy types,

mentalization-based therapy, has some good studies, transfer focus therapy, head-to-head with DBT seems to be pretty similar. Schema-focused therapy, which is more popular in Australia. At DBT, of course, so going back to what you were saying before, have the raised of prescribing change, there's a 20-year observational study in Spain that I found that tracked 620 patients presenting to an outpatient BPD clinic. It showed over time that antidepressants remained fairly stable, about 74% were taking. Benzodiazepines decreased from 77% to 36%.

And second generation antipsychotics increased from 15 to 32%. basically, you know, a lot of people were on medications and antidepressants remained pretty high. Benzos have decreased in favor largely for this population. Yes. Which I think, frankly, my own opinion is that's a good thing. One of the core problems these individuals have is, one, vulnerability to substance abuse, and two, a huge proneness or vulnerability to impulsive behavior. Benzodiazepines are certainly subject to abuse,

and they're also a great way to worsen the person's impulsivity. In fact, there have been several studies and case series over time that suggests that the benzodiazepines, while they may be acutely calming for a person with borderline personality disorder, it also incurs a downside of increased impulsivity and often increased risk of self-harm or suicide. Yeah, so the APA drafted clinical practice guidelines in 2003, it suggests that any psychotropic medication treatment of borderline precise order may be time-limited, aimed at addressing specific measurable target symptoms and adjunctive to psychotherapy.

Yes. And then there's a quote, over-reliance on medication can send the erroneous message that emotional responses can be addressed by pharmacotherapy. Yeah, as you and I've talked about many times, while medications can be highly useful, typically the answer to more complex life-related problems do not come out of pills. And I think that continues to be true, particularly in populations such as those individual suffering with borderline personality disorder. The other comment I would make about the psychotherapies in looking across them and asking the question, what do the ones that work seem to have in common?

And it's something that fits with my own clinical experience working with some of these individuals, is that they make progress in all of the areas of their disorder when they can achieve tolerance of intense emotions and avoidance of impulsive behavior, it was often called acting out. That is, they learn to stay with the emotional state, to think through it more rationally and make better decisions,

and over time, learn to see the shades of gray in life rather than engaging in very black-and-white, rigid, thinking about themselves, their life, and other individuals. Yeah, I think that there's another word that I've come to really appreciate here, which is reflective function, which is out of the adult attachment interview. I actually took a three-day course on this recently, which is more in-depth than maybe I needed to go, but in summary, reflective function is rated on the adult attachment interview. review and it's the complexity of the answers that are given the questions like why did your

parents behave the way they did in impatience in one study the patients with borderline per size are around 2.7 out of a negative one to nine point scale for reflective function and in a good transfer and focus therapy study they showed an increase of a point or a point and a half i forget exactly. But it's this idea of through, through relationship, through talking, through processing, you know, one can have a deeper insight into their childhood. And one thing that I actually haven't mentioned about reflective function because I have mentioned it here that has occurred to me, because I've started testing some of my patients on their adult attachment interview, is patients can come in and there can be one aspect,

or there can be certain stories that they've processed through quite a bit in different therapy. And as they tell that part of their story, there's good narrative coherence. They make sense. This is what happened. This is how I used to feel back then. This is how I feel now. This is how I've changed. This is, you know, there's a depth to the story.

But sometimes these patients come in and there's still parts of their story that are very raw, unprocessed. and would score lower on a reflective function. And so part of, I think, in processing with these patients is to get to those parts as well and to slowly integrate and develop narrative coherence from those more distressing aspects of their childhood. Yeah, very much so. Which brings us back to a point I think we made

in the episode that we did in conjunction with Dr. Melissa Perrault, while a lot of clinicians often have a somewhat nihilistic attitude toward persons with borderline personality disorder, because they can be very intense, often very demanding patients emotionally. The truth is, their prognosis is pretty good. Most of the long-term studies out there suggest that between 45 and 50%, will achieve remission over somewhat varying lengths of time, but on average, about a decade of treatment. Yeah, and there's the really nice longitudinal study on mentalization-based therapy, which I've talked about before as well, which is like showing that the majority of the patients

who did this really intensive therapy no longer met criteria for borderline precise disorder. none of them were on polypharmacy anymore. I'll include that in the handout for you guys. It's by Bateman, Fonagy, et al, 2008. Huge improvements in various aspects of their life, increased employment, decreased hospitalizations, decreased suicide attempts, decreased use of antipsychotics, mood stabilizers,

and even at five years after discharge. And in talking to, If Fonagy, he said one of the things, which I haven't heard except from his mouth, which was so powerful, was one of the things he felt was fundamentally shifted in the patients, was their ability to create and maintain good relationships with other people outside of the therapy relationship. And so one of my barometers of if therapy is working well is like, are they in more vulnerable, connected, meaningful relationships outside of therapy?

is what's happening in the therapy relationship transferring to how they interact in the world in a better complex or empathic-attuned, meaningful, connected way? Yeah, very much so, because these are individuals who come from often very chaotic, very pathological relationships, and indeed when they learn to establish more healthy, more secure attachments, that generally reflects an overall improvement in them both internally, they're in their sense of self as well as their ability to engage in a nuanced relationship with other people

where the other person is not either ideally loved or incredibly severely hated, but there is room for the spectrum of feelings. in between once they essentially become more mature with relation to some of the raw, less well-processed parts of their own history. Shall we talk about this, the Cochrane Review? They did a really nice study in 2022. It's called pharmacological interventions for people with borderline precise order. Basically, a large meta-analysis.

author's conclusions were this review included 18 more trials than the 2010 version. So it had more statistical power. It said very limited data was available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. Right. And indeed, it's those two studies I was referring to earlier that opined that the answer for this disorder, it does not lie in medication per se. Like, is it worth going through different categories and talking about them?

Because, like, I think antipsychotic use in clinical practice, you know, it's not too uncommon. Low-Dose use antipsychotics for impulsivity, agitation, aggression, psychosis, quasi-sicosis. Yeah, I think the chief element of using medications well in this population involves several points. First, recognizing the conclusion of the Cochrane Review, medication is not the principal treatment. That is, you're not going to alter the person's borderline personality structure with any medication. Instead, what you're attempting to do is ameliorate specific symptoms such as psychosis or particularly borderline individuals are prone to become paranoid with respect to others because of their fear of abandonment. Often the antipsychotics may be helpful with dissociation that can include psychotic symptoms, such as elicist.

hallucination, distortion of their interpretation of reality. Antidepressants for those who are very prone to both depressed mood and anxiety. Use of mood stabilizers for those who suffer from often frequent mood instability. They're happy, they're sad, they're enraged, they're in despair, and all of that can occur within a very short span of time. You know, so this is a case of using the medications to deal with specific symptom areas, but always in the context of recognizing that the medication is not going to be curative of the underlying disorder. When I look, Stroffers, Whitney at All, 2022, it's this Cochran review that we're looking at.

but I look at the forest plot for antipsychotics. Overall, it does not cross the statistical significant line, right? It's a mix. There are some studies that are statistically significant, but overall it does not. When looking at one of the studies in particular that was positive, the grant 2022, where they used Bramiprexol or placebo, it's like reported in this study is like okay this is one of the positive studies there was a significant difference in bpd symptoms but only in the very last visit so they had multiple visits that were like

almost identical in the last visit it beat placebo which to me i'm like looking at it makes me less excited right yeah that's you know you wonder if that was uh despite their statistical analysis you wonder if well was that a fluke of some sort since it didn't occur in a more established pattern? Yeah, so it's like there were eight times that they came in to score them, and only the last time,

right, is there a separation? Yes. There was another study Black-At-All 2014, which looked at low-dose quatopine versus high-dose quotapine, low-dose was at 150 milligrams, high-dose was at 300. the difference in improvement was stronger between the low dose and the placebo

with an effect size of 0.8, and the difference between the moderate dosage quatopine group and the placebo was not, did not meet statistical significance. So this may be one of those things of like, you know, if you're treating someone with 150 and you're thinking about going up, it might actually do worse than... Yeah, it might be... worse and I can see reasons for that in that for somebody who does not suffer from a primary

psychotic disorder the antipsychotics can impose fairly serious impairments in cognitive processing which of course is one of the things the person with borderline personality disorder needs to be able to do better not worse while low dose may be providing enough simply quieting of the degree of their affective intensity to provide some benefit. To give you a more concrete example or analogy of how I think about medications and borderline personality disorder, if I'm treating somebody who has pneumonia and they are febrile, will they benefit from me giving them acetaminophen to lower their temperature? The answer is yes.

Will acetaminopin cure their lung infection? No. You could think of borderline personality disorder almost in the same terms. We can give people a mood stabilizer, an antipsychotic, and antidepressant. and it may help ameliorate some symptoms, but it is not treating the underlying borderline personality structure. That has to come via psychotherapy. Yeah, and moving on to the SSRIs, the Cochrane Review,

noted that antidepressants did not significantly reduce overall BPD severity or improve impulsivity or suicidal behaviors with fluoxetine, even associated with an increase in suicidal ideation. Fluvoxamine showed a slight improvement in affective instability, but there was no notable effect on self-harm, feelings of emptiness or anger. Amitriptylene was the only antidepressant found to reduce depressive symptoms. That being said, nothing exciting, right? It's not like...

Nothing exciting. And the one positive drug there, the amyptylene, I would be incredibly reluctant to give amatryptylene or frankly any tricyclic antidepressant to an individual suffering from borderline personality disorder and that the LD50, the lethal dose for 50% of the population, is only 6 to 8 times the therapeutic dose. Right.

It's a sodium channel blocker at higher doses, right? Yes. causing heart issues yeah causes slowing of conduction conduction in the AV node and bundle of his thereby setting the person up for

ventricular arrhythmia yeah so it's like with suicidal patients who are currently suicidal do you give them something that could actually work to allow them to kill themselves if you know sometimes it could accidentally like, oh, I didn't really know that would kill me, but I took a bunch of pills.

Like, I always take a bunch of pills. Yeah. Oh, indeed. You know, for Bramotryptylene, you know, if you think about that, a therapeutic index that is that small means that it will only take about a week's worth of medication and overdose to stand a 50% chance of killing the person. So, Lomotrigine is another medical. that had two studies in the Cochrane Review.

A small preliminary study of 28 people suggested Lamotrogyne may have an effect on impulsivity, anger, behavioral, discontrol, and BPD. That's Reich et al, 2009. However, a larger study of 276 patients, Crawford et al, 2018, showed no evidence to suggest that Lamotrogyne 400 milligrams

per day was useful for treatment of BPD. Any comments on that? I think again it comes down to the effective medications is variable and somewhat

small and often lower doses of medication do better in people with this disorder than higher doses do, especially when you get into doses that are beginning to interfere with neuronal functioning to the point of making it more difficult

for the person to process information. Remember, these are individuals who are facing intense, negative, affective states, and the best counter they have to that is the ability to modulate their limbic system via cognitive processing in the anterior frontal lobe. and if you give them a drug that impairs that ability while you're not doing them much of a favor.

Yeah, absolutely. And so, you know, coming back to this eight-year follow-up of mentalization-based therapy, which is one of the ones that I think best shows, and if you haven't looked at this, there's one table I'll include in my psychiatrybodcast.com article will put up for this. But basically, like, patients who received a very,

large amount of therapy. I mean, we're talking about 432 hours of therapy. That's a lot of, a lot of therapy. But if you think about it, 432 hours in the large scope of life is, is, in the, you know, think about like all of the traumas that, you know, someone with six ACE scores or a score of six on their adverse childhood experiences has endured. a lot of these programs, partial programs, IOP programs, for these patients, we have to get them in and keep them in as long as we can. Sometimes insurance doesn't want to pay for as many days as they need, but sometimes they'll come in and out over the course of several years

and get enough treatment, get that dose response, which is big enough. Yeah, I think indeed one of the important points in talking with an individual who is suffering from borderline personality disorder is to make clear to them when they're in a more stable state, not when they're in distress, is that one, the potential benefits from medication are going to be small, and that the major benefit is going to be from therapy, but we're talking about a long-term therapy. this is not a brief psychotherapy that will benefit them because it's going to require them to restructure themselves in a number of ways. Yeah, so, okay, so one of the cool things about the studies, they looked at how many years the patients had been on the different medication classes in the five years following the treatment. So for example, in the treatment as usual group, they were on antidepressants for 3.3 years out of the five antipsychotics, 3.1 years out of the five, moose stabilizers, two years out of the five, and three or more medications, two years out of the five. Whereas the group that received,

that by the way, were doing a lot better in terms of hospitalizations, job, everything, basically, they had received, on average, one year of antidepressants and just a couple months of antipsychotics and mood stabilizers. And almost none of them had been on three or more drugs at all. Yeah, my interpretation of that is they were being treated by clinicians who are overly dependent on medications as their primary treatment modality. Okay. I see that frequently as a consultant, and although I'm a psychopharmacology consultant,

I spend an awful lot of my time advising clinicians to take people off of medications because frequently when it occurs that when somebody receives a medication and it doesn't work that well, they don't get switched, they get something else added and then something else added, and then something else added, none of which works very well. and the person may not be receiving any form of psychotherapy at all. And it's a case of giving somebody multiple things that are not working is not a good form of treatment.

Yeah, I think about like, you know, around essentially a practice where the people pay me, you know, a lot of the time. And when they're paying me and they come in and they're expecting a medication. Sometimes they leave fairly dissatisfied. And it takes a lot of psychoeducation and just like, hey, like, this is what you need. This is, you know, and then they come back by email and like, can I try this medication? And I'm trying to convince them like, no, like the biggest bang for your buck,

where you want to put your money, invest your time is in therapy, is in exercise, is an eating healthy, you know, but mostly therapy for a lot of these people. I think one of the funniest consults I've had in that, along that vein was I was contacted by a patient in the community who, the crux of the complaint was, my husband is being problematic. I hate some of the things he does. What pill can you give me? To which my initial thought was for you or for him? Right. But, you know, it was a case of where, no, what was needed was a lot of work on their relationship.

It was not a case of there's, you know, there was not a pill out there that was somehow going to fix problems in an interpersonal relationship. Do benzodiazepines make people worse with BPD? Yes, it would be my short answer. there is a lot of suggestion that things such as impulsive behaviors, which can include a lot of things with people with borderline personality disorder, including self-harm, things like excessive spending, risky sexual behaviors, risky behaviors in general. those things get worse with benzodiazepines because you're impairing the person's judgment. And with respect to impulsivity, the core definition essentially is that the person acts before they think through the potential consequences of their action. And giving them a medication that's very likely to further reduce their ability to consider consequences

before acting is not, doesn't strike me as a good idea. And indeed, there are studies out there suggesting that rates of impulsive behavior, rates of violence, rates of aggression all get worse if the person is chronically taking a benzodiazepine. There's one major study that supported this idea that benzodiazepines increased risk of suicide. Leschito et al-2023, it was a study of 22,000,000. individuals with PPD in this Swedish registry that were followed for 16 years.

The authors found a decreased risk of suicide attempts or completed suicide in patients taking ADHD medications, hazard ratio 0.83, no finding for mood stabilizers, increased risk of antidepressants, hazard ratio of 1.38, antipsychotics, hazard ratio 1.18, and benzodiazepines hazard ratio of 1.61. Now, one could say, well, were the ill patients taking more meds because they were ill? And maybe it was just that the more sick the patient, the more meds they were given because they continually go back to their doctor and are really sick. Anyway, any thoughts on this in particular? I would tend to buy the argument except that a very similar pattern has been found in other disorders.

For example, Tahan and Adal looked at rates of both all-cause mortality and suicide-related mortality and people with schizophrenia who either were taking two antipsychotics, an antipsychotic and an antidepressant or an antipsychotic and a benzodiazepine. The effect of two antipsychotics was not significant. It didn't make any difference. The antidepressant actually reduced suicide risk with a relative risk ratio of 0.57. And the benzodiazepines, in contrast, increased all mortality risk

by a ratio of 1.71 and increase the risk of suicide by almost fourfold. So I think this is a pattern seen across disorders where basically reducing someone's, if you will, prefrontal cortical functioning with a benzodiazepine does not help them in terms of being able to modulate their limbic system and make better choices. And that makes perfect sense. You know, the benzodiazepines act at GABA A receptors for the most part. And those receptors are most plentiful in the prefrontal cortex. That's why when people get intoxicated, for example, with alcohol, same receptor system.

system. It's a slightly different mechanism. People essentially become intoxicated from the top down following there's a decreasing gradient in these receptors from the frontal prefrontal cortex as you go further down. They become less plentiful by the time you're down to the brainstem. There are very few. And indeed, if people are drinking large amounts of alcohol, they want to get more boisterous, less inhibited, and are more impulsive. Then if they keep drinking, they start to have fine motor discontrol, then major motor discontrol. And then finally, they'll inhibit the brain stem and they'll pass out. The benzodiazepines follow a similar pattern.

Okay. And then I think that the last category of thing I wanted to get you to weigh on was ECT and borderline per salary disorder. My own reading of the literature is that ECT appears to have a role in those who are comorbidly depressed or psychotic in a more persistent sense, but that ECT does not change the

personality structure per se, or or the core symptoms of borderline personality disorder. So, ECT, certainly if I had somebody who is pharmacologically resistant, who meets the criteria for a comorbid depressive disorder, I think for that person ECT is worth thinking about, again, to treat the depression, not the borderline personality disorder. Okay. Well, okay, great.

I think in just my personal antidotal experience, I've had one patient with pretty severe BPD who had prior ECT, which did not help her, and she had some memory issues from it. And then she eventually got through her BPD with about a year and a half of partial and the processing of some pretty significant trauma that she was not wanting to see.

Yeah. I think in many ways this brings us back around to the conclusion that we had earlier is that, as found in the Cochrane reviews, the somatic treatments we have available to us may be useful in treating targeted symptoms or perhaps comorbid disorders, but the mainstay of treatment for borderline personality disorder is inappropriately chosen and pursued psychotherapy. Yeah. Awesome.

Well, I think in summary, if you're here, if this is the first episode you've heard on BPD, go back and listen to our prior episodes. You can find that in Psychiatrypodcast.com. There's a whole list of them there. And talk to Feinstein about different psychotherapies. We talked to Cummings before about more details on the diagnosis, the history, the symptoms. and treatment. All right, so I hope you enjoyed that discussion with Dr. Cummings. I wanted to go over

a couple things that we looked at since the recording of the episode. One was we looked at the APA American Psychiatric Association Guidelines. They had one in 2001 and a future one coming out in 2025. The 2001 APA guidelines for treating BPD emphasized pharmacotherapy for acute decompensation and for chronic trait vulnerabilities such as affective dysregulation, impulsive behavioral discontrol, and cognitive perceptual symptoms. On a relatively limited amount of evidence, these guidelines suggested trials of SSRIs for effective dysregulation and impulsivity, stating a reasonable trial of SSRI for treatment of patients with BPD is at least 12 weeks. That's a quote. And here's another quote,

if effective dysregulation appears as anxiety and SSRI may be insufficient. At this point, the use of benzodiazepines should be considered, although there is little systematic research on the use of these medications and patients with borderline per seigneuris disorder. You can see how this is largely changed to our current thinking that SSRIs will not be helpful and benzodiazepines should be limited in this population. So the APA guidelines are currently being restructured to incorporate extensive research from the past two decades of pharmacotherapy and BPD. A recent published draft of the upcoming 2025 APA guidelines illustrate these proposed updates.

And we should note that this is a tentative draft. But the proposal guidelines emphasize the importance of informing patients that medications will not address BPDs. features and warns against over-reliance of them for emotional regulation. Additionally, short-term medication use may be appropriate for managing crises such as severe agitation, psychosis, but frequent dose-changing and prolonged use are discouraged. Do you see how different that is from the 2001 guidelines that went on to say medications for managing co-occurring conditions like depression and OCD may be considered, but they should be prescribed cautiously considering risk of toxicity or misuse.

So a lot more conservative approach in general, much shorter term, and not the emphasis on the SSRIs or the benzos. Okay. I also wanted to look at what other countries are doing because my listeners are from all over so the United Kingdom's National Institute for Health and Care Excellence, clinical practice guidelines 2015, advised that pharmaceuticals should not be used for either the treatment of BPD specifically or for the treatment of particular BPD-related symptoms or behaviors. And the guidelines emphasize that if sedative or antipsychotic medications are

utilized for the initial stabilization in the acute setting, they should be used cautiously and with consent from the patient and should not be utilized for duration longer than one week. Isn't that something else? That's my commentary on it. This is a big change, right? That these national guidelines are pushing

for careful use beyond one week. The guidelines specifically recommend against the use of antipsychotic medications for medium to long-term treatment of BPD. Lastly, the nice guidelines do suggest that medications can be considered for treatment of comorbidities in patients with BPD. Here's a couple quotes, and this is on the website as well. Drug treatment should not be used specifically for borderline personality disorder

or for the individual symptoms or behaviors associated with the disorder. For example, repeated self-harm, marked emotional instability, risk-taking behavior, or transient psychotic symptoms. Here's another quote. anti-sacotic drugs should not be used for medium and long-term treatment of borderline personality disorder. Here's another quote. Drug treatment should be considered in the overall treatment of comorbid conditions. So still assess for comorbid conditions and then consider should they be used to treat those comorbid conditions.

Here's another quote. short-term use of sedative medications may be considered cautiously as part of the overall treatment plan for patients with borderline personality disorder in a crisis. I also looked at the European guidelines for personality disorder past, present, and future. It was a recent 2019 study analyzing the various European guidelines for treatment of personality disorders, and it found that most European nations advise against the use of medications as first-line treatment for borderline per size disorder. However, there are notable exceptions. Switzerland, Finland, Finland, and the Netherlands all recommend that medications may be considered for targeting specific

symptoms or behaviors associated with BPD. And here's a quote. Finally, recommendations on pharmacological treatment are an overall agreement that based on sparse trial evidence, medications should not be considered the primary intervention for personality disorders, but should be used mainly for treating comorbid disorders and in some cases used briefly during times of crisis. The Swiss, Finnish, and Dutch guidelines suggest that medications may be used to reduce specific dimensions of BPD, such as anger, impulsivity, or negative mood. however, these specific recommendations are not consistent and are somewhat at odds with the more general recommendations of being cautious with use of medications.

Okay. Once again, I want to emphasize that instead, we should be using known psychotherapies that work for the treatment of borderline precise disorder, such as dialectical behavioral therapy, cognitive behavioral therapy, mentalization-based therapy, transference focus therapy, general psychodynamic psychotherapy or schema focus therapy. And I've covered these in the past and previous podcasts. If you just look at my name, Puter and BPD, you will find all of these things.

So these therapies focus on helping the patient manage these intense emotions without turning to impulsive coping strategies while also promoting the integration of raw emotional experiences into a coherent narrative through promoting reflective function. Of note, object relations approaches help patients develop greater integration in their sense of self and other so that they can approach situations in a more appropriate and nuanced way without resorting to characteristic defenses of splitting projection and projective identification. And also of note, Gunderson, whose work in the 1970s,

identify BPD as a distinct psychiatric disorder. He developed an approach for BPD, which I would like to actually cover more in future episodes called the Handbook of Good Psychiatric Management for Borderline Persiallisorder, which can be utilized by psychiatrists and clinicians without specific training or supervision in the treatment of BPD patients. So it's a good place to start. Okay, there are other things that we did not cover in this episode, which I would like to cover. omega-3 fatty acid supplementation may reduce impulsivity and depressive symptoms in BPD. So, according to a recent meta-analysis, caladitis and colleagues, 2020, omega-3 supplementation has been shown to have potential benefit in treating depression and anxiety,

especially if they have EPA-enriched formulas. And these studies suggest that EPA dose, is between 1 and 2 grams per day may help reduce depressive symptoms. And recent APA MDD guidelines, so American Psychiatric Association guidelines on major depressive disorder, suggest supplementation may be helpful as an adjunct. Okay. And the anxiety, the evidence for anxiety is a little bit less clear. So the therapeutic mechanism of omega-3 supplementation is unclear, but it may be related to reducing inflammation, regulating neurone membrane fluidity, and allowing for greater neurotransmitter receptor availability. BPD patients may have elevated

levels of inflammatory cytokines, possibly linked to early life stress or adverse childhood experiences. Therefore, omega-3 supplementation could help alleviate some symptoms of BPDs, such as mood instability and aggression. And I would also comment, I was recently looking at just how food is made. And, you know, like one of my friends who was getting into farming noted that grass or chickens that eat grass, that wander around grass basically, rather than, you know, corn feed and stuff like that, their omega-3 per egg is so much higher than just the, the chicken that eats, you know, this kind of cornmeal or whatnot. So, you know, we really have to think

about the food we eat and take this, take the science seriously. Okay. So let's, let's keep going. A meta-analysis by Karenz, Swika, and colleagues 2021, reviewed four small randomized controlled trials evaluating the effect of omega-3 supplementation on symptoms related to BPD. The analysis found significant reduction in depressive symptoms, referred to as affective instability by the authors. The standardized mean difference was 0.74 and a decreased impulsivity of 0.45, which was like, when I saw that, I was like, oh, wow, that's something. Like, what is that? Let's look at that. three of the studies compared clinically dosed EPA at around 700 milligrams to 1,220 milligrams, and DHA of about 480 milligrams to 908 milligrams to placebo. So three of the studies looked at that.

Only one study directly measured BPD symptoms using a validated scale. which could be a critique of this meta-analysis. Okay, Bellino and colleagues 2014 found that 12 weeks of treatment with 1,200 milligrams of EPA and 800 milligrams of DHA combined with some valproic acid, small dose 50 to 100 micrograms,

did not significantly reduce BPD symptoms. They used the BPD severity index scale. compared to voproic acid alone. However, small improvements were noted on subscales related to anger and impulsivity. Okay, so although more studies are needed, and hear me out, I do think we need more studies. To fully understand the effect of omega-3s and BPD, this intervention offers a low-risk, well-tolerated adjunct to treatment with the added potential of cardiovascular and cognitive benefits. So this is something that we can recommend. You know, if you're not going to recommend medication,

you can recommend, hey, you need to take some omega-3s and you could look at specifically, how do you get that dose big enough? Okay. So remember the milligrams, and I'll put in my hand out of how many milligrams each of these studies were, but this is more than just one omega-3 pill per day. Okay. So sometimes I'll recommend take three to four omega-3s per day. I don't think there's a magical brand, I think, in general. The brand that's good is the brand they will take. Maybe I'll have more nuance as I sort of move along here. Okay, so I wanted to talk as well about borderline personality disorder and exercise.

There is limited research into exercise and BPD, so I'll start off by saying that. However, we know, and we've talked about this frequently on this podcast, that exercise has shown to have a positive impact on mood, anxiety, and overall mental health. And numerous studies across various populations and conditions have highlighted the benefits of physical activity for improving emotional well-being and reducing symptoms of mood disorders, implying there may be a role for exercise for treating BPD. skeletal muscle acts as a neuroendocrine tissue, releasing myokines during contraction that influence various bodily symptoms, including the brain. Certain myokines, such as caphthason, B, and erasin, can cross the blood-brain barrier where they subsequently influence and indirectly increase brain-derived neurotrophic factor resulting in downstream contributions to improved cognition and neuroprotection.

So people with BPD are known to have high risk of self-harm, suicidal attempts. They are characteristically impulsive with low lethality, right? Low-lethal suicidal attempts are frequent. And previous systematic reviews have demonstrated that exercise significantly decreases suicide attempts in those with mental disorders. as exercise is known to reduce emotional impulsivity. It is hypothesized that regular exercise may serve as a protective factor against suicidal attempts. Further research is required to specifically know this in the BPD population.

However, we know that BPD and suicidality go together. And so it's highly probable that in some of these studies, there were people with BPD that were included in the study. There were probably other people as well, but more studies are needed. Exercise is known to reduce emotional dysregulation, which is a prominent symptom in BPD. Further, BPD is known to be highly comorbid with other mental disorders. Depression, anxiety is how much higher, physical health conditions,

such as metabolic syndrome, cardiovascular disease is very common. which exercise has proven efficacious. So in particular, we know that cardiovascular and endocrine diseases account for about one-third the deaths of patients with Cluster B personality disorder. So as such, and I would say enthusiastically, we need more promising studies where they look at specifically BPD and emotional dysregulation and the treatment of comorbid mental disorders in patients with BPD. But we can recommend exercise enthusiastically to patients

as a way of augmenting therapy. So, you know, when a patient comes in, BPD, therapy, omega-3s exercise makes sense to me. Try to get them into a partial program if they're too acute for outpatient. Okay, so then there's the question of, what about ketamine and es ketamine? for BPD.

Given that BPD is associated with these quasi-psychotic and dissociative symptoms, which ketamine can induce there is concern that patients with BPD may not tolerate ketamine? Could it exacerbate the symptoms? Okay. So a recent randomized controlled trial pilot study attempted to address this question. Finding that dissociative effects of ketamine were transient. however the six ketamine group participants with a history of dissociative episodes experiences had a higher mid-infusion dissociation and also positive psychotic symptoms in the BPRS scale

compared to those without a history of dissociation okay so something to note if they have a history of dissociation and you're outpatient taking care of these patients there's a higher likelihood that they will get more dissociative in the sessions. Okay, so aside from several case reports, Nandadan at all 2023, the only other study assessing ketamine's effects on BPD symptoms was Danion and colleagues, 2020. So we looked at this study specifically in the handout, real world effectiveness of repeated ketamine infusion for treatment resistant depression with

comorbid borderline personality disorder. So note that they are bringing in people with BPD with treatment resistant depression. Okay, so they looked at 50 outpatients with depression and moderate to severe BPD symptoms measured by the borderline symptom list 23 item. And they looked at 50 outpatients with only depression, and they gave them four doses of intravenous ketamine. And I think the dose here is important. It was 0.5 to 0.75 milligrams per kilogram over 40 minutes, over two weeks. Okay, two weeks, two weeks. No, two weeks. We don't have long-term data. And I would say that sometimes in outpatient, they go higher than this. So the 0.5 is kind of on the lower lower side. So the results were that after three infusion, BPD group, BPD symptoms had

improved significantly. Both groups had improved in depressive symptoms, suicidality, and anxiety. And there was no significant differences between the two groups following for infusion. So what this means is that the group with BPD got better just like the other group. Okay, ketamine increased dissociative symptoms in both groups, but not more in the BPD group. So what were the limitations of the study? There was no placebo and no active control condition. The analysis was post-hawk, meaning it was not a randomized trial. And the BSL 23 scores are correlated with deposition.

depression severity and were not reported in BPD negative groups. This means BPD negative group might have had improvements in their BSL 23 scores that the author did not report. Okay, while these initial results are encouraging further randomized controlled trials are needed. These studies should incorporate long-term follow-up monitoring using appropriate tools that assess dissociative depersonalization, identity disturbances, affective instability, in order to evaluate

whether patients with BPD are at greater risk for future destabilization. This is only a two-week study. I'm worried about, you know, as an outpatient doctor, following these people for months, what happens?

And I talked to one of my colleagues, he has a podcast, Craig Hickok, he's a psychiatrist with extensive experience prescribing ketamine therapy for many patients, and he weighed in

on the use of BPD and ketamine. And this was a personal correspondence that he is allowing me to quote here. So he said, quote, I think lower dose oral ketamine can potentially be helpful in the context of ketamine assisted therapy. But it must be cautiously and judiciously and only after strong and a trusting therapeutic relationship has developed. Ketamine can light transference on fire. It can trigger self-harm and suicidal thoughts in BPD. It can exacerbate the fragmented sense of self,

all of which are major challenges for the therapist and the patient. The higher psychedelic doses of ketamine are generally contraintigated for BPD, given the risk of destabilization. So let that be a omen of caution for those of you who are using ketamine in patients with borderline personality disorder. Also looked at TMS studies for the treatment of BPD. There were four studies. Briefly, I will say that they were positive, but they were small and more studies are needed.

and I would like to just leave those on the website. You can go check out our podcast write-ups,psychiatrypodcast.com. For ECT, we looked at that as well. You know, ECT electric convulsive therapy is very helpful for treatment-resistant depression, catatonia, psychosis. There was a study, Zoo et al-20023, and they said there are no ECT studies evaluating BPD symptoms, outcomes. However, studies of ECT patients in comorbid BPD and depression suggest that depressive symptoms were less responsive to ECT compared to depression-only patients. Okay, that's important because the depression, the comorbid depression, a BPD may respond differently to ECT.

And that's where I would say in the university I was associated with, it was the general consensus with those that provided the ECT to screen out patients with BPD and to send them to partial. And we would get these referrals from outpatient providers who were well-meaning, who would send them for ECT because maybe the patient had read about ECT or maybe they didn't know where to go with them. And we would inevitably send them to partial to our dialectal behavioral therapy track that we have. So, conclusion, guys, I'm excited for this episode. I think this is an awesome look at medications, psychotherapy, alternative treatments. We looked at national guidelines. It's exciting to me to look at the science, the state of the science where it's at. I hope you

check out our article. All of our articles are for free as PDFs or blog posts. They're peer-reviewed. They are extensively looked at by multiple eyes and by your eyes. And I'm Someone just let me know the other day, like, hey, you said this one thing, and did you know that this therapist before them came up with that idea? And so I changed the article, and I do that on a regular basis. So it's a living organism this podcast is. And you will find articles that I neglected to add, and I will try to add them in. So always appreciate your input, your feedback, positive, or positive. helpful right so with that i would recommend a holistic approach to patients with bpd

with psychotherapy as the foundation and some integrative approaches such as omega-3 supplementation and exercise and then uh in acute settings you may consider medications but for a short time i think that is a great way of treating ppd and um i think i think that is a great way of treating bpd and um i think that if you look at the comorbidities, the comorbidities may be treated, but also realize that some of the comorbidities will respond differently than they do if the issue was there alone. Okay. Hope you enjoyed this episode. Once again, I hope that I am dry at this point when you're listening to this. And I will be going home right now. I will be boarding up my windows for a hurricane, and I will be putting out some sandbags. So on that note, hurricanes and borderline precisely

disorder will be coming to a close here. All right, thank you.