The Use of Psychiatric Meds in Borderline Personality Disorder

A recent review of the literature on the use of medications in cases of people with borderline personality (BPD) disorder (see reference) concluded that “Despite the common use of pharmacotherapies for patients with BPD, the available evidence does not support the efficacy of pharmacotherapies alone to reduce the severity of BPD.” In addition, “Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD.”

This is hardly surprising in light of the fact that personality disorders are in my opinion, as well as in the opinion of many in the mental health field, primarily disorders of relationships and their subsequent effect on the mental state of participants mired in problematic interactions. Medications do not fix relationships.

Medications for Certain Symptoms

So are medications not indicated at all for people with this relatively common disorder? Well, that’s not true either, because sufferers often have other co-existing anxiety and mood syndromes (comorbid disorders) for which meds are most useful. The most common one in this population is panic disorder. One study showed that 47.8 percent of these people experienced panic attacks, but I think it’s much higher than that, at least in the patients who came to a psychiatrist like me for psychotherapy. It’s also true that rage attacks—another symptom of the disorder—are physiologically identical to panic attacks. It is fight or flight.

I found out relatively early on from my patients in psychotherapy that self-injurious behavior like self-cutting or burning or bulimia often occurred when a patient found themselves in a hopeless bind in their families in which they felt it was imperative to do something to “fix” the situation but they felt helpless to do so. I discovered this the hard way.

A patient would call me, often late at night, asking me what to do about something when they knew very well that I did not yet know enough about their situation to make any suggestions that would actually be helpful. If I dared to offer most anything, they immediately would know that I was full of crap. Talk about a sense of helplessness. I later figured out the best response in this situation was to say, “You don’t have to do anything right now. From what you’ve told me, this crisis will soon pass and be replaced by another crisis in short order.” Patients found this comment had a calming effect.

Medication, Panic Attacks, and Self-Injurious Behavior

So, what medications can reduce the chances of self-injurious behavior by lowering the frequency of panic attacks? When I first started private practice way back in 1979, a psychoanalyst (of all people) told me the secret: a combination of an antidepressant drug called an MAO inhibitor (this was before there were any Prozac-like drugs, which also fill the bill) with a long-acting benzodiazepine like Clonazepam. Prescribing these worked far more quickly for reducing or even stopping self-injurious behavior episodes than the psychotherapy outcomes reported in the literature. In my clinical experience, they were quite effective.

So are there studies that prove this combination is effective in the way I say? Well I’ve been on the lookout for such studies for decades, and there literally aren’t any! The closest that come are those that study SSRIs by themselves in this population without the augmentation. They show some very small effects on self-injury, and on something related to panic attacks called impulsive aggression (see references) but nothing substantial. I asked one guy at a professional meeting who did some of these studies if he ever considered doing the add-on one, and he looked at me as if he didn’t understand what I was talking about. He later gave a talk on BPD and chemicals (neurotransmitters) that help brain cells communicate, and he discussed several of them. Except one—GABA—which is the most important one in anxiety and the target of benzo drugs.

When I prescribed the clinically effective combination, I was criticized for doing so. With MAOIs, the patient would have to avoid certain foods and drugs that interact with these medications and cause an attack of severe high blood pressure. (Luckily with the Prozac-like SSRIs, this is no longer an issue). “You mean you trusted these people to keep to the diet?!? I was asked. My answer, “Yes I do if they tell me they will stick to the diet.” Yes, and if they told me that, they almost always did! I had only one patient take a prescribed medication, ending up in the emergency department, and I took him off the MAOI immediately.

“And benzos can be abused!” was the next critique. Yes, of course. So can pretty much anything. Once again, if the patient agreed to take the meds as prescribed, and I prescribed an adequate dose (patients who were given subtherapeutic doses tended to raise the dose on their own), seemed not to abuse them. I received further confirmation of this belief when states started to produce a database of prescriptions for drugs of abuse, and I saw that my patients were only rarely getting them from another doc (in which case I immediately tapered them off the drug). Luckily, with the exception of Xanax and in methadone treatment centers, there is no large street market offering my patients benzos.