MEDICATIONS IN THE TREATMENT OF BORDERLINE PERSONALITY DISORDER: THE APPROPRIATE USE
Failure to respond to treatment by patients with borderline disorder can often be traced to three major problems: 1) inadequate medication management; 2) the use of an ineffective psychotherapeutic approach; and 3) undiagnosed or ineffectively treated co-occurring disorders such as substance abuse. The latter two issues are discussed elsewhere on this site.
It has been my clinical and research experience in treating BPD for over 50 years that medications often provide a necessary foundation for the effective treatment of the disorder with psychotherapy. The introduction of effective pharmacological treatment for borderline disorder occurred in the mid 1980s. This may explain why almost a decade later different forms of psychotherapy became consistently effective after having failed to do so for a century.
There are two other reasons why it is appropriate to use medications promptly in the treatment of borderline disorder. First, they’ve been shown to be helpful in rapidly stabilizing emotional disturbances and harmful aggression directed at themselves and others. This does not occur with any form of psychotherapy introduced to date. Second, medications are also effective in treating certain symptoms of borderline disorder that have not been shown to be responsive to psychotherapy, such as high levels of suspiciousness, paranoid symptoms, disturbed thought processes including irrational and split-thinking and acute episodes of dissociation under distress.
Nonetheless, a number of psychotherapists and at least one prominent, foreign governmental medical advisory group (NICE) proclaims that medications should not be used in the treatment of borderline personality disorder. This is in spite of significant research evidence to the contrary and the increasing agreement of many psychiatrists and non psychiatric therapists that the combined approach is more effective than either pharmacotherapy or psychotherapy alone. Also, beware of any borderline disorder treatment program that states medications alone are all that are required in the optimal treatment of the disorder. I have seen and treated the occasional patient for whom this is true, but in most cases, psychotherapy is also required.
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 the function of these processes, thereby reducing symptoms and enhancing the therapeutic results of psychotherapy. Also, over time, the improvement in these biological processes resulting from medications and effective psychotherapy often result in a decrease in, and sometimes even the discontinuation of, the medications initially required.
The Four Classes of Medications Most Useful in Reducing Specific Core Symptoms of Borderline Disorder
- Antipsychotic Agents
- Mood Stabilizers
- Antianxiety Agents
The effectiveness of medications in the treatment of borderline disorder depends on: 1) the specific symptoms;27 2) the medication selected; and 3) the biological make up of the person with borderline disorder. In other words, the medications that work best for you may not be effective for another person with borderline disorder, even if they have very similar symptoms. Consequently, it may take some trial and error by your psychiatrist and you to determine which medications and doses best match your unique chemistry.
- Antipsychotics (FGAs; Neuroleptics):
- thiothixene (Navane)*
- haloperidol (Haldol)*
- trifluoperazine (Stelazine)*
- flupenthixol (Depixol)*
- Symptoms Improved
- mood dysregulation (labile & hyper-reactive)
- self-injury, suicide attempts, hostility, assaultiveness
- illusions, suspiciousness, paranoid thinking, psychoticism
- poor general functioning
- Atypical Antipsychotics (SGAs):
- olanzapine (Zyprexa)*
- aripiprazole (Abilify)*
- risperidone (Risperdal)*
- quetiapine (Seroquel)*
- lurasidone (Latuda) –
- clozapine (Clozaril)*/li>
- Symptoms Improved
- severity, anxiety, anger/hostility
- depression, self-injury, impulsive aggression
- suspiciousness, paranoid thinking
- split thinking, personal sensitivity
- interpersonal problems
- positive, negative, and general symptoms
- Mood Stabilizers:
- topiramate (Topamax)*
- lamotrigine (Lamictal)*
- divalproate (Depakote)*
- Symptoms Improved
- unstable mood, anger, irritability,
- anxiety, depression, impulsivity,
- interpersonal problems
- Antianxiety agent:
- buspirone (BuSpar) –
anxiety, irritability, depression, agitation
- Nutraceutical Agent:
- omega-3 fatty acids*
- severity, anger, depression, aggression
* – Placebo-controlled studies; + – open-label studies; – no published studies; FGAs – First generation antipsychotic agents; SGAs – second generation antipsychotic agents
This is one of most useful classes of medications for the treatment of patients with borderline disorder.27 They are most commonly used to treat other mental illnesses, especially bipolar disorder and schizophrenia. However, when prescribed at lower doses than used for these two disorders, these agents also have been found to be quite useful in the treatment of many patients with borderline disorder. This class of medications is the most rational starting point for pharmacotherapy in patients with borderline disorder who have cognitive-perceptual symptoms such as a suspiciousness, paranoia, split (all-or-nothing) thinking, and dissociative episodes. The size of these therapeutic effects are often moderate to large. Studies suggest that Abilify has the largest effect size in this class, and that the effects are sustained over an extended period of time.29
If one or more cognitive-perceptual symptoms are present and respond well to an antipsychotic agent, but other symptoms such as impulsivity and poor emotional control persist, the addition of another medication from the class of mood stabilizers discussed below is indicated.
Special Notes: 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 this class of medications because of a specific side effect that they may produce called tardive dyskinesia. This is an abnormal, involuntary movement disorder that occurs in patients typically receiving average to large doses of these agents.
To my knowledge, there is no scientific evidence that indicates these medications, as typically used in patients with borderline disorder, cause tardive dyskinesia. Nonetheless, although the risk appears to be minimal, it should be noted. The new agents in this class appear to carry a lower risk of causing tardive dyskinesia when prescribed at the usual doses for patients with other mental illnesses. Therefore, these newer medications are now more commonly prescribed for patients with borderline disorder than are the ones originally used.
Both older and newer subtypes of medications in this class may produce other side effects. These vary with the medication being used, and include weight gain, nausea and other GI symptoms, headache, drowsiness, insomnia, breast engorgement and discomfort, lactation, and restlessness. Some of these, and other side effects, are temporary, and others may be persistent, requiring a change in medication. Because Latuda appears to produce less side effects such as weight gain and high lipid levels, I will often begin treatment with this medication. Although its effectiveness for borderline disorder has not yet been reported in the scientific literature, I have found it to be effective for the same symptoms as the other SGA’s mentioned. In addition, because it’s side effect profile is more tolerable for many patients, I have observed that acceptance of the medication appears to be higher. Before you start on any antipsychotic agent, or any medication for borderline disorder, you should review its side effect profile with your psychiatrist.
Another class of medications, referred to as mood stabilizers, has been shown to significantly reduce certain symptoms in patients with borderline disorder.27 These symptoms include impulsivity, anger, anxiety, depressed mood, and general level of functioning. The size of these therapeutic effects range from moderate to large.
Mood stabilizers do not reduce suspiciousness, split-thinking, dissociative episodes and paranoia in borderline disorder. When these symptoms persist after others improve with mood stabilizers, the addition of, or replacement with, an antipsychotic agent is indicated. if the symptoms responsive to antipsychotic agents are controlled, but other symptoms of the disorder persist, I will add a mood stabilizer to the antipsychotic agent in use.
The most commonly used and effective mood stabilizers for borderline disorder are topiramate (Topamax) and lamotrigine (Lamictal). These medications are also referred to as antiepileptic drugs because they are commonly used for people suffering from partial complex seizure disorder. Partial complex seizure disorder has its origin in the medial temporal lobes of the brain, a brain region important in the generation of emotions and theMike control of impulsive behavior.
Weight gain does not appear to present a problem with Topamax, which may acutally normalize weight in some patients, or with Lamictal. The latter medication rarely may result in a serious dermatological problem, especially if the dose is raised too quickly.
Although recommended in the the Guideline for the Treatment of Borderline Personality Disorder published by the American Psychiatric Association in 2001,30 research since then has failed to demonstrate the effectiveness of SSRIs in treating the core symptoms of the disorder.27 Their primary use now in borderline disorder is in the treatment of co-occurring major depressive disorder, if present.
Another class of antidepressants, the monoamine oxidase inhibitors (MAOIs), may be useful in patients with borderline disorder who are resistant to antipsychotics and mood stabilizers. Two studies of the MAOI phenelzine (Nardil) have suggested that it may be effective in some patients.27 However, orally administered MAOIs have the potential to produce very serious, even life-threatening side effects if used improperly. Therefore, some 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.
The tricyclic antidepressants amitriptyline (Elavil, Amitril, Endep) and nortriptyline (Pamelor, Aventyl) may worsen the condition of people with borderline disorder. These and other tricyclic antidepressants should be used with caution in patients with borderline disorder.
Antianxiety Agents and Sedatives
Anxiety, irritability, agitation and poor sleep are common symptoms of borderline disorder. In other disorders, the benzodiazepines are 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.
However, it has now been observed that in patients with borderline disorder who continue to have symptoms of anxiety, irritability and difficulty sleeping, buspirone (BuSpar) is effective in reducing these symptoms when they do not respond to SGA’s and Mood Stabilizers.
Some patients with borderline disorder also experience adverse responses, such as impaired perceptions and greater sleep deterioration, to the non-benzodiazepine sedatives such as zolpidem (Ambien). Therefore, if these medications are prescribed for you, be aware of this possible problem.