02-17-2015, 03:16 PM
Clinical uncertainty related to alternative options for the management of borderline personality disorder
It's really useful to see an important and complex issue related to the management of borderline personality disorder (BPD), approached by the Crawford et al . The authors present an eloquent argument on why the mood stabilizers, and indeed even psychotropic should be avoided as far as possible, . It is interesting to note that the authors also very pertinent point that such patients can be "demanding" and "doctors may feel under pressure to prescribe drugs"; "In addition, patients with BPD have high rates of deliberate self-injury and suicide, a rate that is 20 times higher than that of the general population" .
I have been working as a consultant for 15 years, and after having spent almost half that time in the NHS as a consultant general Adult psychiatrist managing these patients both in community and inpatient settings, I am of the opinion that non-pharmacological recommendations provided by the authors as alternatives to the use of psychotropic (specifically available stabilizers) is easier said than done.
Beneficial effects for both comprehensive and psychotherapies psychotherapeutic interventions non-comprehensive for patients with BPD are recognized as the most recent Cochrane review . However, this must be seen in the perspective of reality existing for land availability and the delivery of psychological therapies in the United Kingdom. Even if mental health services are exempt from the maximum 18-week waiting time for access to services like the NHS Constitution, there is no data to indicate that about 1 in 5 people waiting for over a year, and 1 in 2 must wait at least 3 months . In addition, the improvement of Access to the psychological therapies (IAPT) poll, I saw that, too, among those who were talking therapies use, 58% were not given the opportunity to choose the type of treatments received, and 75% were not given the opportunity to choose where they received . Where an extrapolated these findings in patients with BPD, this will not be in accordance with the General principles of care provided for the management of these patients as NICE Guidance .
In addition, the authors highlighted the excessive use of psychotropic substances for management of patients with BPD of various NHS Trusts . A similar finding was reported in other countries like Germany  where pharmacotherapy tends to be play a major role in managing BPD; One major reason posited that prescribing psychiatrists do not feel confident with the choice of psychological treatment over medication . Although not clearly documented, but for some reason similar could work in the United Kingdom too.
It is well known that patients with BPD tend to be prone to rejection and have an inherent tendency to fragment and/or "sabotage" their care with high rates of disengagement [1, 4.6]. In addition, most professionals (most often mental health nurses), dealing with these patients tend to Harbor negative feelings and attitudes of (uncomfortable, anxious, challenged, manipulated) and against them (dangerous, powerful, harder to take care of, unrelenting, time-consuming, etc.) with behavioral responses of social being openly supportive of less usefulby expressing less empathy, and express anger .
Keeping in mind the interaction between the factors mentioned above, the ground reality of managing patients with BPD (especially those who threaten or to demonstrate self-injury, and are considered to be at a potentially high risk for suicide) is extremely challenging and demanding, and it is not easy to demonstrate full fidelity in translating the theoretical evidence (or lack of it "in the case of BPD) in direct clinical care.
Therefore, the pragmatic management of patients with BPD will continue probably to show the use of psychotropics (including mood stabilizers) on an empirical base and as a stop-gap arrangement up pragmatic and/or controlled by appropriate research evidence becoming available. More importantly, implementing Nice guidance in respect of psychotherapy for BPD , as well as addressing the issues identified above ground realities can be kind of, if not more, important way for clinicians in managing patients with BPD.