0
1

3. Pharmacotherapy and Other Somatic Treatments

  • Principles for choosing specific medications include the following:

    • Treatment is symptom specific, directed at particular behavioral dimensions.

    • Affective dysregulation and impulsivity/aggression are risk factors for suicidal behavior, self-injury, and assaultiveness and are given high priority in selecting pharmacological agents.

    • Medication targets both acute symptoms (e.g., anger treated with dopamine-blocking agents) and chronic vulnerabilities (e.g., temperamental impulsivity treated with serotonergic agents).

  • Symptoms to be targeted

    • Affective dysregulation symptoms (see Figure 1)

      Treat initially with a selective serotonin reuptake inhibitor (SSRI). A reasonable trial is at least 12 weeks.

      • Be cautious about discontinuing successful treatment, especially if the patient has failed to respond to prior medication trials.

      • If response is suboptimal, switch to a different SSRI or a related antidepressant.

      • Consider adding a benzodiazepine (especially clonazepam) when affective dysregulation presents as anxiety.

      • For disinhibited anger coexisting with other affective symptoms, SSRIs are the treatment of choice.

      • For severe behavioral dyscontrol, consider adding low-dose antipsychotics.

      • Monoamine oxidase inhibitors (MAOIs) are effective but are not a first-line treatment because of the risk of serious side effects and concerns about nonadherence with dietary restrictions.

      • Mood stabilizers (lithium, valproate, carbamazepine) are also a second-line treatment (or augmentation treatment).

      • Consider electroconvulsive therapy (ECT) for comorbid severe axis I depression refractory to pharmacotherapy.

    • Impulsive-behavioral symptoms (see Figure 2)

      SSRIs are the treatment of choice.

      • If a serious threat to the patient's safety is present, consider adding a low-dose antipsychotic to the SSRI. Onset of action is often within hours.

      • If an SSRI is ineffective, consider another SSRI or another class of antidepressant.

      • If the patient shows partial response to an SSRI, adding lithium may enhance the effectiveness of the SSRI.

      • If an SSRI is ineffective, switching to an MAOI may be considered after an appropriate drug washout period.

      • Consider valproate, carbamazepine, and second-generation (atypical) antipsychotics. There is widespread use of these agents despite limited data.

      • Clozapine may be warranted after other treatments have failed.

    • Cognitive-perceptual symptoms (see Figure 3)

      • Low-dose antipsychotics are the treatment of choice for psychotic-like symptoms.

      • Antipsychotics may also improve depressed mood, impulsivity, and anger-hostility.

      • Antipsychotics are most effective when cognitive-perceptual symptoms are primary.

      • If response is suboptimal in 4 to 6 weeks, increase dose to the range used for axis I disorders.

      • Clozapine may be useful for patients with severe, refractory psychotic-like symptoms.

+

FIGURE 1. Psychopharmacological Treatment of Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder

+
+
FIGURE 1. Psychopharmacological Treatment of Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder
+

FIGURE 2. Psychopharmacological Treatment of Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality Disorder

+
+
FIGURE 2. Psychopharmacological Treatment of Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality Disorder
aEspecially if serious threat to patient is present.bSSRI treatment must be discontinued and followed with an adequate washout period before initiating treatment with an MAOI.
+

FIGURE 3. Psychopharmacological Treatment of Cognitive-Perceptual Symptoms in Patients With Borderline Personality Disorder

+
+
FIGURE 3. Psychopharmacological Treatment of Cognitive-Perceptual Symptoms in Patients With Borderline Personality Disorder
aThe generally favorable side effect profiles of the second-generation antipsychotics compared with those of first-generation antipsychotics underscore the need for careful empirical trials of these newer medications in the treatment of patients with borderline personality disorder.

FIGURE 1. Psychopharmacological Treatment of Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder

FIGURE 2. Psychopharmacological Treatment of Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality DisorderaEspecially if serious threat to patient is present.bSSRI treatment must be discontinued and followed with an adequate washout period before initiating treatment with an MAOI.

FIGURE 3. Psychopharmacological Treatment of Cognitive-Perceptual Symptoms in Patients With Borderline Personality DisorderaThe generally favorable side effect profiles of the second-generation antipsychotics compared with those of first-generation antipsychotics underscore the need for careful empirical trials of these newer medications in the treatment of patients with borderline personality disorder.

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Related Content
Articles
Books
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 4.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 26.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 1.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 20.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 23.  >
Psychiatric News
PubMed Articles
 
  • Print
  • PDF
  • E-mail
  • Chapter Alerts
  • Get Citation