In my experience, medications most often provide a necessary base for the effective treatment of borderline disorder 2. They significantly reduce some of the most burdensome symptoms of the disorder to a more tolerable level. In addition to feeling better and more under control of your emotions and behavior, you will notice improvement in your ablity to remain engaged productively in psychotherapy, and to more readily learn how to handle conflicts and other problems more effectively than you have in the past. Most patients with moderate to severe symptoms of borderline disorder will require and benefit from medications, as will some with mild symptom severity. Some patients with borderline disorder are resistant to taking medications, regardless of the severity of their symptoms. Under these circumstances, it is helpful to understand that borderline disorder is primarily the result of inherent biological disturbances in certain chemical processes required for optimal brain function. Medications serve to improve these functions, thereby reducing symptoms and enhancing the therapeutic results of psychotherapy. Also, over time, the changes in emotional responses, thought patterns and behaviors resulting from medications and effective psychotherapy often result in a decrease in, and sometimes even the cessation of, the medications initially required.
Nonetheless, a number of psychiatrists and mental health workers, even some quite familiar with borderline disorder, continue to believe that medications play only a minimal or, at most, an adjunctive role in the treatment of borderline disorder. Unfortunately, this belief persists in spite of the growing number of controlled studies demonstrating the effectiveness of medications in treating specific symtoms of the disorder. These studies now represent a body of scientific evidence clearly comparable to similar studies on the efffectiveness of psychotherapy. Failures to respond to treatment by patients with borderline disorder can often be traced to three major problems: inadequate medication management; the use of an ineffective form or the improper application of psychotherapy; and undiagnosed or ineffectively treated co-occuring disorders. The latter two issues are discussed elsewhere on this site.
Three classes of medications have been found to be useful in reducing the core symptoms of borderline disorder:
It is important to understand at the outset that the effectiveness of these classes of medications, and even individual medications within each class, vary significantly from one person with borderline disorder to another. Most likely, this is because the disorder, as is true for most heritable medical disorders, is the result of multiple genetic risk factors operating interactively. These genetic factors vary significantly between patients. This results in differences in the symptoms and in their severity as commonly observed among patients with the disorder, and in their individual responses to medications. The medication(s) that work best for you may not be effective for another person with borderline disorder. Consequently, it may take some trial and error to determine with your psychiatrist which medication(s) best match your particular chemistry .
Neuroleptics and Atypical Antipsychotic Agents
The class of medications that was first studied for the treatment of patients with borderline disorder is the antipsychotic agents (neuroleptics and atypical antipsychotics). Neuroleptics were the first generation of medications used to treat very serious mental illnesses, especially bipolar disorder and schizophrenia. The atypical antipsychotics are the second generation of medications developed to treat these disorders. When precribed in lower doses than ususal, these agents have also been found to be quite useful in the treatment of many patients with borderline disorder. This is one of the two most effective classes of medications for the disorder, and the most rational starting point for pharmacotherapy in patients presenting with high levels of anger, cognitive-perceptual symptoms such as a high level of suspiciousness, paranoid and split (all-or-nothing) thinking, and dissociative episodes. There is now a significant amount of scientific data to support this statement.
Recently, carefull analyses of research with these agents in borderline disorder reveal that they improve the ability to think and reason rationally, reduce over reactive responses of anger, and improve the patients general level of functioning. 3 The size of these therapeutic effects are moderate to large. There also is evidence of clinically relevant decreases in anxiety and impulsivity with at least one of these agents, aripiprazole (Abilify), a finding that is consitent with my clincal experience.
If one or more of these symptoms is present and resoponds well to an antipsychotic agent, but other symptoms such as impulsivity and anxiety persist, the addition of another medication from the class of mood stabilizers discussed below is indicated.
The antipsychotic agents found to be useful in borderline disorder include the neuroleptics thiothixene (Navane), trifluoperazine (Stelazine), and flupenthixol, and the atypical antipsychotics aripiprazole (Abilify), olanzapine (Zyprexa), and risperidone (Risperdal). Medications studied and used in the treatment of Borderline Personality Disorder.
Some patients are concerned about taking a medication that is typically used for people with severe mental illnesses. Also, some physicians are reluctant to prescribe, and some patients are reluctant to take this class of medications because of a specific side effect that neuroleptics and atypical antipsychotics may produce called tardive dyskinesia. This is an abnormal, involuntary movement disorder that typically occurs in patients receiving average to large doses of neuroleptics.
To the best of my knowledge, there is no scientific evidence that indicates low doses of neuroleptics cause tardive dyskinesia in patients with borderline disorder. Nonetheless, although the risk appears to be very small, it should be noted. The atypical antipsychotic agents appear to carry a lower risk of causing tardive dyskinesia than neuroleptics when prescribed at the usual doses for patients with severe mental illnesses. Therefore, these newer medications are now probably more commonly prescribed for patients with borderline disorder than are the neuroleptics.
Atypical antipsychotics and traditional neuroleptics may both produce side effects, some more than others. These include weight gain, headache, drowsiness, insomnia, breast engorgement and discomfort, lactation, and restlessness. Some of these, and other side effects, are temporary, and others may be persistent. Before you start on any antipsychotic agent, or any medication for borderline disorder, you should review its side effect profile with your psychiatrist.
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Mood Stabilizers
Another class of medications, referred to as mood stabilizers, has been shown to significantly reduce certain symptoms in patients with borderline disorder. These symptoms include impulsivity, anger, anxiety, depressed mood, and general level of functioning. The size of these therapeutic effects range from moderate to very large.
Medications in this class do not appear to reduce paranoid thinking or psychotic behavior in borderline disorder. In my experience, they do not reduce suspiciousness, split-thinking or dissociative episodes either. When these symptoms persist after others improve with mood stabilizers, the additional use of the antipsychotic agent most effective for the individual patient is indicated.
The most commonly used class of mood stabilizers includes divalproex (Depakote), topiramate (Topamax), lamotrigine (Lamictal), and carbamazepine, (Tegretol). These medications are also referred to as antiepileptic drugs as they are commonly used for people suffering from partial complex seizure disorder. Partial complex seizure disorder has its origin in the temporal lobes of the brain, a brain region important in the generation of emotions.
A common side effect of Depakote and Tegretol is significant weight gain, a side effect that is especially disturbing to many patients with borderline disorder. This appears to present less of a problem with Topamax, which may acutallly normalize weight in some patients, and with Lamictal. The latter medication should be administered with care as it rarely may result in a serious dermatological problem, especially if the dose is raised too quickly.
Antidepressants
Another class of medications studied for the treatment of the symptoms of borderline disorder are the antidepressants. Medications Studied and Used in the Treatment of Borderline Personality Disorder.
SSRIs and Related Antidepressants
Analyses of placebo controlled trials of SSRIs suggest that they have small to moderate effects only on anxiety and anger, with no significant effects on rapid mood shifts, depression, impulse dyscontrol, aggression and cognitive-perceptual symptoms. This limited range of effectiveness of SSRIs compared to the two classes of medications discussed above has recently suggested a shift from the first line use of SSRIs for borderline disorder to the third tier. Nonetheless, these medications may be useful in treating some patients with borderline disorder who do not respond robustly to antipsychotics or mood stabilizers. It appears their major use may be in the treatment of major depressive episodes co-occuring with borderline disorder.
Some of the enthusiasm for the use of SSRIs in borderline disorder derives from a number of research studies that have demonstrated disturbances in genetic abnormalities related to serotonergic function, and serotonin function itself, in patients with borderline disorder. These findings provide the scientific rationale for the use of SSRIs in the treatment of this disorder, as the SSRIs increase serotonin activity in the brain 4. Therefore, it is surprising that these agents have demonstrated a considerably narrower range and size of therapeutic effect in borderline disorder than antipsychotic and mood stabilizing agents.
The main side effects encountered by many patients taking an SSRI are decreased sexual interest, motivation, and capacity to perform and respond sexually, weight gain, a flattening of emotional response, and the precipitation of hypomanic symptoms in patients who have co-occuring bipolar disorder. Not all patients taking SSRIs experience these side effects, and some who do consider them a tolerable trade off to the reduction of their symptoms. Current concern also has arisen about the possible increase in suicidal behavior of depressed people treated with SSRIs, especially adolescents.
MAOIs
Another class of antidepressants, the monoamine oxidase inhibitors (MAOIs), may be useful in patients with borderline disorder. Two placebo-controlled studies of the MAOI phenelzine (Nardil) have suggested that it may be more effective than SSRIs. However, orally administered MAOIs have the potential to produce very serious, even life-threatening side effects if used improperly. Therefore, most physicians use an MAOI for patients with borderline disorder only after other medications have been tried, and the physician feels confident that the patient will follow the necessary rules that have been clearly outlined to him or her. A new skin patch delivery form of an MAOI (ENSAM) given at its lowest dose appears to eliminate the usual dietary concerns involved in orally administered MAOIs.
Tricyclic Antidepressants
Some antidepressants appear not to be useful in treating patients with borderline disorder. The tricyclic antidepressants amitriptyline (Elavil, Amitril, Endep) and nortriptyline (Pamelor, Aventyl) may even worsen the condition of people with borderline disorder. Other tricyclic antidepressants should also be used with caution in patients with borderline disorder.
Antianxiety Agents and Sedatives
Anxiety and poor sleep are common symptoms of borderline disorder. In other disorders, the benzodiazepines are most frequently used for these symptoms. These include diazipam (Valium), alprazolam (Xanax), temazepam (Restoril), flurazepam (Dalmane), and triazolam (Halcion). These medications should be used with caution in patients with borderline disorder because of their high addictive potential and a reported capacity to increase impulsive behavior in patients with the disorder.
Some patients with borderline disorder also experience adverse responses, such as impaired perceptions and greater sleep deterioration, to the non-benzodiazepine sedative zolpidem (Ambien). Therefore, if this medication is prescribed for you, be aware of this possible problem.
Medications Studied and Used in the Treatment of Borderline Disorder +
|
Drug Class
|
Medications |
Symptoms Improved by One or More Medications in the Class
|
|
Antipsychotics |
|
|
|
Neuroleptics |
thiothixene (Navane)*
haloperidol (Haldol)*
trifluoperazine (Stelazine)*
flupenthixol* |
anxiety, obsessive-compulsivity, depression,
suicide attempts, hostility, impulsivity,
self-injury/assaultiveness, illusions, paranoid
thinking, psychoticism, poor general functioning |
|
Atypical |
olanzapine (Zyprexa)*
aripiprazole (Abilify)*
risperidone (Risperdal)°
clozapine (Clozaril)°
quetiapine (Seroquel)° |
anxiety, anger/hostility, paranoid thinking,
self-injury, impulsive aggression,
interpersonal sensitivity, low mood and agression
|
|
Antidepressants |
|
|
|
SSRIs and related
antidepressants |
fluoxetine (Prozac)*
fluvoxamine (Luvox)*
sertraline (Zoloft)°
venlafaxine (Effexor)° |
anxiety, depression, mood swings,
impulsivity, anger/hostility, self-injury,
impulsive-aggression, poor general functioning |
|
MAOIs |
phenelzine (Nardil)* |
depression, anger/hostility, mood swings,
rejection sensitivity, impulsivity |
|
Mood Stabilizers |
divalproex (Depakote)*
lamotrigine (Lamictal)*
topiramate (Topamax)*
carbamazepine (Tegretol)°
lithium° |
unstable mood, anxiety, depression, anger,
irritability, impulsivity, aggression,
suicidality, poor general functioning |
+ - table adapted from Friedel RO 2
* - placebo-controlled studies;
° - open label studies; SSRIs - selective serotonin reuptake inhibitors;
MAOIs – monoamine oxidase inhibitors
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