Borderline Personality Disorder: Go Easy on SSRIs

Article excerpt

It's been said that psychiatrists are the stepchildren of medicine, and personality disorders are the stepchildren of psychiatry.

Not so long ago, patients with personality disorders were considered beyond professional help. Their symptoms were considered "character flaws," and they were relegated to an Axis II wasteland rarely considered worthy of research dollars or serious study.

Dr. S. Charles Schulz, head of psychiatry at the University of Minnesota, Minneapolis, recalls being told early in his career not to bother studying such patients, because they had no insight into their condition and were completely unreliable.

"They won't even come for a second appointment," he was advised.

Today, a small but growing body of evidence (much of it from Dr. Schulz's lab) suggests that structured psychotherapy and drugs from several classes might have therapeutic benefit for significant symptoms of some personality disorders, especially borderline personality disorder.

Dr. Schulz quickly learned that many patients with personality disorders indeed have insight into the difficulties in their lives, and may participate enthusiastically in therapy and clinical trials. He views his pursuit of a deeper understanding into personality disorders "one of the most rewarding things that I've done."

Increasing attention to personality disorders has come in part as a result of recognition of comorbid links between Axis I and Axis II disorders, with the addition of a personality disorder making depression, bipolar disorder, or schizophrenia harder to treat.

Between 50% and 80% of patients in acute care settings do have a personality disorder, and the psychiatric community has begun to sit up and take notice, said Dr. Deanna Mercer of the University of Ottawa and Ottawa Hospital.

"Personality disorders may be the hypertension and high cholesterol of cardiac disease. If we keep ignoring them, we won't be as effective at treating Axis I disorders," she noted.

Many clinicians historically just followed the symptoms in an attempt to treat patients with personality disorders, perhaps leaning toward atypical antipsychotics for Cluster A disorders (paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder); anticonvulsants and mood stabilizers for Cluster B (antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality-disorder); and maybe antidepressants and/or anxiolytic agents for Cluster C disorders (avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder).

Certainly, psychiatry has a long way to go to find equivalents to ACE inhibitors and statins that will control patients' underlying issues and thereby improve care of acute psychiatric syndromes. But a burgeoning library of clinical trials is beginning to light the way to a more systematic, scientific approach to prescribing.

Borderline personality disorder is by far the most studied in psychopharmacology, although limited studies are also being conducted in other personality disorders. Mount Sinai Medical Center in New York, for example, is conducting extensive studies of approaches to schizotypal personality disorder, with particular attention to the possible usefulness of low-dose atypical antipsychotics.

In 2008, Dr. P. Francis Abraham coauthored a review of 28 randomized, double-blind, controlled trials of drugs used in the treatment of borderline personality disorder, concluding that a wide variety of agents showed evidence of improvement "although often circumscribed and variable" (J. Affect. Disord. 2008;111:21-30).

In general, anticonvulsants and atypical antipsychotics appeared to show greater benefit in this population than did antidepressants, reported Dr. Abraham, a psychiatrist with The Nord Center, a community-based comprehensive behavioral mental health center in Lorain, Ohio. …