Pharmacological treatment of borderline personality disorder

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Many patients with borderline personality disorder (BPD) receive medical treatment. However, there are no medications specifically designed to treat borderline personality disorder. In most cases, a particular medication is chosen because of its known properties for treating co-occurring disorders or because of symptoms of BPD that are known to be present in other conditions, such as depressive, psychotic or anxiety disorders. BPD is characterized by a common pattern of instability in affect regulation (with symptoms such as misplaced anger, chronic feelings of emptiness, and affective instability), impulse control (symptoms: self-harm or suicidal behavior, suicidal thoughts or threats of suicide to others), interpersonal problems (symptoms: frantic attempts to avoid abandonment, unstable relationship patterns with idealization and devaluation of others), and cognitive-perceptual problems (symptoms: impaired self-perception, transient paranoid thoughts or feelings of dissociation in stressful situations). The purpose of this review is to summarize the available evidence on the effects of pharmacological treatments for BPD from high-quality randomized trials.

Available studies have tested the effects of treatment with antipsychotics, antidepressants, and mood stabilizers in BPD. In addition, we tested a dietary supplement of omega-3 fatty acids (usually derived from fish), which is thought to have mood-stabilizing effects. Twenty-eight studies with 1,742 participants were included.

Results generally indicated favorable effects with second-generation antipsychotics, mood stabilizers, and omega-3 fatty acids, but most effect estimates were based on a single study, and it would be useful to replicate them. In addition, the long-term use of these drugs has not been evaluated. The limited information available on individual comparisons indicates little effect of first-generation antipsychotics and antidepressants.

Data also suggest the possibility of increased self-destructive behavior in patients treated with olanzapine. In general, attention should be paid to side effects. Most studies did not provide detailed data on side effects and therefore could not be considered in this review. Their effects were expected to be similar to those seen in patients with other conditions. The available data from the studies included here showed that side effects included weight gain, sedation, and changes in blood counts when treated with olanzapine and weight loss when treated with topiramate. Very few positive effects of first-generation antipsychotics and antidepressants were found. However, they may be useful in the presence of comorbid problems that are not part of the underlying pathology of BPD but are common in patients with BPD.

Results of drug comparison studies are sparse, involving a small number of participants. Thus, the current results of the trials and this review are not reliable and could easily be altered in future studies. In addition, studies may not adequately reflect some characteristics of the clinical setting (including patient characteristics and duration of interventions and follow-up periods).

The available evidence suggests some positive effect of second-generation antipsychotics, mood stabilizers, and dietary supplements with omega-3 fatty acids. However, they are largely based on effect estimates from a single study. Antidepressants do not have broad support for the treatment of BPD, but may be useful in the presence of comorbid conditions. No single drug significantly affected the overall severity of BPD. No encouraging results for major BPD symptoms – chronic feelings of emptiness, identity disorder, and abandonment. Conclusions should be drawn with caution in light of several limitations of RCT evidence that limit applicability to everyday clinical settings (including patient characteristics and length of interventions and follow-up periods).

Medications are commonly used in the treatment of borderline personality disorder (BPD), chosen with reference to their known properties in other psychiatric disorders ("off-label use") and are aimed primarily at affective or impulsive symptom clusters.

Evaluating the effects of medication treatment in patients with BPD.

We searched bibliographic databases in accordance with the Cochrane Group Strategy on Developmental, Psychosocial, and Learning Issues through September 2009, article reference lists, and contacted researchers in the field.

Randomized trials comparing medication versus placebo or medication versus medication in patients with BPD. Results included overall severity of BPD, various aspects of BPD symptoms according to DSM-IV criteria, concomitant nonspecific BPD psychopathology, dropout, and adverse effects.

Two authors independently selected studies, evaluated their quality, and extracted data.

Twenty-eight studies with a total of 1,742 participants were included. First-generation antipsychotics (flupentixol decanoate, haloperidol, tiotixen) were tested; Second-generation antipsychotics (aripirazole, olanzapine, ziprasidone), mood stabilizers (carbamazepine, sodium valproate, lamotrigine, topiramate), antidepressants (amitriptyline, fluoxetine, fluvoxamine, phenelzine sulfate, mianserine) and dietary supplements (omega-3 fatty acids). Older studies tested first-generation antipsychotics, while recent studies have focused on second-generation antipsychotics and mood stabilizers. Data on individual comparisons were sparse, indicating little effect of first-generation antipsychotics and antidepressants.

The findings support the use of second-generation antipsychotics, mood stabilizers, and omega-3 fatty acids, but require replication because most effect estimates were based on single studies. Long-term use of these drugs was not evaluated.

Data on adverse events were sparse, with the exception of olanzapine. Possible increases in self-destructive behavior, significant weight gain, sedation, and changes in hemogram parameters were observed when taking olanzapine. Significant reductions in body weight were observed with topiramate treatment. All drugs were well tolerated in terms of exhaustion.

Direct drug comparisons included two first-generation antipsychotics (loxapine versus chlorpromazine), a first-generation antipsychotic versus antidepressant (haloperidol versus amitriptyline; haloperidol versus phenelzine sulfate), and a second-generation antipsychotic versus antidepressant (olanzapine versus fluoxetine). The data showed better results for phenelzine sulfate, but there were no significant differences for the other comparison drugs, except for olanzapine, which showed greater weight gain and sedation than fluoxetine. One study evaluating treatment with one or more drugs (olanzapine vs. olanzapine plus fluoxetine; fluoxetine vs. fluoxetine plus olanzapine) found no significant difference in outcomes.