TREATMENT: Worsened depression
When Ms. L arrives at our facility, her medication regimen includes fluoxetine, 80 mg/d, risperidone, 2 mg/d, and buspirone, 20 mg/d. Risperidone and buspirone are discontinued because of perceived lack of efficacy. Venlafaxine XR is added and titrated to 300 mg/d, and Ms. L receives lorazepam, 1 and 2 mg as needed. However, lorazepam carries risks because impulsivity and impaired judgment—which are common in BPD—can lead to dependence and abuse. We feel that in a supervised setting the risks can be managed.
Recently, staff witnessed Ms. L experiencing an episode that appeared to be a grand mal seizure. After Ms. L is evaluated at the local emergency room, her EEG is normal, but a neurologic consult recommends discontinuing fluoxetine or venlafaxine XR because they may have contributed to the seizure. We taper and discontinue venlafaxine XR but Ms. L complains bitterly that she is getting increasingly depressed. On several occasions she attempts to pit team members against each other.
Ms. L falls, injures her back, and begins to abuse opiates. After her prescription runs out, she obtains more from an intellectually limited patient in her treatment program. Ms. L says she is getting more depressed, threatens suicide, and is placed in a more restrictive in-patient setting. We consider adding pregabalin to address her pain and help with anxiety and impulse control but the consulting neurologist prescribes carbamazepine, 400 mg/d, and her pain improves.5,6
The authors’ observations
BPD treatment primarily is psychotherapeutic and emphasizes skill building (Table 2) with focused, symptom-targeted pharmacotherapy as indicated.4 Pharmacotherapy typically targets 3 domains:
- affective dysregulation
- impulsive-behavioral dyscontrol symptoms
- cognitive-perceptual symptoms.
Patients with prominent anxiety may benefit from benzodiazepines, although research on these agents for BPD is limited. Recent studies show efficacy with fluoxetine, olanzapine, or a combination of both,7 and divalproex.8 Preliminary data supports the use of topiramate, quetiapine, risperidone, ziprasidone, lamotrigine, and clonidine (Table 3).9-14 A recent review and meta-analysis showed efficacy with topira-mate, lamotrigine, valproate, aripiprazole, and olanzapine.15
For Ms. L, we restart venlafaxine at a lower dose of 50 mg/d and titrate it to 150 mg/d, which is still lower than her previous dose of 300 mg/d. She has no recurrence of seizures and her depression improves.
Table 2
Features of psychotherapeutic modalities for BPD
| Description | Mode of treatment | Skills taught | |
|---|---|---|---|
| Dialectical behavior therapy | Manualized, time-limited, cognitive-behavioral approach based on the biosocial theory of BPD | Individual therapy, group skills training, telephone contact, and therapist consultation | Core mindfulness skills, interpersonal effectiveness skills, emotion modulation skills, and distress tolerance skills |
| Systems Training for Emotional Predictability and Problem Solving | Manual-based, group treatment that includes a systems component to train family members, friends, and significant others | 20-week basic skills group and a 1-year, twice-monthly advanced group program; utilizes a classroom ‘seminar’ format | Awareness of illness, emotion management skills, and behavior management skills |
| BPD: borderline personality disorder | |||
Table 3
Pharmacotherapy for BPD: What the evidence says
| Study | Design | Results |
|---|---|---|
| Hollander et al, 20039 | 96 patients with Cluster B personality disorders randomized to divalproex or placebo for 12 weeks | Divalproex was superior to placebo in treating impulsive aggression, irritability, and global severity |
| Hilger et al, 200310 | Case report of 2 women with BPD and severe self-mutilation receiving quetiapine monotherapy | Quetiapine resulted in a marked improvement of impulsive behavior and overall level of function |
| Rizvi, 200211 | Case report of a 14-year-old female with borderline personality traits admitted to an inpatient facility for suicide attempt, impulsive behavior, and mood lability. Lamotrigine was started at 25 mg/d and titrated to 200 mg/d. At admission, she was receiving clonazepam, valproic acid, quetiapine, and fluoxetine, which were tapered and discontinued | Over 6 months of inpatient treatment, suicidal behavior and ideation diminished and impulse control and mood lability improved; continued improvement at 1-year follow up |
| Rocca et al, 200212 | 15 BPD outpatients with aggressive behavior given risperidone (mean dose 3.27 mg/d) in an 8-week open-label study | Risperidone produced a significant reduction in aggression based on AQ scores, reduction in depressive symptoms, and an increase in energy and global functioning |
| Philipsen et al, 200413 | 14 women with BPD given oral clonidine, 75 and 150 µg, while experiencing strong aversive inner tension and urge to commit self-injury | Clonidine significantly decreased aversive inner tension, dissociative symptoms, and urge to commit self-injury as measured by self rated scales |
| Pascual et al, 200414 | A 2-week open-label study of 10 females and 2 males presenting to psychiatric emergency service for self-injurious behavior, aggression/hostility, loss of impulse control, and severe anxiety/depressive symptoms received IM ziprasidone, 20 mg, followed by flexible oral dosing between 40 mg/d and 160 mg/d | 9 patients who completed the study showed statistically significant improvements on CGI-S, HAM-D-17, HAM-A, BPRS, and BIS |
| AQ: Aggression Questionnaire; BIS: Barratt Impulsiveness Scale; BPD: borderline personality disorder; BPRS: Brief Psychiatric Rating Scale; CGI-S: Clinical Global Impressions-Severity of Illness; HAM-A: Hamilton Anxiety Rating scale; HAM-D-17: 17-item Hamilton Depression Rating scale | ||