Journal of Psychosocial Nursing and Mental Health Services

Psychopharmacology 

Case Study Application for Psychopharmacology With Borderline Personality Disorder

Barbara J. Limandri, PhD, PMHNP, BC

Abstract

Using an evolving case study, the current article demonstrates the principles of working with a client who has borderline personality disorder in relation to medications. The case study poses questions for the reader to consider and answers at the end of the article. [Journal of Psychosocial Nursing and Mental Health Services, 56(5), 16–19.]

Abstract

Using an evolving case study, the current article demonstrates the principles of working with a client who has borderline personality disorder in relation to medications. The case study poses questions for the reader to consider and answers at the end of the article. [Journal of Psychosocial Nursing and Mental Health Services, 56(5), 16–19.]

The Psychopharmacology article in the April 2018 issue of the Journal of Psychosocial Nursing and Mental Health Services (JPN) (Limandri, 2018) described the neurobiological basis of symptoms common in borderline personality disorder (BPD) and medications with mechanisms of action to modify the neurobiological misfiring. This column presents a case study that applies that knowledge and assists the psychiatric nurse in working collaboratively with the patient to better manage symptoms and behavior.

Case Study

Ann is a 28-year-old single woman currently working as a barista in a coffee shop while attending college part time. She has been pursuing her college education for 8 years, as she has changed majors several times. She intermittently lives with her widowed mother and several short-term significant others. She describes herself as polyandrous, with her longest relationship lasting 2.5 years, which she attributes to others “not getting” her. Although she has several friends, she admits that her relationships are highly “dramatic,” with few enduring friendships. Ann has many pastimes, including roller derby, downhill skiing, bungee jumping, rock climbing, and kayaking.

Ann is the middle child with an older brother, who is a successful businessman, and a younger sister, who is in dental school. Ann describes herself as the “underachiever.” Growing up was somewhat chaotic, as both parents were active duty military and the family moved every 18 months on average. Although neither parent had combat assignments, Ann believes her mother had a traumatic career due to possible military sexual assault. She describes her mother as tense and overprotective, as well as distant and aloof. Ann denies witnessing any violence in her family or experiencing abuse or neglect; however, she describes invalidation from her family regarding anything she did or tried. Ann believes her parents favor her siblings because she is the “overly sensitive one” in the family.

Beginning in her sophomore year of high school, Ann secretively cut her abdomen and thighs when she felt anxious and lonely because “it helped relieve the emotional pain.” She denied wanting to kill herself; however, in her senior year of high school she took an overdose of Advil® after a girl-friend ended their romantic relationship. Ann was hospitalized for 3 days on a psychiatric unit and began weekly therapy for approximately 3 months after discharge. She said the therapy helped some, but she continued to feel displaced and without a purpose. She experimented with relationships with men and women, always anticipating being rejected. She would go to great extents to please others but also acknowledged intense moodiness, irritability, and temper tantrums if she did not get what she wanted.

This year, Ann's college advisor referred her to the student counseling center because he thought she was depressed and not doing well in her course work.

The psychiatric–mental health nurse practitioner (PMHNP) at the counseling center diagnosed Ann with BPD after several assessment sessions. After he explained BPD, Ann agreed with the diagnosis. They discussed the most distressing behaviors/symptoms that Ann wanted to focus on: moodiness with intense swings of anger and happiness even within a few hours; impulsiveness that sometimes included cutting and recklessness; unstable relationships with a prolonged sense of loneliness; and general depression with episodic intense anxiety that interfered with her studying. Ann denied suicidal ideation or substance use except for occasional marijuana use (legal in her state) and excessive alcohol consumption at parties.

The PMHNP met with Ann weekly for individual therapy sessions that focused on building a commitment to change targeted behaviors and learning coping skills. Ann agreed to call her therapist when she had the urge to cut and receive coaching to use alternative coping. After 6 weeks, she agreed to also participate in weekly skills group to learn mindfulness, emotional regulation, interpersonal effectiveness, and stress management. Even with this plan, Ann expressed intense sadness, despair, shame, and impulsive self-destructive urges. Finally, the PMHNP suggested they discuss medication to augment her psychotherapy and support her while she became more effective in her skills. He explained neurobiological reasons for her impulsivity and impaired judgment and ability to problem solve in stress situations (i.e., her frontal lobe [dorsolateral prefrontal cortex] that mediated problem solving and judgment had a broken connection with her limbic area [amygdala] that mediated her intense emotions). Because dopamine was a major neural circuit that connected these two regions and the neural firing of these nerves seemed to be irregular, two different types of medications might help her feel more in control of her emotions and behaviors. He discussed the medications for her to consider as possible choices and the side effects of each, as well as the process of titrating the dose over time to achieve relief of some symptoms. He emphasized that it would take time because the brain does not tolerate rapid change and she would have to tolerate side effects until the beneficial effects became evident. He validated that this would be difficult for her because he understood how much she wanted immediate relief. However, he emphasized that the medication would provide some relief as she became more skillful with her behavioral and environmental strategies.

Case Study Questions

  1. What medication classes do you think the PMHNP recommended?

  2. What specific mechanism of actions of these medications would target Ann's symptom clusters to provide the widest spectrum of outcomes?

  3. What agreements does the PMHNP need to secure before initiating the medication regimen?

Continuation of Treatment

The PMHNP and Ann agreed that she would try aripiprazole 2.5 mg daily, even though she was fearful of gaining weight. She agreed to continue with the daily dosage for 4 weeks and call if she had the urge to suddenly stop taking the medication or change the dosage. At every follow-up appointment, the PMHNP assessed for extrapyramidal effects and akathisia, which Ann experienced mildly for the first 3 weeks. The dosage was increased to 5 mg after 4 weeks because Ann felt little improvement in her moodiness or impulsivity. After 2 months on the medication, Ann noticed she had gained 5 pounds without change in her diet or exercise and insisted that this was unacceptable. They agreed to taper the aripiprazole and try the other medication that the PMHNP recommended, lamotrigine. Ann was fearful of trying this medication because of the possible rash and the amount of time it would take to achieve a therapeutic dosage, but she was not willing to continue with the aripiprazole or try the alternative brexpiprazole.

Case Study Questions

  • What alternatives to aripiprazole could the PMHNP offer and why?

  • Given Ann's concerns, what are the risks and benefits to consider for such possibilities as quetiapine, olanzapine, or risperidone?

  • Why might the PMHNP suggest lamotrigine over valproate, lithium, or topiramate? What would you offer?

Changing Medication

For 1 week, Ann took aripiprazole 2.5 mg with lamotrigine 25 mg daily. The next week she stopped aripiprazole but continued lamotrigine 25 mg daily. The next 2 weeks she increased the lamotrigine to 50 mg daily and noticed a slight improvement in her impulsivity but was concerned that she was getting a rash. The PMHNP asked her to send him a picture of the rash and compared it with images of Stevens–Johnson rash before her next visit. He asked if she had other symptoms (e.g., fever, itching, malaise, achy muscles, mouth sores), which she denied. He advised her that the rash appeared to be a contact dermatitis but if she was worried to go to Urgent Care. At the next appointment, he saw that the rash was flat and reddish without blistering, which Ann noted was itchy. The rash covered approximately 3 mm under her chin. He recommended monitoring it for 1 week, using an over-the-counter cortisone cream, and not changing her soap or laundry detergent or eating unusual foods for the time being. The rash subsided in 10 days and Ann continued the lamotrigine at an increase of 75 mg for the next 2 weeks. She expressed concern that she was still feeling somewhat impulsive, needing to use her emotional regulation skills several times per day, but was otherwise managing. She expressed frustration at how long it was taking to get results and that she would never get better. The PMHNP acknowledged how frustrating it was and added that he noticed improvement in her thinking about her urges, absence of any cutting for 4 weeks, and persistence in therapy and school. He reminded her of how long she had experienced these symptoms and that even small improvement was indication that she could get better. Although she expressed anger with his unwillingness to add more medication, she agreed to continue with the regimen.

Case Study Questions

  • In response to Ann's request for additional medication (she asked if he would prescribe lorazepam for a few days), how would you respond?

  • Why would the PMHNP not increase the lamotrigine titration to 100 mg daily in response to Ann's request instead of continuing with the 75 mg after the fifth week of gradual titration?

  • What is the target dosage of lamotrigine to level the daily dosing?

Medication Maintenance

After 6 weeks of gradual titration of the lamotrigine, Ann was noting in her daily diary card that she had fewer episodes of angry outbursts, had no urges to cut in the past 1 week, and was using her skills 5 of 7 days per week with effective results. She still felt “barely in control” and depressed. She complained that “this is too hard” and asked if there were other medications to help her feel better. She told her skills group leader that the PMHNP was being cruel and did not realize how difficult it was for her. The skills group leader and PMHNP met with Ann together to discuss her plan of care and what additional resources she needed to feel successful. After a long meeting, they agreed Ann would continue the lamotrigine and weekly individual sessions and skills group. She would advance to the next level of group where she would practice her skills more than the didactic group. Ann also agreed to pair with another group member to coach each other through instant messaging. After 3 weeks of this plan, Ann noted she was feeling more confident and wanted to stop therapy altogether. The therapist and PMHNP met with Ann separately and assured her that this was a positive indication of her improvement and a “flight into health.” They negotiated with her to continue lamotrigine at 100 mg daily and check in monthly with the PMHNP. She would continue with peer coaching and advanced skills group and check in with her therapist monthly for the next 3 months. Both clinicians emphasized their availability for coaching calls or scheduled appointments as needed.

Case Study Answers

Answers to the questions may vary with your interpretation of the information, but should be within this range. Please refer to the article in the April 2018 issue of JPN (Limandri, 2018) for support.

  1. Although it is reasonable to select from any of the drug classes, Ann noted her impulsivity and emotional dysregulation were what bothered her most, so it is best to start with these symptoms. Because the mesolimbic and corticolimbic dopamine circuits are involved with integrating emotionality and cognitive function and judgment, serotonin dopamine antagonist (SDA) agents are a reasonable choice, with research evidence showing the strongest support for aripiprazole (Starcevic & Janca, 2018). In contrast, it is reasonable to consider a drug in the GABA class, as these regulate neural firing throughout the central nervous system, thereby affording smooth dopamine firing along these same circuits. Lamotrigine, valproate, and topiramate have the strongest evidence (Ripoll, 2012).

  2. SDA agents briefly block dopamine binding in the dorsolateral prefrontal cortex, preventing an overload that would contribute to increased anxiety. These drugs also close the somatodendritic serotonin receptors, thereby activating the release of dopamine at the axon. The release of dopamine stimulates the dorsolateral prefrontal cortex to inhibit impulsive behaviors (Stahl, 2013). Because the dopamine occupancy is brief, there is reduced risk of extrapyramidal effects in the nigrostriatal pathway. GABA-ergic agents enhance GABA, an inhibitory neurotransmitter, thereby extending the refractory period in the action potential and preventing overlapping/irregular neural firing of the dopamine nerves. The frontal lobe now has more time to allow thinking through an action.

  3. Trust and commitment to the treatment plan (pharmacological and psychotherapeutic) are essential. Although both medication classes are relatively safe, there also needs to be a frank discussion about taking the medication as prescribed and reporting urges to overdose or perform other self-harming behaviors.

  4. Olanzapine, quetiapine, and risperidone have similar efficacy as aripiprazole but with greater risk of metabolic syndrome and weight gain (Stahl, 2013). These medications would not only be detrimental to Ann's overall health, but likely unacceptable to her and may introduce resistance.

  5. The risks are noted in Answer 4. Additional benefits may be sedation (i.e., if the medication is given at bedtime) and mild antidepressant effects.

  6. Valproate has lower risk of Stevens–Johnson syndrome but greater risk for headache, somnolence, and weight gain. Topiramate has a significant risk of metabolic acidosis and somnolence (Stahl, 2013). Both are known to contribute to cognitive dulling, which would interfere with Ann's use of psychotherapy and coping skills development.

  7. It is important to validate Ann's distress while encouraging her use of self-affirming skills that will reinforce her sense of competence. Benzodiazepine medications contribute to apathy, cognitive deficit, irritability, and disinhibition—all responses that are counter to her treatment plan. Because these medications act immediately to block the awareness of anxiety, they are strongly reinforcing external control rather than the self-regulation of her treatment plan.

  8. Escalating the lamotrigine places Ann at risk for Stevens–Johnson syndrome, as well as reinforces her urge for immediate external control.

  9. The target dose for lamotrigine is between 100 mg and 150 mg, depending on symptom relief and serum testing.

Conclusion

Assisting individuals with BPD to manage their illness requires psychotherapy and a judicious use of medication that specifically targets problematic behaviors and symptoms. PMHNPs and PMHNs must work collaboratively with these individuals to understand how medications are an adjunct to overall self-care.

References

  • Limandri, B.J. (2018). Psychopharmacology for borderline personality disorder. Journal of Psychosocial Nursing and Mental Health Services, 56(4), 8–11. doi:10.3928/02793695-20180319-01 [CrossRef]
  • Ripoll, L.H. (2012). Clinical psychopharmacology of borderline personality disorder: An update on the available evidence in light of the Diagnostic and Statistical Manual of Mental Disorders-5. Current Opinion in Psychiatry, 25, 52–58. doi:10.1097/YCO.0b013e32834c3f19 [CrossRef]
  • Stahl, S.M. (2013). Stahl's essential psychopharmacology (4th ed.). Cambridge, MA: Cambridge University Press.
  • Starcevic, V. & Janca, A. (2018). Pharmacotherapy of borderline personality disorder: Replacing confusion with prudent pragmatism. Current Opinion in Psychiatry, 31, 69–73. doi:10.1097/YCO.0000000000000373 [CrossRef]
Authors

Dr. Limandri is Professor Emerita, Linfield College, School of Nursing, McMinnville, Oregon.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Barbara J. Limandri, PhD, PMHNP, BC, Professor Emerita, 9136 SW 36th Avenue, Portland, OR 97219; e-mail: limandribj@gmail.com.

10.3928/02793695-20180322-04

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