Psychodynamic Therapy
Psychodynamic psychotherapy has the potential to disorganize some patients if the focus is too exploratory or if there is too much emphasis on transference without an adequately strong alliance. Intensive dynamic psychotherapy may also activate strong dependency wishes in the patient as transference wishes and feelings develop in the context of the treatment. It is the exploration of such dependency that is often essential to help the patient to achieve independence. This dependence may elicit countertransference problems in the therapist, which can lead to inappropriate or ineffective treatment. The most serious examples of this include unnecessary increases in the frequency or duration of treatment or transgression of professional boundaries.
Cognitive Behavior Therapy
Although there are no reports of adverse effects of cognitive behavior therapy, including dialectical behavior therapy, as administered on an outpatient basis, one inpatient study reported a paradoxical increase in parasuicidal acting out in the dialectical behavior therapy group compared with the control group -- a finding thought perhaps to be due to the contagion effect within a closed, intensive milieu.
Group Therapy
Acute distress from exposure to emotionally arousing group issues has been reported. Other potential risks of treating patients with borderline personality disorder in group settings include shared resistance to therapeutic work, hostile or other destructive interactions among patients, intensification of transference problems, and symptom "contagion."
Couples Therapy
One report described an escalation of symptoms when traditional marital therapy was used with a couple who both were diagnosed with borderline personality disorder. Clinical experience would indicate the need for careful psychiatric evaluation of the spouse. When severe character pathology is present in both, the clinician will need to use a multidimensional approach, providing a holding environment for both partners while working toward individuation and intrapsychic growth. Because the spouse’s own interpersonal needs or behavioral patterns may, however pathological, serve a homeostatic function within the marriage, couples therapy has the potential to further destabilize the relationship.
Family Therapy
Some clinicians report that traditional dynamically based family therapy has the potential to end prematurely and have a poor outcome, since patients may alienate their family members or leave the treatment themselves because they feel misunderstood when family involvement is indicated. A psychoeducational approach appears to be less likely to have such adverse effects; however, even psychoeducational approaches can upset family members who wish to avoid knowledge about the illness or involvement in the family member’s treatment.
Selective Serotonin Reuptake Inhibitors
The side effect profile of the selective serotonin reuptake inhibitors is favorable compared with that of older tricyclic, heterocyclic, or monoamine oxidase inhibitor antidepressants, including low risk in overdose. Side effects reported in these studies are consistent with routine clinical usage.
Tricyclic and Heterocyclic Antidepressants
Common side effects of tricyclic antidepressants include sedation, constipation, dry mouth, and weight gain. The toxicity of tricyclic antidepressants in overdose, including death, indicates that they should be used with caution in patients at risk for suicide. Patients with cardiac conduction abnormalities may experience a fatal arrhythmia with tricyclic antidepressant treatment. For some inpatients with borderline personality disorder, treatment with amitriptyline has paradoxically been associated with behavioral toxicity, consisting of increased suicide threats, paranoid ideation, demanding and assaultive behaviors, and an apparent disinhibition of impulsive behavior.
Monoamine Oxidase Inhibitors
Phenelzine can cause weight gain and can be difficult to tolerate. Other side effects include orthostatic hypotension. Fatal hypertensive crises are the most serious potential side effect of monoamine oxidase inhibitors, although no study reported any hypertensive crises due to violation of the tyramine dietary restriction. The initial clinical picture of monoamine oxidase inhibitor poisoning is one of agitation, delirium, hallucinations, hyperreflexia, tachycardia, tachypnea, dilated pupils, diaphoresis, and, often, convulsions. Hyperpyrexia is one of the most serious problems.
Lithium Carbonate and Anticonvulsant Mood Stabilizers
Although lithium commonly causes side effects, most are minor or can be reduced or eliminated by lowering the dose or changing the dosage schedule. More common side effects include polyuria, polydipsia, weight gain, cognitive problems (e.g., dulling, poor concentration), tremor, sedation or lethargy, and gastrointestinal distress (e.g., nausea). Lithium may also have renal effects and may cause hypothyroidism. Lithium is potentially fatal in overdose and should be used with caution in patients at risk of suicide.
Carbamazepine’s most common side effects include neurological symptoms (e.g., diplopia), blurred vision, fatigue, nausea, and ataxia. Other side effects include skin rash, mild leukopenia or thrombocytopenia, and hyponatremia. Rare, idiosyncratic, but potentially fatal side effects include agranulocytosis, aplastic anemia, hepatic failure, exfoliative dermatitis, and pancreatitis. Carbamazepine may be fatal in overdose. In studies of patients with borderline personality disorder, carbamazepine has been reported to cause melancholic depression.
Common dose-related side effects of valproate include gastrointestinal distress (e.g., nausea), benign hepatic transaminase elevations, tremor, sedation, and weight gain. With long-term use, women may be at risk of developing polycystic ovaries or hyperandrogenism. Mild, asymptomatic leukopenia and thrombocytopenia occur less frequently. Rare, idiosyncratic, but potentially fatal adverse events include hepatic failure, pancreatitis, and agranulocytosis.
Anxiolytics
Behavioral disinhibition, resulting in impulsive and assaultive behaviors, has been reported with alprazolam in patients with borderline personality disorder. Benzodiazepines, in general, should be used with care because of the potential for abuse and the development of pharmacological tolerance with prolonged use. These are particular risks in patients with a history of substance use.
Neuroleptics
Dropout rates in neuroleptic trials in borderline
outpatients range from 13.7% for a 6-week trial to 48.3% for a 12-week trial to 87.5% for a 22-week continuation study. In acute studies, patient nonadherence
is often due to typical medication side effects, e.g., extrapyramidal symptoms, akathisia, sedation, and hypotension. Patients with borderline personality
disorder who have experienced relief of acute symptoms with low-dose neuroleptics may not tolerate the side effects of the drug with longer-term treatment. The risk of tardive dyskinesia must be considered in any decision to continue neuroleptic medication over the long term. Thioridazine has been associated with cardiac rhythm disturbances related to widening of the Q-T interval and should be avoided. In the case of clozapine, the risk of
agranulocytosis is especially problematic. While the newer atypical neuroleptics promise a more favorable side effect profile, evidence of efficacy in borderline
personality disorder is still awaited. Neuroleptics should be given in the context of a supportive doctor-patient relationship in which side effects and
nonadherence are addressed frequently.
Subgroups Most Likely to be Harmed:
- Some studies suggest ethnic groups may differ in
their response to psychotropic medications and antidepressants. Asians, for
example, may require lower doses of haloperidol and have higher serum levels
of haloperidol after oral administration than Caucasian patients.
- Diagnosis should be made with care with adolescents
whose personalities are still developing.
- Elderly patients are particularly prone to certain medication side effects (e.g., orthostatic hypotension and anticholinergic effects).