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Polypharmacy in BPD — MRCPsych Paper B MCQ

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HardPersonality DisordersPolypharmacy in BPDMRCPsych Paper B

A 22-year-old woman with borderline personality disorder is prescribed quetiapine 400 mg daily, diazepam 20 mg daily, promethazine 50 mg at night and sertraline 100 mg daily. The medicines were initiated by different clinicians during several crises over the previous 2 years. She is not currently in crisis, has no diagnosed comorbid mental or physical disorder, and the records document neither continuing target symptoms nor clear benefit from any medicine. What is the most appropriate approach?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Identify a coordinating prescriber, review each medicine collaboratively, and plan reduction or withdrawal of unnecessary treatment

Explanation lettering: E = shown as A · A = shown as D · D = shown as E

B is correct. NICE CG78 advises that medication should not be used specifically to treat borderline personality disorder or its individual symptoms, and that antipsychotics should not be used as medium- or long-term treatment. In a person without a comorbid disorder, existing prescribing should therefore be reviewed with the aim of reducing and stopping unnecessary medication. A coordinating prescriber should clarify indications, benefits, harms and the order of withdrawal. The drugs should not all be stopped immediately: long-term diazepam and sertraline require an individualised withdrawal plan because abrupt cessation may cause withdrawal symptoms. Continuing treatment merely until psychotherapy is completed is not justified. Neither quetiapine nor sertraline should automatically be retained for affective instability, and clozapine has no routine role in treating borderline personality disorder.

Reference: National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management (CG78), recommendations 1.3.5.1–1.3.5.6 and 1.3.7.2. Published 2009; last reviewed 30 July 2024. https://www.nice.org.uk/guidance/cg78/chapter/Recommendations