Psychotherapy is generally the primary treatment in borderline personality disorder, but medication is almost always part of the picture.
A National Institute of Mental Health--sponsored study of patients with any of four personality disorders or a major mood disorder showed that lifetime use of both pharmacotherapy and psychotherapy was highest in those who had a borderline diagnosis.
"They were given more antidepressants than depressed patients," said Dr. John Oldham, an investigator in the multisite study and chair of psychiatry and behavioral science at Medical University of South Carolina, Charleston.
The extensive armamentarium had "a shotgun flavor. ... I can't think of much that wasn't on the list," he said.
This complex, challenging disorder demands a systematic approach, he said. Dr. Oldham, who chaired the committee that produced the American Psychiatric Association's 2001 "Practice Guideline for the Treatment of Patients With Borderline Personality Disorder," advocates an algorithm that looks for predominant patterns rather than chasing crises, aims to keep doses low, and integrates time-limited regimens with ongoing psychotherapy.
Medications should address specific symptom domains, said Dr. Paul Soloff, who developed the pharmacotherapy section of the APA's guideline. The assumption is that these are aspects of temperament, regulated by the same neurotransmitters that cause similar phenomena in axis I disorders.
"The distinction between axis I and II is arbitrary." said Dr. Soloff, professor of psychiatry at the University of Pittsburgh. "Neurotransmitters don't know about it."
For example: Impulsivity, as commonly manifested in aggressive and self-destructive acts, is associated with decreased serotonergic function in the prefrontal cortex, and so a selective serotonin reuptake inhibitor (SSRI), which increases its availability, is rational therapy, he said.
In fact, SSRIs are favored overall because of their safety and broad spectrum of action. The APA guidelines endorse them as first-line treatment for "affective dysregulation" symptoms, such as depression, mood lability, rejection sensitivity, and intense anger, as well as for impulsive, disinhibited behavior.
Dr. Kenneth Silk, professor of psychiatry at the University of Michigan, Ann Arbor, prescribes the same SSRI dosages for borderline personality disorder (BPD) as for depression, although patients whose emotional lability appears to be driven by high levels of anxiety may require higher dosages.
"The anxiety component of borderline personality is underappreciated," he said, noting that nearly as many borderline patients have comorbid anxiety disorders as depression (70% vs. 90%).
A brief course (3-4 days) of a benzodiazepine, prescribed on a fixed schedule rather than as required, may be indicated for high anxiety during a crisis, he said.
If one SSRI is ineffective, Dr. Soloff recommends trying a different one (or venlafaxine); data show that the second drug may be effective, he said.
If a patient's affective or impulsive symptoms are severe, particularly if they include gross agitation, anger, or hostility, Dr. Soloff may also prescribe a low-dose antipsychotic sooner rather than later. "These drugs have a nonspecific effect on symptom severity. ... They provide a 'chemical cocoon,'" he said.
He considers a brief course of olanzapine (Zyprexa) at a low dosage as an "anger drug" for periods when temper outbursts become problematic.
For mood lability that doesn't respond to an SSRI, Dr. Silk favors the use of a low-dose antipsychotic when cognitive distortions or paranoia exist. …