PSYCHOPHARMACOLOGY OF BORDERLINE PERSONALITY DISORDER

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The treatment of personality disorders is one of the last areas in psychiatry to fully embrace a psychobiologic perspective. Although personality is traditionally defined as an integrated structure of biologic temperament and learned character, treatments for personality disorders have historically emphasized the psychodynamic or behavioral correction of maladaptive learning. Temperament was viewed as contributing a biologic basis to the regulation of perception, cognition, affect, and impulse, contributing to the phenomenology of behavior, not to interpersonal meaning. Advances in dimensional modeling of personality, and a growing body of empiric literature on the psychobiology of personality dimensions, have invigorated the search for pharmacologic treatments in personality disordered patients. The neurotransmitter mediation of important dimensions of personality provides a powerful theoretic framework for pharmacologic trials in patients with personality disorders.

This article reviews pharmacologic approaches to the treatment of borderline personality disorder (BPD), which has been the focus of more medication trials than any other Axis II disorder. Medications from every major psychotropic drug family have been employed against aspects of BPD. The background for these studies and quality of existing evidence are reviewed for each drug class. A practical, symptom specific approach to pharmacotherapy in the patient with BPD is presented.

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DEFINITIONS: BPD AS A SYNDROMAL DISORDER

BPD is not a disease. It is a syndromal disorder defined by dysregulated temperament and maladaptive character. The symptom domains of BPD may be divided into cognitive-perceptual symptoms, affective dysregulation, impulsive-behavioral dyscontrol, and interpersonal psychopathology. Cognitive-perceptual symptoms in BPD are those stress-related, micropsychotic distortions in thinking, and perception which first gave this syndrome its borderline (e.g., borderline psychotic) appelation. Affective

CLINICAL PRESENTATIONS IN BPD

BPD was an early focus for pharmacologic intervention because of the clinical seriousness of the patient's symptomatic presentations, the high morbidity and mortality associated with the disorder. Suicide attempts are reported in as many as 73% of borderline patients admitted to inpatient hospital, with an average of 3.4 (±2.9) lifetime attempts per patient.51 Similar rates are reported in outpatient settings.66 With a completed suicide rate of 3% to 9.5%, BPD is one of the most lethal of

Background

Borderline disorders historically encompassed a spectrum of clinical presentations including both affective and schizotypal subtypes. Terms such as borderline, pseudoneurotic, or pseudopsychopathic schizophrenia, and latent and larval psychosis illustrate some of the diagnoses used to define the patient with BPD, “at the psychotic border,” (i.e., the patient with BPD characterized by odd-thinking and a vulnerability to brief, stress-related micro-psychotic episodes. Over the many iterations of

Background

The prominence of depressive moods and affective lability in the core pathology of BPD suggests a role for antidepressant medication. Some authors consider BPD, as currently defined, to be a subaffective disorder, or a temperament related to affective spectrum disorders.1 Comorbidity with Axis I affective disorders is highly prevalent in BPD, adding further clinical justification to the consideration of antidepressant medications. However, it is often unclear whether the depressed borderline

Background

Brief, reactive episodes of rage, affective and behavioral dyscontrol are among the core characteristics of BPD. Transient experiences of derealization, depersonalization, illusions, hallucinations, and other perceptual distortions also are commonly reported. These transient distortions in perception, mood and impulse bear a superficial resemblance to symptoms commonly found in temporal lobe epilepsy. Neurologically minded psychiatrists, noting the resemblance, postulated a limbic system cause

Background

The mood lability of the borderline patient provides a rationale for the empirical use of lithium carbonate, a medication highly effective against mood lability in bipolar disorders. Early empirical trials with patients termed emotionally unstable character disorder (EUCD) (DSM–II) demonstrated efficacy against mood lability.43 These patients were histrionic, adolescent girls with impulsive behaviors and hedonistic abuse of drugs and alcohol. Although there is some controversy as to whether

Background

Anxiety is a common presenting complaint in patients with BPD. Although the diathesis to disruptive anxiety may be a chronic trait in the borderline patient, (historically called “pan-anxiety” or “free-floating” anxiety), the symptom presentation is most often acute and reactive to clear interpersonal stressors such as perceived rejection, or abandonment issues. In this setting, many clinicians rely on rapid acting benzodiazepine anxiolytics to treat both the acute presentations and the

PUTTING IT ALL TOGETHER: A SYMPTOM-SPECIFIC APPROACH

Target symptoms for pharmacotherapy of the borderline patient can be divided into three domains: cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol. Clinical treatment algorithms may be developed for each symptom domain using the available empirical literature.54 Although based on a small empiric database, algorithms for treatment of the BPD patient can offer initial guidance to the clinician.

Cognitive-perceptual symptoms include: suspiciousness,

CONCLUSION

  • 1

    Pharmacotherapy should be viewed as an adjuvant to psychotherapy in the treatment of the borderline patient (i.e., diminishing cognitive-perceptual, affective, and impulsive-behavioral symptom severity). Much of borderline psychopathology lies in the interpersonal domain, beyond the scope of medication management. Effective pharmacotherapy may make it possible for the patient to engage productively in psychotherapy; however, medications do not cure character and are never a substitute for

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    Address reprint requests to Paul H. Soloff, MD, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213

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    Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania

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