Are mood stabilisers helpful in treatment of borderline personality disorder?BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5378 (Published 16 September 2014) Cite this as: BMJ 2014;349:g5378
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Mark Agius’ response to our paper is helpful. People with borderline personality may have a number of co-morbid axis one disorders and it is right that these should be treated in accordance with recommended guidelines. In our article we argued that interpersonal problems that are central to personality disorder can lead to people being given inappropriate and unhelpful prescriptions. Interpersonal problems can also lead to people being denied interventions that may be of benefit. The work of Dr Agius and colleagues is important in highlighting that a minority of people with borderline personality disorder have coexisting bipolar disorder which may benefit from treatment with mood stabilizers.
Competing interests: No competing interests
The Clinical Uncertainty related to Alternative Options for Management of Borderline Personality Disorder
It is indeed helpful to see an important and complex issue related to the management of the borderline personality disorder (BPD) being addressed by Crawford et al . The authors present an eloquent argument as to why mood stabilizers, and indeed even psychotropics, should be avoided as far as possible . It is interesting to note that the authors also very pertinently point that such patients can be ‘demanding’ and ‘clinicians may feel under pressure to prescribe drugs’; “additionally, patients with BPD have high rates of deliberate self-harm and a rate of suicide that is 20 times that of the general population” .
I have been working as a Consultant for 15 years, and after having spent nearly half that time in the NHS as a General Adult Consultant Psychiatrist managing such patients in both community and inpatient settings, I am of the opinion that the non-pharmacological recommendations provided by the authors as alternatives to use of psychotropics (especially mood stabilizers) is easier said than done.
Beneficial effects for both comprehensive psychotherapies and non-comprehensive psychotherapeutic interventions for patients with BPD are acknowledged as per the most recent Cochrane review . However, this needs to be seen in perspective of the ground reality existing for availability and delivery of psychological therapies in the UK. Even though mental health services are exempt from the 18-week maximum waiting time for access to services as per NHS Constitution, there is data to indicate that roughly 1 in 5 people wait for over one year, and 1 in 2 have to wait for at least 3 months . Additionally, under the Improving Access to Psychological Therapies (IAPT) survey, it was also seen that amongst people who were using talking therapies, 58% were not offered a choice in the type of therapies received, and 75% were not given a choice where they received it . If one extrapolates these findings to patients with BPD, this will not be in keeping with the broad principles of care laid down for managing these patients as per the NICE Guidance .
Additionally, the authors have highlighted the inordinately high use of psychotropics for managing patients with BPD from various NHS Trusts . A similar finding has been reported from other countries like Germany  where pharmacotherapy tends to be play a major role in the management of BPD; one major reason postulated being that prescribing psychiatrists do not feel confident with the choice of psychological treatment over medication . Though not clearly documented, but a similar reason could operate in the UK too.
It is well known that patients with BPD tend to be prone to rejection and have an inherent tendency to fragment and/or ‘sabotage’ their own care with high rates of disengagement [1,4,6]. Additionally, majority of the professionals (most commonly mental health nurses) dealing with these patients tend to harbor negative feelings and attitudes for self (uncomfortable, anxious, challenged, manipulated) and towards them (dangerous, powerful, more difficult to take care of, unrelenting, time-consuming etc.) with behavioral responses of social distancing, being less helpful, expressing less empathy, and expressing anger .
Keeping in view the interplay of the above mentioned factors, the ground reality of managing patients with BPD (especially those who threaten or demonstrate self-harm, and are deemed to be at a high potential risk for suicide) is extremely challenging and demanding, and it is not easy to demonstrate complete fidelity in translating theoretical evidence (or ‘lack of it’ in the case of BPD) into direct clinical care.
Hence, the pragmatic management of patients with BPD will probably continue to show use of psychotropics (including mood stabilizers) on an empirical basis and as a stop-gap arrangement till appropriate pragmatic and/or controlled research evidence becomes available. More importantly, the implementation of NICE guidance regarding psychotherapy for BPD , and addressing the issues related to the ground realities identified above may be an equally, if not more, important way forward for clinicians in managing patients with BPD.
 Crawford MJ, MacLaren T, Reilly JG. Are mood stabilizers helpful in treatment of borderline personality disorder? BMJ 2014; 349: g5378.
 Stoffers JM, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2012; Aug 15;8:CD005652. doi: 10.1002/14651858.CD005652.pub2.
 Department of Health. Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence. Department of Health, London, pp 207.
 National Institute for Health and Clinical Excellence. Borderline personality disorder: treatment and management. NICE, 2009.
 Knappich M, Hogz-Sagstetter S, Schwerthoffer D, Leucht S, Rentrop M. Pharmacotherapy in the treatment of patients with borderline personality disorder: results of a survey among psychiatrists in private practices. Int Clin Psychopharmacol 2014; 29: 224-228.
 Gupta N. The conundrum of emotionally unstable personality disorders. IJSP 2012; 28: 36-42.
 Sansone RA, Sansone LA. Responses of mental health clinicians to patients with borderline personality disorder. Innov Clin Neurosci 2013; 10: 39-43.
Competing interests: No competing interests
Crawford et al (1) discuss very appropriately the difficulty in deciding whether patients with borderline personality disorder should be treated with mood stabilisers.
This raises the important issue that it is possible for patients to suffer from two comorbid but distinct conditions; Bipolar II Affective Disorder, and Borderline Personality Disorder. Bipolar Disorder is basically an illness with an important genetic component, often related to a family history of the illness, while Borderline Personality Disorder has mostly an environmental component, including often the fact that the sufferer has been exposed to abuse. However it is indeed possible that both conditions may exist in the same patient (2).
Mood stabilisers are essential treatment for patients who suffer from bipolar disorder, since they are essential in stabilising mood and reducing suicidality (3).
Patients with borderline personality disorder, who do not have comorbid bipolar disorder, do demonstrate mood lability, but do not demonstrate hypomanic or manic episodes, as defined by DSM V, in other words they do not demonstrate a history of at least 4 days of clearly euphoric [high]mood(2).
Borderline patients may instead demonstrate mood lability, as in changes from euthymicity to depressed mood and back again, and also impulsivity, but this does not indicate hypomanic episodes required to diagnose bipolar illness (2).
However, there do occur cases when borderline traits can be co-morbid with bipolar disorder(4). If the bipolar illness is ignored in these cases, so that the patients are only diagnosed as having borderline personality disorder, then these bipolar patients will not be diagnosed , and hence they will not receive the mood stabilising treatment they need. This will have an impact on their prognosis, since patients with Bipolar II are known to have a relatively high risk of suicidality (5), and this can be expected to be exacerbated by the impulsivity and self harming behaviour caused by the comorbid borderline traits.
We therefore propose that patients with possible borderline personality disorder be carefully assessed for hypomanic episodes as described in DSM(6). If they can be shown to have such episodes, then a diagnosis of Bipolar Disorder with comorbid borderline features can be considered , while if not then the patients may well have borderline personality disorder alone. Only if the patients are shown to have bipolar disorder should mood stabilisation be prescribed.
We have recently been able to demonstrate that bipolar disorder is still often underdiagnosed in community mental health teams(7), and this implies risk to the patients not diagnosed. We feel that misdiagnosis of bipolar disorder comorbid with borderline traits does contribute to this misdiagnosis. We have also been able to publish an audit which shows that by adopting the policy of identifying hypomanic episodes, we found that in our sample, 14.66% of patients were found to have bipolar disorder co-morbid with borderline personality disorder , and therefore we did not exceed the number of patients [12-23%] which are predicted in the international literature as having both borderline and bipolar conditions(6).
1.Crawford M, MacLaren T, Reilly JG Are mood stabilisers helpful in treatment of borderline Personality Disorder? BMJ 2014:349:g5378.
2. Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar or borderline: a clinical overview. ActaPsychiatrScand 2014: 130: 99–108
3.Bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care NICE 2014
4..Elisei S, Anastasi S, VerdoliniN.The continuum between Bipolar Disorder and Borderline Personality Disorder.PsychiatrDanub. 2012 Sep;24Suppl 1:S143-6
5.Costa LD, Alencar AP, Neto PJ, Santos MD, da Silva CG, Pinheiro SD, TeixeiraSilveira R, Bianco BA, PinheiroJúnior RF, de Lima MA, Reis AO, Neto MLRisk factors for suicide in bipolar disorder: A systematic review.J Affect Disord. 2014 Sep 16;170C:237-254.
6.Agius M, Lee J, Gardner J, Wotherspoon D. Bipolar II Disorder and Borderline Personality Disorder - co-morbidity or spectrum?PsychiatrDanub. 2012 Sep;24Suppl 1:S197-201
7. Bongards EN, Zaman R, Agius M. Can we prevent under-diagnosis and misdiagnosis of bipolar affective disorder? Repeat audits to assess the epidemiological change in the caseload of a community mental health team when bipolar disorder is accurately assessed and diagnosed.PsychiatrDanub. 2013 Sep;25Suppl 2:S129-34
Competing interests: No competing interests