Borderline and antisocial personality disorders: summary of NICE guidanceBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b93 (Published 28 January 2009) Cite this as: BMJ 2009;338:b93
All rapid responses
We read the article (1) with great interest. The NICE recommendation
on borderline personality disorder emphasis two key issues such as the
psychological treatment and to avoid use of drug treatment specifically
for borderline personality disorder or for individual symptoms or
behaviour associated with it.
We strongly argue that the recommendation to avoid pharmacological
agents negates the biological basis of the disorder, ignore the current
nature of psychopathology. It also adds to the myth that people with
borderline personality disorder are in control of their life, symptoms are
deliberate or psychological.
Patients with borderline personality disorder experience pathological
mood swings, impulsive and aggressive behaviours, features of depression
and short lasting psychotic symptoms. The evidence suggests that the
symptoms in borderline personality disorder are linked to impulsive and
aggressive spectrum disorders (2). Antidepressants, mood stabiliser and
antipsychotics are effective in providing symptomatic relief and reducing
the risk and their use are justified on biological basis (2,) and research
In addition there is significant overlap of symptoms of personality
disorder with other psychiatric illness (6). It will have a detrimental
effect if co morbid condition left untreated. Drug treatment can also
enhance the chances of patient engaging with services and chances of
benefiting from long-term psychological treatment.
The evidence for psychological treatment is not inspiring and are
unlikely to be available to general patient due to lack of resources and
skilled therapists(7). It is also possible that certain patients may not
be willing or psychologically minded for therapy.
The denial of drug treatment to borderline patient will have huge
impact on acute inpatient and community services. It may also have
negative impact on frequency and length of admission, morbidity and
1. Kendall T, Pilling S, Tyrer P et al Borderline and antisocial
personality disorder: summary of NICE guideline. BMJ 2009:338; b93 (31
2. Tyrer P and Bateman A W Drug treatment for personality disorder.
Advances in Psychiatric Treatment 2004 (10) 389-398
3. Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C
Pharmacological interventions for people with borderline personality
disorder Cochrane Database of Systematic Reviews, 2006, vol./is.
4. Hollander E, Tracey KA, Swann AC, Coccaro EF, McElroy SL, et al
Divalproex in the treatment of impulsive aggression: efficacy in cluster B
personality disorders. Neuropsychopharmacology 2003; 28(6):1186-97
5. Newton-Howes G, Tyrer P. Pharmacotherapy for personality
disorders. Expert Opinion on Pharmacotherapy 2003: 4 (10): 1643-1649
6. Zanarini MC, Frankenburg FR, Dubo ED, et al. Axis I Comorbidity
of borderline Personality Disorder. Am J Psychiatry 1998:155:1733-1739.
7. Binks CA,Fenton M,McCarthy L,Lee T,Adams CE,Duggan C Psychological
therapies for people with borderline personality disorder Cochrane
Database of Systematic Reviews, 2006, vol./is. /1(CD005652), 1469-493X
Bettahalasoor Somashekar Consultant Psychiatrist, Coventry and
Warwickshire Partnership Trust, The Caludon Centre Coventry CV2 2BF.
Ashok Kumar Jainer Consultant Psychiatrist, Coventry and Warwickshire
Partnership Trust, The Caludon Centre Coventry CV2 2BF.
Competing interests: No competing interests