Treating Anxiety and Depression in Patients with Borderline Personality Disorder

1. Treating Anxiety and Depression in Patients with Borderline Personality Disorder Donald W. Black, MD Professor and Program Director Department of Psychiatry University of Iowa Carver College of Medicine AACP/Current Psychiatry Meeting April 8-10, 2010 Chicago, IL donald-black@uiowa.edu

2. Disclosures Research Support: AstraZeneca Forest Labs Nellie Ball Trust Fund NIDA Honoraria: Biomedecon Royalties: Oxford University Press American Psychiatric Publishing, Inc.

6. Overview 1) BPD Overview Epidemiology Comorbidity Etiology 2) Clinical Management Psychological Pharmacologic 3) Conclusions

7. History of BPD • Introduced in DSM-III in 1980 • Antecedents include: • Emotionally unstable personality (DSM-I) • Explosive personality (DSM-II) • Borderline schizophrenia • Kernberg’s borderline personality organization

8. History of BPD • One of the most frequently used PD diagnosis • Retained in DSM-V draft as a personality ”type” • May become a dimensionally rated construct (Zimmerman et al., 2005)

9. Epidemiology • 1-2 % of adult population • 6% primary care • 10% psychiatric outpatients • 20% psychiatric inpatients • 30% prison population • Sex ratio • 70% women • 30% men

10. An Expensive Disorder • Significant psychosocial impairment • Marital discord • Domestic violence • Work-related issues • Impaired quality of life • High medical/mental health service utilization (Lieb et al., 2004)

11. An Expensive Disorder • Associated with • Chronic medical illness • Increased Body Mass Index (BMI) • Significant morbidity/mortality • Suicide in up to 10% • Poor medication response (Black et al., 2004; Frankenburg and Zanarini, 2004)

12. The most worrisome symptoms make the greatest demand on MH professionals 73% attempt suicide 3.4 mean lifetime attempts 75% deliberate self-harm Suicidal and Self-harm Behavior (Black et al., 2004)

13. Axis I Comorbidity (Lieb et al., 2004; Zimmerman and Mattia, 1999)

14. Axis II Comorbidity • 43-47% Avoidant PD • 16-51% Dependant PD • 14-30% Paranoid PD • 23-26% Antisocial PD (Lieb et al., 2004)

15. Etiology Adverse childhood experiences • Genetic: • Familial • High heritability • Environment: • Abuse/neglect • Chaotic home Genetic factors Emotional dysregulation Impulsivity Dysfunctional behaviors Psychosocial conflicts and deficits (Lieb et al., 2004)

16. Natural History • Onset late teens/early 20s • Most severe early in its course • Tendency for “burn out” • Older patients less impulsive • Fewer suicidal behaviors • In the McLean follow-up, 75% no longer met DSM-IV criteria at 6 years • Emotional disturbances persisted in 60-80% (Blum et al., 2008; Zanarini et al., 2003)

17. Undue Pessimism • Prognosis better than for many other personality disorders • Psychiatrists do not expect quick and easy results with other chronic patients… BPD should not be an exception! (Paris, 2005)

18. Treatment Received by BPD Patients 97% Outpatient care 95% Individual therapy 56% Group therapy 42% Family/Couples therapy 37% Day treatment 72% Psychiatric hospitalization 24% Halfway house * 9-40% frequent users of inpatient services (Lieb et al., 2004)

19. BPD Treatment “… is generally viewed as disappointing and unsatisfactory. With medication, patients show mild degrees of improvement with many drugs, but fail to respond definitively to any.” (Paris, 1994)

20. Multiple Medications the Norm • 71- 86% prescribed psychotropics • 37- 46% ≥ 3 medications • 20 - 29% ≥ 4 medications • 10 - 18% ≥ 5 medications (Zanarini et al., 2004)

21. Which Medications? Antidepressants 47 -74% Antipsychotics 22 -32% Mood stabilizers 23 -39% Sedatives 12 -27% Stimulants 7 -13% (Black et al., unpublished)

22. Psychological treatments Pharmacologic Other Support groups Community services Self-help books Treatment Considerations

23. Psychological Treatments • Individual psychotherapy • Family/couples therapy • Group treatment programs • Evidence-based • Comprehensive programs • Adjunctive programs • Implementation problems • Program length • Lack of trained therapists • Expense/training

24. Psychopharmacology of BPD • Drugs from all major classes have been used • Antidepressants • Mood stabilizers • Antipsychotics • Benzodiazepines • No drug targets all symptoms • No FDA approved medications

25. Treatment Guidelines • APA Practice Guidelines for the treatment of BPD (2001) • Guideline watch (2005) • BPD: NICE Guideline on Treatment and Management (2009) • Royal College of Psychiatrists and British Psychological Society • www.nice.org.uk • Cochrane review of psychological treatments (2006) • Cochrane review of pharmacological treatments (2010)

26. Dialectical Behavior Therapy 1 year program CBT orientation Mentalization-based therapy 18-month duration Partial hospital setting Psychoanalytic Schema-focused Therapy 3 year program Psychoanalytic/CBT hybrid STEPPS program 5 months CBT/SST/psychoeducation Evidence-based Group Treatments

27. Psychological Treatments: RCTs

28. What is STEPPS? (Systems Training for Emotional Predictability and Problem Solving) • Group treatment for outpatients with BPD • Combines CBT elements, skills training, and psychoeducaton • Detailed manual • Systems component for family members, friends, and significant others • Developed at the University of Iowa (www.steppsforbpd.com) Nancee Blum, MSW

29. NICE Guidelines: Psychotherapy • NICE reviewed 16 RCTs for individual/group therapies (7 for DBT) and concluded that • Evidence base was poor • Few subjects/low power • Multiple outcome measures • Comprehensive programs - evidence for reduced suicidal behavior, anger, depression, anxiety • Adjunctive programs - evidence for improved general functioning • Interventions should last > 3 months

30. Cochrane Review: Psychotherapy • Reviewed 7 RCTs involving 262 subjects “ This review suggests that some of the problems ……may be amenable to talking/behavioural treatments but all therapies remain experimental and the studies are too few and small to inspire much confidence in their results.” (Binks et al., 2007)

31. NICE Guidelines: Medication • Reviewed 22 RCTs involving antidepressants, antipsychotics, and mood stabilizers • Concerns with • Variable inclusion criteria • Variable outcome measures • High attrition • Small numbers/low power • Evidence that medication treats depression, anxiety, hostility, and impulsivity • No evidence that meds alter the fundamental nature of BPD • Concern with weight gain and tardive dyskinesia • Medication should be directed at the comorbid disorder

32. Cochrane Review: Medication • 27 RCTs reviewed with 1714 subjects • Antipsychotics • FGAs: haloperidol - ↓ anger; flupentixol - ↓ suicidal behavior • SGAs: aripiprazole, olanzapine -↓ BPD sxs • Antidepressants • Amitriptyline - ↓ depression • Mood stabilizers • Valproate - ↓ interpersonal problems, depression • Lamotrigine - ↓ impulsivity; • Topiramate ↓ interpersonal problems, anxiety, general sxs • Omega-3 • ↓ suicidality, depression (Lieb et al., 2010)

33. Cowdry and Gardner (1988) Alprazolam compared to: carbamazepine, tranylcypromine, trifluoperazine 16 subjects; double-blind crossover Alprazolam led to ↑ behavioral dyscontrol, and ↑ suicidality Bottom line: avoid BZPs because of Behavioral dyscontrol Abuse potential What about Benzodiazepines?

34. Rational Approach to Treatment:Begins with Assessment • Thorough evaluation with consideration of comorbid disorders • Consider patient’s stage of illness and psychosocial situation and needs • Safety concerns • Consider patient’s desires

35. Rational Approach to Treatment:Consider Spectrum of Services • Spectrum of services • Inpatient • Outpatient • Partial hospital • ACT type program • Role of psychotherapy • Individual psychotherapy – the treatment mainstay • Adjunctive Group therapy (e.g., STEPPS) • Comprehensive program (e.g., DBT) • Availability of psychotherapy and community services • Evidence-based psychotherapies not widely available

36. Rational Approach to Treatment: Therapy and Lifestyle Issues • Psychotherapy targets • Depression/anxiety • BPD symptoms • Impulsivity • Suicidal behavior • Service utilization • Pay attention to the patient’s lifestyle behaviors • Medical needs/Diet • Physical activity • Sleep • Leisure activities

37. Rational Approach to Treatment: Medication • Medications should target the patient’s symptoms • Mood instability - mood stabilizers, antipsychotics • Anger/irritability - antipsychotics • Depression/anxiety - SSRIs • Psychotic-like symptoms - antipsychotics • Self-harm - antipsychotics

38. Rational Approach to Treatment: Medication • Medications have modest benefit • Prescribing multiple medications is common but few empirical data • Avoid benzodiazepines • Avoid potentially dangerous medications (TCAs, MAOIs)

39. “It’s my expectation and hope that in less than 10 years, BPD will be an approved indication … for one or more of the atypical antipsychotic agents.” Bob Friedel’s Opinion: Borderline Personality Disorder Demystified (2004)

40. Rational Approach to Treatment: Comorbidity • Treat the comorbid Axis I disorders • Mood disorder • Anxiety disorder • Other comorbidity • ADHD • Eating disorder • Addictions

41. Support Organizations • TARA (www.tara4BPD.org) • NEA-BPD • BPD Research Foundation

42. Self-help Books

43. Conclusions • BPD common in clinical settings • Psychological therapies a mainstay • Evidence-based group therapy programs • Medication • Limited but important role • Treat comorbid disorders • Don’t forget patient’s other needs

44. Thank you!

45. Questions?

46. References 1) American Psychiatric Association. Practice guidelines for the treatment of patients with borderline personality disorder. Am J Psychiatry 2001; 158 (suppl 1):1-52. 2) Binks CA, Fenton M, Lee T, et al,: Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2006; Jan 25. 3) Black DW, Blum N, Pfohl B, Hale N: Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction and prevention. J Person Disord 2004a; 18:226-239. 4) Blum N, Pfohl B, St. John D, et al.: Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry 2008b; 165: 468-478. 5) Friedel RO: Borderline Personality Disorder Demystified. New York: Marlowe, 2004.

47. References, cont. 6) Lieb K., Zanarini MC, Schmahl C, et al.: Borderline personality disorder. Lancet 2004; 364: 453-461. 7) Lieb K, Vollm B, Rucker G, et al.: Pharmacotherapy for borderline persoanaility disorder: Cochrane systematic review of randomised trials. Br J Psychiatry 2010; 196: 4-12. 8) National Institute for Health and Clinical Excellence (NICE): Borderline personality disorder: treatment and management. January 2009 (http://guidance.nice.org.uk/CG78) 9) Zanarini MC, Frankenburg FR, Hennen J, Silk KR: Mental health service utilization by borderline personality disorder patients and comparison subjects followed prospectively for 6 years. J Clin Psychiatry 2004; 65: 28-36. 10) Zimmerman M, Mattia JI: Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry 1999; 40: 245-252. 11) Zimmerman M, Rothschild L, Chelminski I: The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 2005; 162: 1911-1918.