Pharmacotherapy and Personality Disorder

Question 1

Define personality

Answer 1

The pattern of thoughts, feelings, and behaviours which makes every individual the person that they are. This pattern is flexible, with behaviour differing according to social situation

Question 2

Define personality disorder

Answer 2

An enduring maladaptive pattern of perceiving, relating to, and thinking about the environment and oneself - this pattern is inflexible, deviates from cultural expectations, and impairs function

Question 3

Give some reasons for treating personality disorder

Answer 3

Ease the distress it causes, ease suffering, reduce the impact of stigma, reduce service use, reduce associated morbidity and mortality

Question 4

What is the main cause of death in individuals with personality disorder? (Fok et al, 2012)

Answer 4

Cardiovascular disease

Question 5

What is the primary treatment for personality disorder?

Answer 5

Psychotherapy

Question 6

State the ICD-10 definition of emotionally unstable personality disorder

Answer 6

A marked tendency to act impulsively with affective instability and minimal ability to plan ahead

Question 7

Name the 2 variants of emotionally unstable personality disorder defined in ICD-10

Answer 7

Impulsive type and borderline type

Question 8

Which classes of drugs could be useful for borderline personality disorder based on its symptoms?

Answer 8

Antidepressants (chronic feelings of emptiness), mood stabilisers (affective instability), antipsychotics (transient paranoid ideation)

Question 9

Describe the evidence around antidepressants for personality disorder

Answer 9

Out of the 7 trials, 6 found no beneficial effects. The last found amitriptyline caused a reduction in depressive symptoms - but these individuals could have had comorbid depression

Question 10

Describe the evidence around antipsychotics for personality disorder

Answer 10

Antipsychotics reduce hostility, anger, and impulsivity, but also have significant side effects such as weight gain and many patients do not adhere

Question 11

Describe the impact of clozapine on personality disorder (Frankenburg & Zanarini, 1993; Chengappa et al, 1999; Frogley et al, 2013)

Answer 11

Clozapine reduces impulsive behaviour, affect-related symptoms, aggresion, and self-harming behaviour, It effects appear greatest in the first 6 months, and are associated with a significant increase in weight

Question 12

Describe the evidence around mood stabilisers for personality disorder

Answer 12

Mood stabilisers reduce anger, depression, and impulsivity - although all trials have been small and of poor quality

Question 13

What do the 2009 NICE guidelines state about pharmacological treatment and borderline personality disorder?

Answer 13

Drug treatment should not be used specifically for borderline personality disorder or behaviour associated with it

Question 14

What does Lieb et al’s 2010 Cochrane review state about pharmacological treatment and borderline personality disorder?

Answer 14

Mood stabilisers and 2nd generation antipsychotics may be effective in treating symptoms associated with borderline personality disorder

Question 15

What percentage of borderline personality disorder patients have a comorbid mental health condition?

Answer 15

75%

Question 16

State the 2 most common comorbidities of borderline personalty disorder

Answer 16

Depression and substance misuse

Question 17

Why is the level of medication prescription high in personality disorder?

Answer 17

Patient’s fear of abandonment, lack of trust (no drugs = no care), clinician counter-transference, clinician guilt over not doing enough

Question 18

Describe the results of Evans’ 2014 study on the clinician-patient relationship in personality disorder

Answer 18

It is punctuated by feelings of helplessness and discontinuity. Patients feel there is a lack of knowledge and understanding, and clinicians rely on medication due to a lack of involvement. Patients also believe they should help to decide if medication is appropriate

Question 19

What is lamotrigine?

Answer 19

A sodium channel blocker used in treatment of epilepsy and as a mood stabiliser in bipolar disorder

Question 20

State some side effects of lamotrigine

Answer 20

Nausea, insomnia, fatigue, rhinitis, rash, neck stiffness. 1 in 1,000 develop a severe rash that is fatal if not treated

Question 21

Describe the results of the LABILE study on lamotrigine for borderline personality disorder

Answer 21

Lamotrigine had no benefit over placebo on any outcome - including BDI score, alcohol use, substance misuse, or self-harm