Taking A "Practical Approach" When Treating Patients With Borderline Personality Disorder

Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, Rhode Island, summarizes ways clinicians can take a "practical approach" when treating patients with borderline personality disorder (BPD) with medication. He discusses 7 key aspects to the approach, such as the work the patients must do in partnership with their medication, the placebo effect, not medicating crises, avoiding polypharmacy, and symptom management rather than symptom elimination.

In the previous part 2, Dr Zimmerman shares the key takeaways from his live Psych Congress 2021 his session titled "Not Too Much or Too Little: Facing the Challenges of Pharmacotherapy in Borderline Personality Disorder " (BPD) that explored the pharmacology of the disorder. He selects influential studies in the field and their impact on treatment.

In part 1, Dr Zimmerman discusses the diagnoses and treatment of BPD.

Read the transcript:

Let me wrap this up by summarizing a few practical issues, or taking a practical approach in the use of medication when treating patients with BPD.

First, note that I said in treating patients with BPD, not treating BPD, because when we're treating patients with BPD, almost everybody has a comorbid disorder. We probably shouldn't be thinking so much about treating BPD by itself in isolation. We're really treating BPD in the context of other symptomatic disorders.
I think one of the things that I do in my practice is I set expectations for patients. I let them know that there is no magic pill, and that the goal of treatment is to help them manage their emotions better, not eliminate their emotions. It's unlikely that it's going to eliminate their symptoms, but hopefully they will feel that they're more emotionally stable and better able to handle stress and cope with life.

Third, I discuss with individuals, at times, the downside of prescribing medication. I don't want individuals to have the sense that there is a magic pill and that they do not need to engage in psychotherapy. That's one of the risks of prescribing medication, that individuals, despite what you say, will nonetheless still hold out hope that medication will relieve all their problems and they really don't need to do the work in psychotherapy.

Fourth, never forget that when patients improve, it might be the placebo effect. Not that I want to denigrate the placebo effect    I love the placebo effect but I always have in the back of my mind that I don't know for sure whether or not it was the molecule that made a difference or just all the other factors that go into the placebo effect.

Fifth, and perhaps most important or as important as other factors when treating individuals with borderline personality disorder, is to not medicate crises. If you start medicating crises, and patients with BPD frequently are in crisis related to some psychosocial stressor, that's how you can end up with patients end up being on multiple medications.
I've seen too many patients come to me on 6, 7 or 8 psychotropic medications. I'll usually begin by discussing and suggesting to them, "You can be feeling just as bad on a lot less medicine." We start taking away medications, rather than adding something.

Related to that, 6, try and avoid polypharmacy, or particularly poly polypharmacy. There's no evidence of efficacy. Certainly, there is evidence of side effects. Too many patients have complained about significant weight gain, particularly on second-generation agents.

As much as possible, related to that, seven, when you can, switch rather than augment. If something is not helping, don't just add something else to it. Switch it to something else if you're going to be working pharmacologically.

Last, when I'm treating individuals with borderline personality disorder, plus their comorbidities, I'm frequently emphasizing functioning symptom management, rather than symptom elimination, so that their overall quality of life has improved.

Thank you very much for your attention. Have a pleasant day.

Mark Zimmerman, MD, is a Professor of Psychiatry and Human Behavior at Brown University and director of the Partial Hospital Program and Outpatient Practice at Rhode Island Hospital. Dr Zimmerman is principal investigator of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. The MIDAS project has been ongoing for more than 25 years. The goal of the MIDAS project has been to integrate research methodology into routine clinical practice in order to improve clinical practice. 

Dr Zimmerman is the author of more than 450 articles published in peer-reviewed journals, and serves on the editorial board of 10 journals. He is the associate editor of the Journal of Personality Disorders. He has developed several measures of psychiatric disorders for use in clinical practice. He is the author of the Interview Guide to Diagnose DSM-5 Psychiatric Disorders and the Mental Status Examination.