Section Free - Video Lectures

02. Antipsychotics for BPD

Published on January 1, 2022 Certification expiration date: April 1, 2028

Paul Links, M.D.

Professor with the Department of Psychiatry and Behavioural Neurosciences - McMaster University, Hamilton ON, Canada

Key Points

The use of antipsychotics in patients with BPD can be useful for:
- Anger.
- Impulsivity.
- Aggression.
- Cognitive–perceptual disturbances.
Side effects of antipsychotics can limit their usefulness.

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Slides and Transcript

Slide 1 of 10

The next section of our talk is going to talk about antipsychotic medication for patients with borderline personality disorder.

Antipsychotics for BPD Slide 1 of 10

Slide 2 of 10

And we'll review a study by Black from 2014 which I think highlights some of the strengths and weaknesses of the research. So, these researchers studied quetiapine extended release versus placebo in a randomized controlled trial for borderline personality disorder. It was a large trial, 95 participants. And they compared 300 mg of quetiapine ER to 150 mg versus placebo.

References:

Black, D. W., Zanarini, M. C., Romine, A., Shaw, M., Allen, J., & Schulz, S. C. (2014). Comparison of low and moderate dosages of extended-release quetiapine in borderline personality disorder: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry, 171(11), 1174-1182.

Antipsychotics for BPD Slide 2 of 10

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Slide 3 of 10

They found that the lower dose was more effective than placebo on borderline symptoms which was the primary outcome. And it actually had an effect size that was almost 0.8 which is quite meaningful. The moderate dose wasn't significantly better than placebo. There were no significant differences between the two doses themselves. On the secondary outcomes which were things like physical and verbal aggression, both medication doses were superior.

References:

Black, D. W., Zanarini, M. C., RComparison of low and moderate dosages of extended-release quetiapine in borderline personality disorder: A randomized, double-blind, placebo-controlled trial. omine, A., Shaw, M., Allen, J., & Schulz, S. C. (2014). American Journal of Psychiatry, 171(11), 1174-1182.

Antipsychotics for BPD Slide 3 of 10

Slide 4 of 10

But as you might expect, this medication caused many side effects like sedation. And sedation was a reason that patients discontinued the trial. And the study had quite a few exclusions in terms of comorbid diagnoses. So, it does make it limited in terms of generalizing to all clinical situations.

References:

Black, D. W., Zanarini, M. C., Romine, A., Shaw, M., Allen, J., & Schulz, S. C. (2014). Comparison of low and moderate dosages of extended-release quetiapine in borderline personality disorder: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry, 171(11), 1174-1182.

Antipsychotics for BPD Slide 4 of 10

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Slide 5 of 10

But this study really highlights the points of the use of antipsychotics in patients with borderline personality disorder. They do have benefits. They can be particularly useful for anger, impulsivity and aggression and they do have some value for the cognitive-perceptual disturbances, you know, non-delusional paranoid ideation or even some dissociative features. These medications can be useful when the patient is in distress and showing a lot of borderline symptoms.

References:

Black, D. W., Zanarini, M. C., Romine, A., Shaw, M., Allen, J., & Schulz, S. C. (2014). Comparison of low and moderate dosages of extended-release quetiapine in borderline personality disorder: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry, 171(11), 1174-1182.

Antipsychotics for BPD Slide 5 of 10

Slide 6 of 10

Then to work collaboratively with a patient to use low-dose antipsychotics and have them use them for a period of time, maybe two or three months, and then have them taper and stop the medication. And they may see this as a tool they can use in the future if they're really struggling with their symptoms.

References:

Black, D. W., Zanarini, M. C., Romine, A., Shaw, M., Allen, J., & Schulz, S. C. (2014). Comparison of low and moderate dosages of extended-release quetiapine in borderline personality disorder: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry, 171(11), 1174-1182.

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Slide 7 of 10

There's a very interesting study that was using large databases looking at exposure to clozapine in patients who were diagnosed with borderline personality disorder. And on the basis of large datasets, they were able to show that clozapine may have a role in decreasing self-harm, suicide, overdosing behavior.

References:

Rohde, C., Polcwiartek, C., Correll, C. U., & Nielsen, J. (2018). Real-world effectiveness of Clozapine for borderline personality disorder: Results from a 2-Year mirror-image study. Journal of Personality Disorders, 32(6), 823-837.

Antipsychotics for BPD Slide 7 of 10

Slide 8 of 10

The use of antipsychotics in patients with borderline personality disorder can be particularly useful for anger, impulsivity and aggression and they do have some value for the cognitive perceptual disturbances.

Antipsychotics for BPD Slide 8 of 10

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Slide 9 of 10

And of course, you do have to remember the many side effects of antipsychotic medication, particularly weight gain, sedation that can limit their usefulness with these patients.

Antipsychotics for BPD Slide 9 of 10

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Next Section

03. Mood Stabilizers for BPD: Lamotrigine and Lithium

Learning Objectives:

After completing this activity, the learner will be able to:

Understand the importance of good psychiatric management in BPD.
Determine which psychotropic medication may be appropriate for each symptom domain and comorbidity in BPD.
Discuss the available evidence about novel pharmacologic approaches and future research directions in the treatment of BPD.

Original Release Date: January 01, 2022

Review and Re-release Date: April 1, 2025

Expiration Date: April 1, 2028

Expert: Paul Links, M.D.

Medical Editor: Paz Badía, M.D

Relevant Financial Disclosures:

The following planners, faculty, and reviewers have the following relevant financial relationships with commercial interests to disclose:

Dr. Links has disclosed the following relationships:

http://peerpoint-medical.force.com/apex/SiteDisclosureForm?did=a035b00001HcBqIAAV: book author

All of the relevant financial relationships listed for these individuals have been mitigated.

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