Drug Treatment for Borderline Personality Disorder Not Supported By Evidence

Justin Karter
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New research published in the August issue of Psychiatric Annals evaluates the results of randomized control trials on the use of various psychotropic drugs for patients diagnosed with borderline personality disorder (BPD).  Despite the “American Psychiatric Association’s practice guidelines endorsement of SSRIs as first-line therapies for BPD,” the results of the meta-analysis reveal that pharmacotherapy in BPD is “not supported by the current literature,” and “should be avoided whenever possible.”

The Borderline Personality Disorder diagnosis, according to the NIH, is characterized by problems regulating emotions and thoughts, reckless behavior, and unstable relationships. However, it is evident the BPD is often misdiagnosed, and the National Comorbidity Survey Replication study reveals that 85% of people diagnosed with BPD also meet the DSM diagnostic criteria for other disorders.

Currently, the FDA has not approved any medications for BPD but, as the researchers point out, “approximately 80% of patients with the disorder take medications regularly, and more than 40% take three or more medications daily.”

The recent review of the research examined randomized control trial studies on the efficacy of antidepressants, mood stabilizers, and antipsychotics in BPD published prior to 2015.  The researchers found no statistically significant effects for SSRI antidepressants on BPD.  There was limited statistical power for studies on mood stabilizers though certain drugs were observed to have a limited impact on specific symptoms, such as anger or interpersonal sensitivity.

Similarly, research on antipsychotics was limited to effects on specific symptoms associated with BPD. The review also examined several studies on the effects of omega-3 fatty acids on BPD and reported significant improvements in “characteristic BPD symptoms” such as impulsive behavioral control, outbursts of anger, self-mutilating conduct, as well as reductions in aggressive behaviors and depressive symptoms.

The reviewers caution that the RCT results are limited by small size, short duration, high dropout rates, inconsistent outcome measures, enrollment biases, and lack of replication.  They conclude that “the mainstay treatment for BPD is still psychotherapy,” and that “polypharmacy should be avoided whenever possible,” while also signaling some support for symptom-specific pharmacologic therapies.

The results of the review are in line with the World Federation of Societies of Biological Psychiatry guidelines for biological treatment of personality disorders, which conclude that “there is no evidence at either level of evidence that any drug improves BPD psychopathology in general.”

 

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Francois, D., Roth, S. D., & Klingman, D. (2015). The Efficacy of Pharmacotherapy for Borderline Personality Disorder: A Review of the Available Randomized Controlled Trials. Psychiatric Annals, 45(8), 431. (Full Text)

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20 COMMENTS

  1. This article is on the right track. Let me add a few points, as someone who was once diagnosed as BPD – and did in fact have all the symptoms that make one supposedly “borderline” – but is now quite well much of the time:

    – medications cannot be “approved” for BPD in any scientific sense, because BPD is totally lacking in reliability and validity.

    – medications cannot possibly help with the core drivers of “borderline” symptoms – neglect, abuse, and the resultant all-good / all-bad splitting of self and object images, plus impoverishment of good interpersonal relationships. This splitting and lack of trust/good relationships is what creates and drives all the supposedly “borderline” symptoms like emotional dysregulation, acting out behaviors, lack of identity, and so on.

    – No pill can possibly treat these problems; only loving human relationships and understanding one’s defenses can lead to recovery. The most a pill can do is dull down one’s pain temporarily. Medication does nothing to reverse the emotional developmental arrest, but it does create bad side effects, does block access to negative emotions which need to be worked through, and does create the fantasy that a pill can cure.

    – It’s not that “BPD” is “misdiagnosed” – that presumes that BPD is a valid illness that could be reliably diagnosed. Rather, BPD has never been a discrete, reliable, valid illness. Borderline mental states based on splitting and lack of good relationships exist on a continuum between more neurotic states and more psychotic state. There’s no point at which someone is suddenly borderline or not borderline, and if someone is in a “borderline” state at a certain point in their life, it doesn’t mean they “have BPD” at all or forever. That myth is causing a lot of damage.

    I wrote more about this here in “5 Myths About BPD Debunked”:
    https://bpdtransformation.wordpress.com/2014/08/07/five-myths-about-bpd-debunked/

    • I agree except for “emotional developmental arrest”. It sounds like someone has not developed properly emotionally, which has nothing to do with it. It’s simply a natural response to abusive relationship and persistent situation of being intimately involved with people one can’t trust. For some people it starts from the get go with abusive childhood but for some only appears in adulthood (like finding oneself in an abusive relationship with romantic partner). In such a situation lack of trust is normal. The “splitting” is just trying to deal with impossible situation: one one hand I know (whether consciously or not) that this person is abusing me and I can’t trust them etc. on the other I love that person and I’m attached to them and I’m trying to preserve this connection. That leads to a whole lot of erratic behaviour because you can’t acknowledge reality and stay in this situation without going crazy and bouncing from one wall (trying to defend oneself against the abuser) to the other (trying to keep the relationship and avoid abuse). Given that abusive people almost always engage in gaslighting you end up with someone who is “paranoid” (which is anyway usually right 99% of the time) and distrustful but in the same time trying to cater to abusers needs and blames self for the problems. It’s really a very understandable behaviour but completely weird when looking from the outside especially for someone who has never experienced such a dynamic (that’s why most therapists have no clue). And even after the abusive relationship has stopped it takes time and effort to be able to trust people and not fear falling into the trap. All these things that psych professionals describe as “symptoms” and produce some bs theories about what part of you didn’t develop are only normal reactions of normal humans to situations of cognitive dissonance and extreme emotional distress.

      “only loving human relationships and understanding one’s defenses can lead to recovery” Exactly true.

        • I don’t think people with that label are not developed. I think they are poisoned. They may have been “developed” OK before the abuse started and they will be fine when it ends and when they are able to find safe and loving environment.

          • Maybe it’s a matter of semantics… but my opinion and experience is there are some people labeled “BPD” who experience neglect and/or abuse starting very early in childhood, and who therefore do not get a chance to ever develop a healthy personality that they could have. (In psychodynamics terms, the nuclear self never develops because holding and mirroring self-objects are not sufficient).

            But you’re right that regression to borderline states can occur later in life, and that removing people from an abusive situation and finding a safe and loving environment are crucial to feeling better.

          • Well, maybe it’s semantics but this whole “not developed” sounds to me too much like the broken brain. There’s nothing broken. Or nothing “not-developed”. Sure, people do change upon such experiences and they do change when they recover. People change. All the time, from day to day, more so when crisis happen and less so when the lives stay stable but they change. For me judging if someone has “developed” or not is stigmatising and suffers the same problems as DSM labels – there’s no definition of normal. I don’t know what a “developed” personality is. People are different and they change. Sometimes you like them, something you don’t. But that can’t be measured and defined and any attempt of doing so is suspicious for me.

          • Hi again B – saying someone has a developmental arrest or is emotionally undeveloped is not at all meant to be judgmental, nor does it intend to resemble the broken brain theory, which is itself a ridiculous false idea.

            Rather this viewpoint attempts to empathically understand how human beings have certain common emotional needs for safety, mirroring (support), dependence (vulnerability), intimacy, etc; and to the degree that these needs are not met, the person may get frozen or stuck at a developmentally early level of relating. It’s not bad or judgmental to be in such regressed states at a given time… it just is whatever it is. And it is individual in every case, and people shift back and forth along the continuum or where they are in their level of relationships / self development throughout life.

          • I still disagree ;).
            I simply don’t believe there’s any way to say if someone is developed or stuck early or late. It’s like saying human social and emotional development is some kind of a line and you’re somewhere on it and you move in one or the other direction. I don’t see it this way. I think people have unique ways of relating to others, maladaptive or not which change in time, space and depending on the person you’re interacting with. Even when you were abused your whole life and relate to people round you accordingly I don’t think it’s a regressed state – it’s a state that is developed and just as the appropriate as the one which you’d have were your life history different.

        • Agree. I like this description. It is about how things grow– all things actually grow in response to a constantly changing environment, and just like all things are in a continual state of flux, we, too are changing and cannot be freeze framed into a particular identity or label.

          It is the label that causes the maladaptive behaviors to persist and morph into self damaging – opposite of growth. And it is the BPD label that freezes the bud before it blooms–

          There was something like a subculture around BPD patients on inpatient units where I have worked– and dynamics played out, as if everyone had the same script — stagnation, withering– drying up–

          B.’s description here reminded me about Chinese Medicine, that it was developed in concert with cosmology, which is a life philosophy that illustrates our connection to the heavens and earth by way of comparisons of the life cycle and processes of all living things and all phenomena in the Universe–

          I think it would be interesting to employ these metaphors–. life cycle of a cherry tree for instance– and use descriptive language that focuses on the beauty and continuity of growth–rather than mundane scientific, behavioral developmental jargon that is analogous to what our mechanic tells us when our car acts up.

          Yeah– the label, a diagnosis— and ?treatment?–is the problem–
          Suggested tx for BPD sx:
          Maybe some fertilizer–? more time in the sunshine-?- a little less watering– ? transplant into a bigger pot?

    • hing I was going to, and said it so very well. BPD is a creation, a description of what happens to many adults who received inconsistent and/or abusive care when they were very young. It’s no more a “disorder” than having a limp is a “disorder” after having had one’s leg broken. The “symptoms” of BPD are scars from psychic injuries that were perpetrated upon a helpless infant. To blame the victim the way psychiatry does just adds insult to injury.

      Additionally, many so-called “clinicians” treat “borderlines” as if they were pariahs, subject to some untreatable condition that renders them chronically annoying and intractable. I have never found that to be the case. Some of my greatest successes in the realm of helping people were with victims of childhood abuse who bore the “borderline” label. It’s really just a way of stigmatizing and dismissing clients that our so-called “clinicians” are too incompetent or too lazy to deal with.

      Thanks for your tireless efforts to bring attention to this travesty of a “diagnosis.”

      — Steve

      • Thanks for your support Steve. I wish more of the people who are afraid about being labeled borderline on forums like Reddit, Psychforums, and PsychCentral could hear your type of attitude. The negativity and pessimism around BPD is causing a lot of damage to people getting labeled with it, every day. It’s almost harder to recover from that stigma than from what actually happened to these people.

  2. Really? So drugs which act by numbing down your normal emotional and cognitive functions and turning you into a zombie with sociopathic tendencies (if you’re lucky and don’t go suicidal or homicidal) don’t change your personality for the better and cure trauma? Who would have predicted that…

    People don’t have personality disorders. People have personalities. If you don’t like it – well it’s not your f***ing business. If they don’t like it there are good ways of working to improve oneself and none of them involves psychoactive drugs. Plus being a victim of trauma, abuse etc. and reacting to it is not a disorder either. Psychiatry should get out of business of blaming the victim. In fact they should just go out of business entirely.

  3. “However, it is evident the BPD is often misdiagnosed, and the National Comorbidity Survey Replication study reveals that 85% of people diagnosed with BPD also meet the DSM diagnostic criteria for other disorders.”

    Btw, ain’t that true for all the DSM labels? Or in fact for all the people on the planet? how often does someone go to psychiatrists office and goes out with no diagnosis? Like “don’t worry, it’s just normal emotional response, take it easy, talk to a friend and get some rest”. Does that ever happen? We’re seriously down to discussing how many devils sit at the tip of a pin and writing “scientific” papers about it. It’s absurd.

  4. From what I recall in the 1990’s when it was the Diagnosis of the Day, they’d give it to anyone who showed up at hospitals a lot. That seemed to be the main criteria. Or to people that just didn’t get better. Or for insurance reasons.

    I believe the behaviors that are characteristic of BPD are ALL learned in therapy. They are bad habits picked up in treatment and encouraged by the providers. It is the providers that LOVE a crisis. it keeps them in the business, and it maintains their rescuer status. They are addicted to keeping their patients sick, and diagnosis does a darned good job of keeping people repeatedly doing those behaviors.

    I was not abused nor neglected by my parents and had a decent childhood I’d say. Average. Happy. I was given the BPD diagnosis at age 38 or 39 when I suddenly acted all spaced out. They knew they had damaged me from ECT. They had to explain why I was so confused. However, it makes little sense, if you believe the DSM at all, that a person would suddenly develop those symptoms at such a late age. The dx was given for convenience.

    Suddenly, as soon as they started expecting these behaviors, I began to cut. This was something I had done only once before, when I was much younger. I wasn’t a chronic cutter. Suddenly, I became one. i started to threaten suicide. Yes, it got very scary. Diagnosis kills.

    Funny, once I got away from that facility and the ECT wore off, I didn’t do any of those things anymore. Hmm…so I “recovered” from a so-called personality disorder? The DSM says bpd’s are hopeless. Guess I proved ’em wrong. I don’t know anyone who is borderline. It’s all caused by treatment.

    Oh, yes I do. Some people have salt and pepper hair. That’s borderline gray. I think I’ll go out and have fun diagnosing a few. It’ll feel so powerful and will satisfy a deep inner need for control.

  5. “I believe the behaviors that are characteristic of BPD are ALL learned in therapy. They are bad habits picked up in treatment and encouraged by the providers. It is the providers that LOVE a crisis. it keeps them in the business, and it maintains their rescuer status. They are addicted to keeping their patients sick, and diagnosis does a darned good job of keeping people repeatedly doing those behaviors.”

    You hit the nail on the head Julie.