Donald W. Black, MD Professor Emeritus Department of Psychiatry University of Iowa Carver College of Medicine Staff Psychiatrist Iowa City Veterans Administration Medical Center Iowa City, Iowa
Disclosure Dr. Black is a consultant to Otsuka. He is an Associate Editor for Current Psychiatry.
Avoid polypharmacy.Many patients with borderline PD are prescribed multiple psychotropic medications.16,17 This approach leads to greater expense and more adverse effects, and is not evidence-based.
Avoid benzodiazepines.Many patients with borderline PD are prescribed benzodiazepines, often as part of a polypharmacy regimen. These drugs can cause disinhibition, thereby increasing acting-out behaviors and self-harm.35 Also, patients with PDs often have SUDs, which is a contraindication for benzodiazepine use.
Rate the patient’s improvement.Both the patient and clinician can benefit from monitoring symptomatic improvement. Several validated scales can be used to rate depression, anxiety, impulsivity, mood lability, anger, and aggression (Table 436-41).Some validated scales for borderline PD align with DSM-5 criteria. Two such widely used instruments are the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD)42 and the self-rated Borderline Evaluation of Severity Over Time (BEST).43 Each has questions that could be pulled to rate a symptom dimension of interest, such as affective instability, anger dyscontrol, or abandonment fears (Table 542,43).
A visual analog scale is easy to use and can target symptom dimensions of interest.44 For example, a clinician could use a visual analog scale to rate mood instability by asking a patient to rate their mood severity by making a mark along a 10-cm line (0 = “Most erratic emotions I have experienced,” 10 = “Most stable I have ever experienced my emotions to be”). This score can be recorded at baseline and subsequent visits.
Take-home points
PDs are common in the general population and health care settings. They are underrecognized by the general public and mental health professionals, often because of stigma. Clinicians could boost their recognition of these disorders by embedding simple screening questions in their patient assessments. Many patients with PDs will be interested in pharmacotherapy for their disorder or symptoms. Treatment strategies include targeting the comorbid disorder(s), targeting important PD symptom dimensions, choosing medication based on the similarity of the PD to another disorder known to respond to medication, and targeting the PD itself. Each strategy has its limitations and varying degrees of empirical support. Treatment response can be monitored using validated scales or a visual analog scale.
