Personality disorder integrated care pathway
| Symptom cluster | First line drug choices | Second line drug choice | Third line drug choices |
| Impulsive-behavioural dyscontrol symptoms |
Generic SSRI |
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| Affective dysregulation |
Generic SSRI or Mirtazapine |
Different generic SSRI or Mirtazapine |
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| Cognitive-perceptual symptoms | Low does antipsychotic | Different low dose anti psychotic | No third line recommendation |
| Inter-personal difficulties | Drug treatment inappropriate for this symptom cluster | ||
Medication for personality disorder
A single page summary and treatment algorithm can be found in the Appendix.
If prescribing is unavoidable, the specific prescribing principles detailed below should be followed, ideally using a written prescribing agreement, a copy of which should be sent to the patient, a copy to the GP, and a copy kept in the casenotes. This prescribing process is likely to have more therapeutic benefit than the medication itself and is informed by the general principles of management of personality disorder.
For understandable reasons, some people with personality disorder are keen for a “quick fix” to their difficulties in the form of a medication. There can be resistance to any suggestion that medication may not be helpful, especially when they may have experience of other people experiencing benefit from psychotropic medication with other mental disorders. It is not hard to understand why many people would prefer the relatively easy solution of taking a tablet versus a lengthy and perhaps challenging psychosocial treatment. This position should be validated and if a patient remains keen for a trial of medication, despite explanation of the lack of evidence, effective alternatives and possible adverse effects, then the prescribing process below should be used.
For some people, this prescribing process (which effectively functions as a series of behavioural experiments) can be helpful in demonstrating that medication is of limited value in the treatment of personality disorder. Patients may then be more likely to recognise the need to assume greater responsibility in their own recovery and may begin to consider engaging more personally demanding but potentially more effective psychosocial treatments.
Medication should be directed at specific symptoms or related symptom clusters rather than the overall disorder. See the table in the subsection below for guidance on choices of medication according to the higher order domain to which the symptom belongs. This guidance is based upon the American Psychiatric Association’s guideline for the treatment of patients with borderline personality disorder (itself based upon earlier work by Soloff, 1998) and recommendations by Tyrer and Bateman (2004). The guidance represents expert opinion and should be used in the context of the extremely limited evidence base for benefit of drugs in the treatment of personality disorder.
A review of drug treatment in borderline personality disorder carried out by the Cochrane library (Cochrane Library, 2010) describes mixed results from individual studies. It was unable to draw firm conclusions in favour of benefit or harm and stated that “current findings of trials and this review are not robust and can easily be changed by future research endeavours. In addition, the studies may not adequately reflect several characteristics of clinical settings (among others, patients’ characteristics and duration of interventions and observation periods).”
The NICE Guideline for the Treatment of Borderline Personality Disorder (NICE, 2009) recommends that drug treatment should not be used “specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder” and that “antipsychotic drugs [should not be] used in the medium- or long-term treatment of borderline personality disorder”.
The NICE Guideline for the Treatment of Borderline Personality Disorder suggests:
• considering “drug treatment in the overall treatment of comorbid conditions”
• cautiously considering “short-term use of sedative medication as part of the overall treatment plan for people with borderline personality disorder in a crisis. . . [for] no longer than one week”. When prescribing in these circumstances, the recommendation is to choose a drug with a low side effect profile, low addictive properties, minimum potential for misuse and relative safety in overdose, for example a sedating anti-histamine like Hydroxyzine or Promethazine. Please note that sedative antihistamines are not licensed for this purpose and informed consent should be obtained and documented (completion of the Prescribing Agreement Form serves this purpose). Prescribe the lowest effective dose and issue fewer tablets more frequently if there is a significant risk of overdose.
• reviewing “the treatment of those who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs…[aiming] to reduce and stop unnecessary drug treatment”.
The NICE Guideline for the Treatment of Antisocial Personality Disorder (NICE, 2009) recommend that “pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder or associated behaviours of aggression, anger and impulsivity”. While evidence for the use of medications in personality disorder is scant overall, occasionally patients do appear to gain individual benefit from specific drugs. In these cases the drug should be kept under regular review at the lowest effective dose and stopped if benefit is not sustained.
Polypharmacy is common in patients with personality disorder. Patients are frequently prescribed a greater number of psychotropic medications in higher doses than many individuals with severe mental illnesses like bipolar affective disorder and schizophrenia in which the evidence base for use of medication is much stronger. This is often because of the distress in which these patients present and an understandable desire on the part of the prescriber to “do something”. Very often, short term medications become long term medications, with upward creep of doses and new medications added. Sometimes there can be reluctance (from both patient and prescriber) to stop medication despite any apparent benefit in case the medication is actually having some effect and its withdrawal leads to a deterioration. The end result is often a patient on inappropriately high doses of unlicensed, often sedative, medication with significant adverse effects in multiple domains. Impairments may involve the cognitive and motivational domains crucial for most psychosocial treatments, and reduction in general functioning which can negatively affect the person’s environment, interpersonal situation and mental state.
Regular review of medication is recommended for all patients. If polypharmacy is an issue, the following approach to address the problem is recommended.
Review each medication individually:
- How long the patient has been on the drug?
- Establish dose, frequency, compliance.
- Establish the patient’s view on the target or purpose of the drug - for example, ‘anxiety’.
- Ask the patient to self-rate the symptom or problem which the medication is being used to treat — for example 8/10 anxiety.
- If the medication is effectively controlling the problem (for example, self-rated anxiety 1/10), continue prescription at the lowest effective dose. Keep under regular review and stop if benefit is not sustained.
- If the medication is not effectively controlling the problem (for example, self-rated anxiety 8/10), stop the drug. Some medications, such as benzodiazepines, may require a relatively slow downward titration and appropriate guidelines should be followed, for example those in the British National Formulary.
Aim to stop all ineffective medications as soon as is safely possible. A period of at least 3 months is advised before any further psychotropics are prescribed. Any further prescriptions should be under the terms of the outlined prescribing agreement.
- Explain that if the patient stops taking the drug for any reason, no alternative drug will be prescribed until the trial period has elapsed.
- Agree how symptom change will be objectively measured. There are no specific tools for this purpose but improvement should be measurable in clearly operationalised terms. For example, if an SSRI is prescribed in an attempt to modify self-cutting behaviour, a specific target should be developed in collaboration with the patient before starting treatment. If the target specified is: “a reduction in the number of episodes of self-cutting in a seven day period”, then a baseline frequency is required against which to measure change. A diary card or similar would clearly be useful here. Less objectively measurable symptoms such as dysphoria can also be measured. This could be achieved by a simple ‘1 to 10’ self-rating of mood. Formal rating scales for depression are probably of little value for measuring this symptom unless the patient is actually suffering with clinical depression as opposed to dysphoria, because they measure the depressive syndrome rather than individual symptoms. Tools such as the BEST and CORE can measure overall progress but it is important to be mindful that any drug treatment should be targeted at a specific symptom (or related symptom cluster) and not the entire disorder.
- Agree on a measure of improvement in the target symptom which will represent an acceptable outcome for the patient. For example, a reduction in dysphoria from 8/10 to 4/10.
- The clinician and patient should then sign the prescribing agreement. This gives the patient the opportunity to give their informed consent to treatment and gives the prescriber written documentation to refer to at subsequent reviews.
The prescribing agreement can be found in the Appendix.
- Prescribe within safety limits; consider weekly scripts.
- Meet with the individual regularly to discuss response and side effects.
- After agreed trial period, stop the drug if patient experiences no improvement.
- If the patient decides for any reason to stop the medication before the agreed trial period ends, no other drug should be prescribed until that period has elapsed. This should be discussed with the patient before starting the drug and prior to signing the prescribing agreement.
- At the end of the agreed period, review the self-recorded measure of the target symptom. If the agreed goal is met, continue the medication and regularly review its effect on the agreed treatment target. If the medication ceases to be effective it should be stopped.
- Change doses gradually as individuals with personality disorder frequently complain of increased sensitivity to side effects and discontinuation effects.
- Regularly review prescribed medication and aim to stop any unnecessary or ineffective treatments for either the personality disorder itself or any comorbidity.
- Aim to keep drug treatment at the lowest effective dose for the shortest duration.