Notable progress has been made in our understanding of borderline personality disorder and its treatment. However, there are many remaining questions regarding treatments with demonstrated efficacy, including how to optimally use them to achieve the best health outcomes for patients with borderline personality disorder. In addition, many therapeutic modalities have received little empirical investigation for borderline personality disorder and require further study. The efficacy of various treatments also needs to be studied in populations such as adolescents, the elderly, forensic populations, and patients in long-term institutional settings.
Practice Guideline for the Treatment of Patients With Borderline Personality Disorder
Tricyclic and heterocyclic antidepressants
Lithium carbonate and anticonvulsant mood stabilizers
ECT (electroconvulsive therapy)
BACKGROUND INFORMATION AND REVIEW OF AVAILABLE EVIDENCE
VI. REVIEW AND SYNTHESIS OF AVAILABLE EVIDENCEC. REVIEW OF PHARMACOTHERAPY AND OTHER SOMATIC TREATMENTS
1. SSRI antidepressants
a) Goals. In borderline personality disorder, SSRIs are used to treat symptoms of affective dysregulation and impulsive-behavioral dyscontrol, particularly depressed mood, anger, and impulsive aggression, including self-mutilation.
b) Efficacy. Early case reports and small open-label trials with fluoxetine, sertraline, and venlafaxine (a mixed norepinephrine/serotonin reuptake blocker) indicated significant efficacy for symptoms of affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual difficulties in patients with borderline personality disorder (44–49, 67). Aggression, irritability, depressed mood, and self-mutilation responded to fluoxetine (up to 80 mg/day), venlafaxine (up to 400 mg/day), or sertraline (up to 200 mg/day) in trials of 8–12 weeks (45). An unexpected finding in some of these early reports was that improvement in impulsive behavior appeared rapidly, often within the first week of treatment, and disappeared as quickly with discontinuation or nonadherence. Improvement in impulsive aggression appeared to be independent of effects on depression and anxiety and occurred whether or not the patient had comorbid major depressive disorder (67). Nonresponse to one SSRI did not predict poor response to all SSRIs. For example, some patients who did not respond to fluoxetine, 80 mg/day, responded to a subsequent trial of sertraline. Similarly, patients who did not respond to sertraline, paroxetine, or fluoxetine subsequently responded to venlafaxine. In one study, higher doses and a longer trial (24 weeks) with sertraline converted half of sertraline nonresponders to responders (45).
Three double-blind, placebo-controlled studies have been conducted. Salzman and colleagues (44) conducted a 12-week trial of fluoxetine (20–60 mg/day) in 27 relatively high-functioning subjects (mean Global Assessment Scale score of 74) with borderline personality disorder or borderline traits.
Markovitz (45) studied 17 patients (nine given fluoxetine, 80 mg/day, and eight given placebo) for 14 weeks
A double-blind, placebo-controlled study by Coccaro and Kavoussi (67) focused attention on impulsive aggression as a dimensional construct (i.e., a symptom domain found across personality disorders but especially characteristic of borderline personality disorder)
In summary, these three randomized, double-blind, placebo-controlled studies show efficacy for fluoxetine for affective symptoms—specifically, depressed mood (44, 45), anger (44), and anxiety (45, 67)—although effects on anger and depressed mood appear quantitatively modest. Efficacy has also been demonstrated for impulsive-behavioral symptoms—specifically, verbal and indirect aggression (67)—and global symptom severity (44, 45, 67). Effects on impulsive aggression (67) and anger (44) were independent of effects on affective symptoms, including depressed mood (44, 67) and anxiety (67). Although the three published double-blind, placebo-controlled trials used fluoxetine, open-label studies and clinical experience suggest potential usefulness for other SSRIs.
c) Side effects. The side effect profile of the SSRIs is favorable compared with that of older tricyclic, heterocyclic, or MAOI antidepressants, including low risk in overdose. Side effects reported in these studies are consistent with routine clinical usage.
d) Implementation issues. The SSRI antidepressants may be used in their customary antidepressant dose ranges and durations (e.g., fluoxetine, 20–80 mg/day; sertraline, 100–200 mg/day). One investigator used very high doses of sertraline (200–600 mg/ day) for nonresponders, with some improved efficacy (45). At these high doses, peripheral tremor was noted. There are no published studies of continuation and maintenance strategies with SSRIs, although anecdotal reports suggest continuation of improvement in impulsive aggression and self-mutilation for up to several years while the medication is taken and rapid return of symptoms upon discontinuation (49, 172, 173). The duration of treatment is therefore a clinical judgment that depends on the patient’s clinical status and medication tolerance at any point in time.
2. Tricyclic and heterocyclic antidepressants
a) Goals. In borderline personality disorder, antidepressants are used for affective dysregulation, manifested most commonly by depressed mood, irritability, and mood lability. Evaluation of antidepressant trials in the treatment of borderline personality disorder must take into account the presence of comorbid axis I mood disorders, which are common in patients with borderline personality disorder
b) Efficacy. Double-blind, placebo-controlled trials of tricyclic antidepressants in borderline personality disorder have used amitriptyline, imipramine, and desipramine in both inpatient and outpatient settings
These data suggest that the utility of tricyclic antidepressants in patients with borderline personality disorder is highly questionable. When a clear diagnosis of comorbid major depression can be made, SSRIs are the treatment of choice. When atypical depression is present, the MAOIs have demonstrated superior efficacy to tricyclic antidepressants; however, they must be used with great caution given the high risk of toxicity. (Although the SSRIs have not been extensively studied in atypical depression, at least one double-blind study has indicated comparable efficacy for fluoxetine and phenelzine for the treatment of atypical depression .) The efficacy of SSRIs in borderline personality disorder and their favorable safety profile argue for their empirical use in patients with borderline personality disorder with atypical depression.
At best, the response to tricyclic antidepressants (e.g., imipramine) in patients with borderline personality disorder appears modest. The possibility of behavioral toxicity and the known lethality of tricyclic antidepressants in overdose support the preferential use of an SSRI or related antidepressant for patients with borderline personality disorder.
c) Side effects. Common side effects of tricyclic antidepressants include sedation, constipation, dry mouth, and weight gain. The toxicity of tricyclic antidepressants in overdose, including death, indicates that they should be used with caution in patients at risk for suicide. Patients with cardiac conduction abnormalities may experience a fatal arrhythmia with tricyclic antidepressant treatment
d) Implementation issues. Other antidepressants are generally preferred over the tricyclic antidepressants for patients with borderline personality disorder. If tricyclic antidepressants are used, the patient should be carefully monitored for signs of toxicity and paradoxical worsening. Doses used in published studies were in the range of 150– 250 mg/day of amitriptyline, imipramine, or desipramine. Blood levels may be a useful guide to whether the dose is adequate or toxicity is present.
3. MAOI antidepressants
a) Goals. MAOIs are used to treat affective symptoms, hostility, and impulsivity related to mood symptoms in patients with borderline personality disorder.
b) Efficacy. MAOIs have been studied in patients with borderline personality disorder in three placebo-controlled acute treatment trials (55–57).
Cowdry and Gardner (55) noted that, "the MAOI proved to be the most effective psychopharmacological agent overall, with clear effects on mood and less prominent effects on behavioral control."
When borderline personality disorder is the primary diagnosis, with no selection for atypical depression or hysteroid dysphoria, results are clearly less favorable.
On balance, these studies suggest that MAOIs are often helpful for atypical depressive symptoms, anger, hostility, and impulsivity in patients with borderline personality disorder. These effects appear to be independent of a current mood disorder diagnosis (56), although one study found a nonsignificantly higher rate of MAOI response for patients with a past history of major depression or bipolar II disorder (55).
c) Side effects. Phenelzine can cause weight gain (56) and can be difficult to tolerate. Other side effects include orthostatic hypotension (55). Fatal hypertensive crises are the most serious potential side effect of MAOIs, although no study reported any hypertensive crises due to violation of the tyramine dietary restriction. The initial clinical picture of MAOI poisoning is one of agitation, delirium, hallucinations, hyperreflexia, tachycardia, tachypnea, dilated pupils, diaphoresis, and, often, convulsions. Hyperpyrexia is one of the most serious problems (178).
d) Implementation issues. Doses of phenelzine and tranylcypromine used in published studies ranged from 60–90 mg/day and 10–60 mg/day, respectively. Experienced clinicians may vary doses according to their usual practice in treating depressive or anxiety disorders. Adherence to a tyramine-free diet is critically important and requires careful patient instruction, ideally supplemented by a printed guide to tyramine-rich foods and medication interactions, especially over-the-counter decongestants found in common cold and allergy remedies. Given the impulsivity of patients with borderline personality disorder, it is helpful to review in detail the potential for serious medical consequences of nonadherence to dietary restrictions, the symptoms of hypertensive crisis, and an emergency treatment plan in case of a hypertensive crisis. Patients must be instructed to discontinue an SSRI long enough in advance of instituting MAOI therapy to avoid precipitating a serotonin syndrome.
4. Lithium carbonate and anticonvulsant mood stabilizers
a) Goals. Lithium carbonate and the anticonvulsant mood stabilizers carbamazepine and divalproex sodium are used to treat symptoms of behavioral dyscontrol in borderline personality disorder, with possible efficacy for symptoms of affective dysregulation.
b) Efficacy. The efficacy of lithium carbonate for bipolar disorder led to treatment trials in patients with personality disorders characterized by mood dysregulation and impulsive aggression.
In summary, preliminary evidence suggests that lithium carbonate and the mood stabilizers carbamazepine and divalproex may be useful in treating behavioral dyscontrol and affective dysregulation in some patients with borderline personality disorder, although further studies are needed. The only report on the newer anticonvulsants (i.e., gabapentin, lamotrigine, topiramate) in borderline personality disorder is a case series in which three of eight patients had a good response to lamotrigine (183). Because of the paucity of evidence concerning these agents, careful consideration of the risks and benefits is recommended when using such medications pending the publication of findings from systematic studies.
c) Side effects. Although lithium commonly causes side effects, most are minor or can be reduced or eliminated by lowering the dose or changing the dosage schedule
More common side effects include polyuria, polydipsia, weight gain, cognitive problems (e.g., dulling, poor concentration), tremor, sedation or lethargy, and gastrointestinal distress (e.g., nausea). Lithium may also have renal effects and may cause hypothyroidism. Lithium is potentially fatal in overdose and should be used with caution in patients at risk of suicide.
Carbamazepine’s most common side effects include neurological symptoms (e.g., diplopia), blurred vision, fatigue, nausea, and ataxia
Carbamazepine may be fatal in overdose. In studies of patients with borderline personality disorder, carbamazepine has been reported to cause melancholic depression (64).
Common dose-related side effects of valproate include gastrointestinal distress (e.g., nausea), benign hepatic transaminase elevations, tremor, sedation, and weight gain
d) Implementation issues. Full guidelines for the use of these medications can be found in the APA Practice Guideline for the Treatment of Patients With Bipolar Disorder (85). Lithium carbonate and the anticonvulsant mood stabilizers are used in their full therapeutic doses, with plasma levels guiding dosing. Routine precautions observed for the use of these medications in other disorders also apply to their use in borderline personality disorder, e.g., plasma level monitoring of thyroid and kidney function with prolonged lithium use, periodic measure of WBC count with carbamazepine therapy, and hematological and liver function tests for divalproex sodium.
5. Anxiolytic agents
a) Goals. Anxiolytic medications are used to treat the many manifestations of anxiety in patients with borderline personality disorder, both as an acute and as a chronic symptom.
b) Efficacy. Despite widespread use, there is a paucity of studies investigating the use of anxiolytic medications in borderline personality disorder. Cowdry and Gardner (55) included alprazolam in their double-blind, placebo-controlled, crossover study of outpatients with borderline personality disorder, comorbid hysteroid dysphoria, and extensive histories of behavioral dyscontrol. Use of alprazolam (mean dose=4.7 mg/day) was associated with greater suicidality and episodes of serious behavioral dyscontrol (drug overdoses, self-mutilation, and throwing a chair at a child). This occurred in seven (58%) of 12 patients taking alprazolam compared with one (8%) of 13 patients receiving placebo. However, in a small number of patients (N=3), alprazolam was noted to be helpful for anxiety in carefully selected patients with borderline personality disorder (52). Case reports suggest that clonazepam is helpful as an adjunctive agent in the treatment of impulsivity, violent outbursts, and anxiety in a variety of disorders, including borderline personality disorder (54).
c) Side effects. Behavioral disinhibition, resulting in impulsive and assaultive behaviors, has been reported with alprazolam in patients with borderline personality disorder. Benzodiazepines, in general, should be used with care because of the potential for abuse and the development of pharmacological tolerance with prolonged use. These are particular risks in patients with a history of substance use.
d) Implementation issues. In the absence of clear evidence-based recommendations, dose and duration of treatment must be guided by clinical need and judgment, keeping in mind the potential for abuse and pharmacological tolerance.
6. Opiate antagonists
a) Goals. It has been suggested that the relative subjective numbing and physical analgesia that patients with borderline personality disorder often feel during episodes of self-mutilation, as well as the reported sense of relative well-being afterward, might be due to release of endogenous opiates (185–187). Opiate antagonists have been employed in an attempt to block mutilation-induced analgesia and euphoria and thereby reduce self-injurious behavior in patients with borderline personality disorder.
Despite the few promising clinical case reports, these reports are very preliminary, and there is no clear evidence from well-controlled trials indicating that opiate antagonists are effective in reducing self-injurious behavior among patients with borderline personality disorder.
c) Side effects. Nausea and diarrhea are occasionally reported (190).
d) Implementation issues. In published reports, the typical dose of naltrexone was 50 mg/day. No time limit for treatment emerges from the literature, but the effect is presumably reversed when the medication stops.
a) Goals. The primary goal of treatment with neuroleptics in borderline personality disorder is to reduce acute symptom severity in all symptom domains, particularly schizotypal symptoms, psychosis, anger, and hostility.
b) Efficacy. Early clinical experience with neuroleptics targeted the "micropsychotic" or schizotypal symptoms of borderline personality disorder. However, affective symptoms (mood, anxiety, anger) and somatic complaints also improved with low doses of haloperidol, perphenazine, and thiothixene. An open-label trial of thioridazine (mean dose=92 mg/day) led to marked improvement in impulsive-behavioral symptoms, global symptom severity, and overall borderline psychopathology (78). Similar findings were reported for adolescents with borderline personality disorder treated with flupentixol (mean dose=3 mg/day) (77), with improvement in impulsivity, depression, and global functioning.
The introduction of the newer atypical neuroleptics increases clinicians’ options for treating borderline personality disorder.
Despite a lack of data, clinicians are increasingly using olanzapine, risperidone, and quetiapine for patients with borderline personality disorder. These medications have less risk than clozapine and may be better tolerated than the typical neuroleptics.
These medications require further investigation in double-blind studies.
In summary, neuroleptics are the best-studied psychotropic medications for borderline personality disorder.
The literature supports the use of low-dose neuroleptics for the acute management of global symptom severity, with specific efficacy for schizotypal symptoms and psychoticism, anger, and hostility
Acute treatment effects of neuroleptic drugs in borderline personality disorder tend to be modest but clinically and statistically significant.
More controlled trials are needed to investigate low-dose neuroleptics in continuation and maintenance treatment.
c) Side effects.
Patients with borderline personality disorder who have experienced relief of acute symptoms with low-dose neuroleptics may not tolerate the side effects of the drug with longer-term treatment.
Neuroleptics should be given in the context of a supportive doctor-patient relationship in which side effects and nonadherence are addressed frequently.
d) Implementation issues. All studies have used a low dose and demonstrated beneficial effects within several weeks
Acute treatment studies are a good model for acute clinical care and typically range from 5 to 12 weeks in duration. There is insufficient evidence to make a strong recommendation concerning continuation and maintenance therapies. At present, this is best left to the clinician’s judgment after carefully weighing the risks and benefits for the individual patient. CBC monitoring must be done if clozapine is used.
8. ECT (electroconvulsive therapy)
a) Goals. The goal of ECT in patients with borderline personality disorder is to decrease depressive symptoms in individuals with a comorbid axis I mood disorder, which is present in as many as one-half of hospitalized patients with borderline personality disorder.
b) Efficacy. Most of the clinical and empirical literature that describes experience with ECT in patients with major depression comorbid with personality disorders does not report results specifically for borderline personality disorder
Although the results of these studies appear somewhat divergent, most found that patients with major depression and a personality disorder have a less favorable outcome with ECT than depressed patients without a personality disorder.
c) Adverse effects. Because ECT is not recommended for borderline personality disorder per se, adverse effects are not described here.
d) Implementation issues.
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All the informations on this site are with an aim of helping to understand a "particular" disease at the very least and puzzle
But more especially to support peoples who suffer, sick or not. In all cases, it is ESSENTIAL to have recourse to a therapist specialized in the disease to confirm or to cancel a diagnosis
Though it is the name doesn't much matter, which is important, it is to apply "the right" treatment to each patient