Expert: The Evolving Landscape of Pharmacologic Research and Clinical Management of Symptoms in Borderline Personality Disorder

In an interview with Pharmacy Times, Katharine "Kaz" Joyer Nelson, MD, DFAPA, Adjunct Professor, University of Nebraska Medical School Department of Psychiatry Associate Professor, University of Minnesota Department of Psychiatry and Behavioral Sciences Chief Psychiatrist, discusses her presentation at the 2024 American Association of Psychiatric (AAPP) Conference. Joyer shares the evolving state of research on borderline personality disorder and need for more studies focusing on specific symptoms rather than the disorder as a whole. She emphasizes the importance of an accurate diagnosis, education, and compassionate care for patients using an interdisciplinary team approach. Joyer also addresses the role of pharmacotherapy in managing severe symptoms, challenges like misconceptions around treatability, and factors like minimizing polypharmacy when considering or deprescribing medications.

Can you elaborate on the current state of research regarding pharmacologic treatments for symptoms associated with borderline personality disorder?

Key Takeaways

Research on borderline personality disorder is limited and needs more funding, with studies focusing on individual symptoms rather than the disorder as a whole.
An accurate diagnosis, education, and compassionate care for patients is crucial, best provided through an interdisciplinary team approach.
Medications may have a role for severe BPD presentations but should generally be avoided if possible, and polypharmacy minimized if used long-term.

Well, borderline personality disorder is really under researched condition, especially when you consider the impact that it has and the risks to patients and their families. It really ought to be the focus of much more research for effective treatments, both psychotherapy treatments, other kinds of direct interventions and pharmacology. But it's really underserved in terms of pharmacology. We don't have a lot of new studies coming out, especially when you consider the impact. It's also an evolving diagnosis, there's a lot of scrutiny on how to properly make the diagnosis, which of course impacts the research that we do on the condition and its associated symptoms. So, it really is an evolving landscape that requires us to look at the existing literature that exists, and then use our clinical understanding expertise to do the best for the patient.

Timestamps

(0:00:12)Current state of research on pharmacologic treatments for BPD symptoms, lack of new studies.

(0:01:06) Emerging trends showing importance of study design focused on specific symptoms rather than BPD as a whole.

(0:01:32) Role of interdisciplinary team approach and importance of accurate diagnosis and education.

(0:03:14) Common misconceptions like BPD not being treatable, and suggestions on daily medication use rather than PRN.

(0:05:04) Factors for deprescribing like prioritizing non-medication options and minimizing polypharmacy.

How do you suggest psychiatric pharmacists navigate these differing recommendations to provide optimal care for patients with borderline personality disorder?

Well, increasingly, we're finding that the study design is really making a critical difference in how we understand and utilize the research. It seems that when we've been doing studies, for borderline personality disorder as a whole. For example, maybe somebody comes into the study with borderline personality and then you use a pharmacological intervention for a period of 6 to 12 weeks, the patient still has borderline personality disorder at the end of that. So, we're seeing a lot of negative trials, when the outcome measure is the presence of BPD. Increasingly, we're learning that it's going to be important to distill the symptoms of BPD and design research trials that focus on specific symptoms. And whether addressing that symptom of the disorder actually helps mitigate some of the overall symptoms over time, with the idea that the condition will improve and has a generally good prognosis, with effective overall treatment, and pharmacology playing a small role in overall treatment.

Partnership with the interdisciplinary clinical team is keyb ecause we really need diagnostic precision. A lot of patients with BPD are misdiagnosed with other conditions. And, frankly, sometimes people with other conditions are diagnosed with BPD in a sort of punitive way, or where the diagnosis is weaponized. We must be compassionate towards people with BPD. We must provide them with an accurate diagnosis and education about the diagnosis. I think the interdisciplinary team needs to start there. These are basic clinical practices, that unfortunately, people with borderline personality disorder have not had privilege of access to really basic medical care when it comes to disclosure of the diagnosis, education about the diagnosis, prognosis, and available treatments.

Well, the biggest misconception from all clinicians comes from our training, and that is that borderline personality sorter is not treatable. So you ought not try to treat it or you ought to try to make a parallel or different diagnosis and treat that. Those are big misconceptions— BPD is treatable. Now it's high risk, if somebody loses their life related to BPD, that's a bad outcome, of course. But if we can get through the period of time, with appropriate education, patient care and treatment, the data is showing that this is a better prognosis disorder than many other the psychiatric conditions that we treat. Hopefulness is warranted, compassion is warranted. Really partnering with the patient is absolutely indicated. Another misconception that I see is that sometimes people think that we shouldn't be using medications at all, except in the setting of a crisis, and then maybe using a PRN medication. I think that for patients for whom a medication is the right thing, it's a lot better to prescribe a daily medication to overall mitigate the symptom profile, and then equip the patient with skills and other strategies for those spikes or flare as they come along. Because it gets into a vicious cycle of it intense emotionality or emotional dysregulation, and then ingesting of pills and looking back over time, that's caused a lot of harm.

What are some of the most common challenges or misconceptions that psychiatric pharmacists may encounter when considering pharmacologic treatment for patients with borderline personality disorder and how can these be addressed in clinical practice?

When it comes to deprescribing medications for patients with borderline personality disorder, what factors should psychiatric pharmacists consider?

The first thing to consider is that most patients with borderline personality disorder will not require a medication for the BPD. It is a treatable condition, it's treatable without medications. Now if they happen to have a comorbid diagnosis, and it makes sense to use medications for the comorbid diagnosis, then that can absolutely be pursued. But we don't have to add a medication just for the BPD itself. However, there may be people with severe presentations of BPD, or life-threatening presentations, or the nature of their symptoms are so severe that they're really not able to engage in other forms of care for their BPD. And that might be a population where standing medication— a daily medication, depending on their symptoms may be warranted. Now that's 1 medication, not 1, because we can go down that road as well of prescribing 10 different medications for the multiple symptoms that come up within BPD. I would advocate for a more rational approach, minimizing any form of polypharmacy and monitoring the medication over time and then ultimately tapering when that very severe period of illness has resolved.