See article by Paton et al.

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Why Patients With Severe Personality Disorders Are Overmedicated

Joel Paris, MD

Emotionally unstable personality disorder (EUPD), more widely known as borderline personality disorder (BPD), has long been considered a clinical challenge.1 Patients meeting criteria for these diagnoses are emotionally dysregulated, impulsive, and involved in troubled relationships; in clinical settings, they may threaten suicide or attempt it and are frequently seen in emergency departments.2 Patients with BPD can be treatment resistant, even when clinically depressed, to both pharmacotherapy and standard types of psychotherapy.3 However, it is now known that specialized treatments such as dialectical behavior therapy4 and mentalization-based treatment5 can be helpful for most cases.

Although these more specific psychological treatments are known to be efficacious, they are not readily available. The reason is that therapy takes time and is expensive in human resources. This leaves harried clinicians with an inadequate set of options. The easiest choice is to focus on pharmacologic therapy for target symptoms rather than the personality disorder as a whole. However, as reviewed in the NICE guidelines,6 this approach is not particularly effective. That is why psychiatrists prescribe drugs outside of licensed indications. Faced with desperate patients, and with limited access to specialized psychotherapy, they do what they know how to do—they prescribe.

The problem may even be worse than the description of prescription practices revealed by Paton and colleagues’ data.7 The survey obtained data from clinics where the personality disorder is recognized (often as the primary diagnosis), but it did not examine clinical settings where personality disorder is either ignored or misdiagnosed. In contemporary practice, many personality disorder patients are given the diagnosis of bipolar disorder8 and treated accordingly. If more clinicians knew that BPD is treatable and has a better long-term prognosis than mood disorders,9 this scenario would be less likely.

Clearly, psychiatrists need to receive better education about evidence-based treatments for severe personality disorders. However, much of what they think they know is filtered through a climate of opinion shaped by neurobiological models and psychopharmacologic options.

The current situation, in which patients with severe personality disorders receive almost routine polpharmacy,10 is unsatisfactory. The only way this situation can change is to make specialized psychotherapy more readily available. If it were, then psychiatrists would be slower to reach for their prescription pad and more likely to make referrals for psychological treatment. This problem requires a different kind of mental health system. In the United States, access to psychotherapy in mental health practice is becoming more difficult.11 While the National Health Service in the United Kingdom has been making a serious attempt to hire psychologists to provide more psychotherapy,12 an enormous need that will not be easily met still exists.

Author affiliation: Department of Psychiatry, Institute of Community and Family Psychiatry; McGill University, Montreal, Quebec, Canada.

Potential conflicts of interest: None reported.

Funding/support: None reported.

REFERENCES

1. Paris J. Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice. New York, NY: Guilford Press; 2008.

2. Forman EM, Berk MS, Henriques GR, et al. History of multiple suicide attempts as a behavioral marker of severe psychopathology. Am J Psychiatry. 2004;161(3):437–443. doi:10.1176/appi.ajp.161.3.437 PubMed

3. Newton-Howes G, Tyrer P, Johnson T. Personality disorder and the outcome of depression: meta-analysis of published studies. Br J Psychiatry. 2006;188(1):13–20. doi:10.1192/bjp.188.1.13 PubMed

4. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757–766. doi:10.1001/archpsyc.63.7.757 PubMed

5. Bateman A, Fonagy P. Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment. Oxford, UK: Oxford University Press; 2004.

6. National Institute for Clinical Excellence. Borderline Personality Disorder—Treatment and Management. London, UK: National Institute for Clinical Excellence; 2008.

7. Paton C, Crawford MJ, Bhatti SF, et al. The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services. J Clin Psychiatry. 2015;76(4):e512–e518.

8. Parker G. Clinical differentiation of bipolar II disorder from personality-based “emotional dysregulation” conditions. J Affect Disord. 2011;133(1–2):16–21. doi:10.1016/j.jad.2010.10.015 PubMed

9. Olfson M, Marcus SC. National trends in outpatient psychotherapy. Am J Psychiatry. 2010;167(12):1456–1463. doi:10.1176/appi.ajp.2010.10040570 PubMed

10. Zanarini MC, Frankenburg FR, Khera GS, et al. Treatment histories of borderline inpatients. Compr Psychiatry. 2001;42(2):144–150. doi:10.1053/comp.2001.19749 PubMed

11. Zanarini MC, Frankenburg FR, Reich DB, et al. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and Axis II comparison subjects: a 16-year prospective follow-up study. Am J Psychiatry. 2012;169(5):476–483. doi:10.1176/appi.ajp.2011.11101550 PubMed

12. Richards DA, Suckling R. Improving access to psychological therapies: phase IV prospective cohort study. Br J Clin Psychol. 2009;48(pt 4):377–396. doi:10.1348/014466509X405178 PubMed

Submitted: August 8, 2014; accepted August 8, 2014.

Corresponding author: Joel Paris, MD, Department of Psychiatry, Institute of Community and Family Psychiatry; McGill University, 4333 cote Ste Catherine, Montreal, Quebec, H3T1E4, Canada (joel.paris@mcgill.ca).