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BPD Polypharmacy Reduction — MRCPsych Paper B MCQ

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HardPersonality DisordersBPD Polypharmacy ReductionMRCPsych Paper B

A 29-year-old woman with established borderline personality disorder is reviewed 6 weeks after a crisis. Across several previous crisis contacts, she accumulated sertraline, quetiapine, lamotrigine and promethazine, prescribed for emotional instability, impulsivity, transient stress-related paranoid ideas and insomnia. Comprehensive reassessment identifies no depressive episode, bipolar disorder, psychotic disorder, post-traumatic stress disorder, substance dependence or relevant physical indication. She is no longer in crisis and is starting a structured psychological treatment programme. What is the most appropriate pharmacological plan?

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Reveal the answer and explanation

Correct answer: C — Undertake a collaborative medication review and gradually reduce and stop drugs without another indication, accounting for withdrawal risks

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

B is correct. NICE advises that medication should not be used specifically to treat borderline personality disorder or its individual symptoms. A person taking medication without a diagnosed comorbid mental or physical illness should receive a collaborative review aimed at reducing and stopping unnecessary treatment. This should account for benefits, harms and drug-specific withdrawal risks rather than involve abrupt cessation. Stability does not establish that all four drugs are effective, so A is inappropriate. C is too absolute: medication may be indicated for a genuine comorbidity or used cautiously and briefly during a crisis. D conflicts with the recommendation against medium- or long-term antipsychotic treatment for borderline personality disorder. E similarly substitutes unsupported maintenance pharmacotherapy for the recommended structured psychological and psychosocial treatment approach.

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. 2009. https://www.nice.org.uk/guidance/cg78/chapter/Recommendations