Download Guidelines for the Pharmacological Treatment of Antisocial and

SH CP 189
Guidelines for the Pharmacological
Treatment of Antisocial and Borderline
Personality Disorder
Version 2
Summary:
Advice and guidelines on the use of medication in
the treatment of personality disorders
Keywords (minimum of 5):
(To assist policy search engine)
Antisocial, borderline, personality disorder,
pharmacological treatment, BPD, ASPD
Target Audience:
Mental health staff working with patients with a
personality disorder
Next Review Date:
March 2020
Approved & Ratified by:
Medicines Management
Committee
Date issued:
March 2017
Author:
Dr Gwen Adshead, Consultant Forensic
Psychiatrist, Rebecca Henry, Principal Pharmacist
Specialised Services
Sponsor:
Dr Lesley Stevens – Medical Director
Date of meeting:
15 March 2017
1
Guidelines for the pharmacological treatment of antisocial and borderline personality disorder
Version: 2
March 2017
Version Control
Change Record
Date
Author
Version
Page
Reason for Change
Dec
2016
Dr Gwen
Adshead and
Rebecca Henry
2
4-6
Dec
2016
Dr Gwen
Adshead and
Rebecca Henry
Dr Gwen
Adshead and
Rebecca Henry
2
7
Text changed to flow charts to improve clarity.
Suggested treatment table added to improve clarity.
“Additional points” section expands on flow charts and
incorporates text from previous version, to improve clarity.
New references 5-10 included from updated literature search
2
1
Co-badged with Solent NHS Trust to work collaboratively.
Dec
2016
Reviewers/contributors
Name
Dr Amanda Taylor
Dr Catherine Sherwin
Stephen Bleakley
Mental Health Drugs and Therapeutics
Forum
Medicines Management Committee
Dr Gwen Adshead
Rebecca Henry
Position
Version Reviewed &
Date
Clinical Director Specialised Mental Health
Services
Specialist Registrar forensic Psychiatry
Deputy Chief Pharmacist
Trust wide representation
V1, Dec 2015
Trust wide representation
Consultant forensic psychiatrist
Principal pharmacist specialised services
V1 Jan 2016
V2 Dec 2016
V2 Dec 2016
V1, Dec 2015
V1, Dec 2015
V1 Dec 2015
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Guidelines for the pharmacological treatment of antisocial and borderline personality disorder
Version: 2
March 2017
CONTENTS
Page
1.
Guidelines for Antisocial Personality Disorder, ASPD
4
2.
Guidelines for Borderline Personality Disorder, BPD
5
3.
Suggested Treatments based on symptoms
6
4.
References
7
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Guidelines for the pharmacological treatment of antisocial and borderline personality disorder
Version: 2
March 2017
GUIDELINES FOR THE PHARMACOLOGICAL TREATMENT OF ANTISOCIAL
PERSONALITY DISORDER (ASPD)
Pharmacological interventions should not be routinely used for the treatment of antisocial personality
disorder or associated behaviours of aggression, anger and impulsivity. If the MDT is of the opinion that a
pharmacological intervention is necessary, the following protocol should be followed:
Accurate Diagnosis
Treat co-morbid conditions eg: depression, anxiety, PTSD, psychosis, insomnia,
mood disorders, drug/alcohol addictions.
See relevant Trust Guidelines
Behavioural interventions, cognitive behavioural therapy
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Adjunctive medications;
Discuss in MDT; need clear and collaborative goals to manage specific symptoms.
Inform the patient that the medication(s) is/are being prescribed off license.
Consider risks vs benefits, including misuse, toxicity and overdose risks.
Document rationale and care plan.
Doses should remain within BNF limits
Consider prescribing a second generation antipsychotic or benzodiazepine, in the short term, to
control arousal levels to enable the patient to engage with the treating team
Regular review, at least every 3 months, including physical health and
compliance, poor compliance is common.
Stop ineffective medications
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Guidelines for the pharmacological treatment of antisocial and borderline personality disorder
Version: 2
March 2017
GUIDELINES FOR PHARMACOLOGICAL TREATMENT OF BORDERLINE
PERSONALITY DISORDER (BPD)
Current NICE guidelines CG78 recommend that drug treatment should not be used specifically for
borderline personality disorder or for the individual symptoms or behaviour associated with the disorder 1.
However, there are situations where clinicians may need to use pharmacological interventions with BPD
patients. This may be in outpatient settings including crisis teams or in inpatient (including forensic)
settings. There is little evidence available for the psychopharmacological treatment of these patients as
there are few RCTs so the following protocol is based on the limited evidence available2. Pharmacological
treatments should not be a substitute for psychological interventions. The reason for the use of
pharmacological intervention must be properly recorded and reviewed at regular intervals.
Accurate Diagnosis
Treat co-morbid conditions eg: depression, anxiety, PTSD, psychosis, insomnia,
mood disorders, drug/alcohol addictions.
Patients may be more resistant to treatment.
See relevant Trust Guidelines
Psychosocial treatments; Cognitive Behavioural Therapy, Dialectical
Behavioural Therapy, Mentalisation Based Therapy, Schema Focused Therapy
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Adjunctive medications;
Discuss in MDT; need clear and collaborative goals to manage specific symptoms.
Time limited, crisis management should be for one week only.
Inform the patient that the medication(s) is/are being prescribed off license.
Consider risks vs benefits, including toxicity and overdose risks.
Document rationale and care plan.
Regular review, at least every 3 months, including physical health and
compliance, poor compliance is common.
Stop ineffective medications
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Guidelines for the pharmacological treatment of antisocial and borderline personality disorder
Version: 2
March 2017
Suggested treatment based on symptoms experienced in both ASPD and BPD
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Anger
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Suicidal behaviour
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Anxiety
Topiramate
Affective dysregulation
Lamotrigine
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Valproate
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Haloperidol
Cognitive perceptual disturbances
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Flupentixol
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Olanzapine
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Quetiapine
Aripiprazole
Low Dose
Clozapine
Impulse control
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Aggression
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Self-directed aggression
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Social professional relationships
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Additional points
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Clinicians may find it helpful to remember that people can have more than one personality disorder
i.e. a patient may have elements of BPD and ASPD.
Consider overdose risk, side effects including sedation and weight gain, compliance.
Insomnia, consider sleep hygiene, hypnotic or antihistamine for 1 week.
Clozapine greatest improvement first 6 months, mean dose <300mg/day, weight gain same as
schizophrenia but glucose intolerance is less common.
All treatments should be prescribed within BNF limits.
Avoid prescribing more than one medication at a time, where possible.
Caution with prescribing mood stabilisers (such as sodium valproate or lamotrigine) in women of
childbearing age (See SPC).
In crisis situations consider the cautious use of sedative medication, as part of an overall treatment
plan but this should be reviewed after one week. Short term prescribing in crises should attempt to
use drugs with low side effect profile, minimal potential for misuse and relatively safe in overdose.
The Maudsley prescribing guidelines recommend promethazine for BPD3 but in practice
benzodiazepines (lorazepam or diazepam) are often used although prescribers should be aware of
the risks of disinhibition, excessive sedation, tolerance and addiction.
There is limited evidence for the use of Carbamazepine, but it can be considered in patients who
have been non responsive to other medications.
SSRIs are not recommended, if there is no evidence of depression.
There is little evidence available for the psychopharmacological treatment of these patients as there
are few RCTs so the protocol is based on the limited evidence available.
Ensure that all patients are referred for psychological treatments.
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Guidelines for the pharmacological treatment of antisocial and borderline personality disorder
Version: 2
March 2017
Note: These guidelines reflect the latest evidence and have been developed by specialists from both
primary and secondary care. Clinicians are expected to consider the recommendations made in these
guidelines but they do not override individual clinical judgements in consultation with the patient, carer or
guardian.
References:
1. National Institute for Health and Care Excellence (NICE) Borderline personality disorder: recognition
and management. Nice guideline CG78, January 2009. Available at: www.nice.org.uk
2. Leib K et al. Pharmacotherapy for Borderline Personality Disorder: Cochrane systemic review of
randomised trials. The British Journal of Psychiatry 2009 ;196: 4-12
3. Taylor D et al . The Maudsley Guidelines 12th edition. John Wiley Ltd, Chichester: 2015
4. Frogley C et al. A Case Series of Clozapine for Borderline Personality Disorder. Annals of Clinical
Psychiatry 2013; 25: 125-134
5. Treatment of personality disorder, Anthony Bateman et al, Lancet, vol 385, Feb 21, 2015
6. World Federation of societies of biological psychiatry (WFSBP) guidelines for the biological treatment of
personality disorders, Herpertz et al, The World Journal of Biological Psychiatry, 2007; 8(4): 212-244.
7. Treatment of personality disorder, Anthony W Bateman, John Gunderson, Roger Mulder, The
Lancet,Vol 385 February 21, 2015
8. Challenging behaviour and learning disabilities: prevention and interventions for people with learning
disabilities whose behaviour challenges. National Institute of Health and Care Excellence. Accessed via
www.nice.org.uk (12/1/17)
9. SHFT Guidelines for Insomnia, Depression, Psychosis, BPAD, Lithium, Physical health monitoring,
Anxiety, Rapid Tranquilisation.
10. Argent SE, Hill SA. The novel use of clozapine in an adolescent with borderline personality disorder.
Therapeutic Advances in Psychopharmacology 2014; vol 4, is 4: 1-7
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Guidelines for the pharmacological treatment of antisocial and borderline personality disorder
Version: 2
March 2017