Synopsis
Apply NICE recommendations that medication does not treat personality disorder itself, distinguish legitimate comorbidity prescribing from symptom-driven polypharmacy, and review crisis medicines, overdose risk, dependence and deprescribing collaboratively.
- NICE advises that drug treatment should not be used specifically for borderline personality disorder or its individual behaviours and symptoms, including repeated self-harm, emotional instability and transient psychotic symptoms.
- Antipsychotic medication should not be used as medium- or long-term treatment for borderline personality disorder, and medication should not routinely treat antisocial personality disorder or associated aggression, anger or impulsivity.
- Diagnose and treat a comorbid disorder according to its own guidance within a coherent personality-disorder treatment programme rather than prescribing for vague distress.
- Before prescribing, name the indication, target outcome, expected time course, stop rule, review date, adverse effects, interactions, overdose toxicity and misuse or dependence risk.
- Review all current and recently stopped medicines, over-the-counter products, alcohol and drugs; avoid duplicating classes or adding a medicine to treat another medicine's adverse effect without reassessment.
- Crisis prescribing, if used, should be cautious, time limited and integrated with the crisis plan; NICE expects a plan to stop medicine started in a borderline crisis, usually within one week.
- Safer prescribing after self-harm may include smaller quantities, coordinated dispensing, limiting duplicate supplies and choosing lower-toxicity options for a genuine indication.
- Deprescribing is shared clinical work: prioritise highest-risk or unsupported medicines, discuss withdrawal and fears, reduce safely, and monitor the target problem and function.
Key red flags
Unknown or mixed overdose, modified-release preparation, delayed-toxicity medicine or increasing drowsiness needs urgent poison-information and emergency assessment.
Several sedatives, opioids, alcohol or illicit drugs create additive respiratory, falls and cognitive danger even when each prescribed dose appears modest.
Abrupt cessation of a dependence-forming medicine, alcohol or sedative drug can cause severe withdrawal and requires a planned syndrome-specific approach.
Large repeat quantities, stockpiling, sharing, diversion or escalating use during crises should trigger immediate safer-prescribing and means-safety review.
Investigation priorities
Identify prescribed, over-the-counter, online, borrowed and illicit substances, recent changes and actual use.
Management branches
Medication is considered because distress, insomnia, aggression, anxiety or unusual experiences are prominent.
- Assess the time course and diagnostic criteria, substances, physical causes, current medicines and whether a comorbid disorder or emergency syndrome is actually present.
- If an indication is supported, agree the target, alternative options, benefit-harm balance, review time, stop rule, responsibility and safer quantity.
- Continue the psychological, social and crisis plan and document that the medicine treats the comorbid condition rather than personality disorder itself.