Drug class
Findings
Studies
Antidepressantsa
Affect instability
Binks et al. [69]
Herpertz et al. [79]
Nosè et al. [82]
Anger
Binks et al. [69]
Anxiety
Herpertz et al. [79]
Antipsychotics
(Primarily but not exclusively atypicals)
Affect instability
Lieb et al. [71]
Mercer et al. [81]
Anger
Herpertz et al. [79]
Ingenhoven et al. [80]
Lieb et al. [71]
Nosè et al. [82]
Aggression
Herpertz et al. [79]
Ingenhoven et al. [80]
Lieb et al. [71]
Nosè et al. [82]
Global functioning (weak evidence)
Binks et al. [69]
Nosè et al. [82]
Cognitive perceptual symptoms
Binks et al. [69]
Duggan et al. [78]
Herpertz et al. [79]
Ingenhoven et al. [80]
Lieb et al. [71]
Mood stabilizers
Affect instability
Ingenhoven et al. [80]
Lieb et al. [71]
Mercer et al. [81]
Nosè et al. [82]
Anxiety
Ingenhoven et al. [80]
Impulsivity/aggression
Duggan et al. [78]
Anger
Herpertz et al. [79]
Ingenhoven et al. [80]
Lieb et al. [71]
Mercer et al. [81]
Global functioning
Ingenhoven et al. [80]
Nonetheless, a few guidelines should be mentioned and these are elaborated in more detail elsewhere [89]:
1.
There should be a frank discussion of what the patient means when she uses the word depression, and if appropriate, there should be further discussion about how the depression that the patient is suffering differs from that in a major depressive episode. This discussion can address the fact that antidepressant medication effectiveness has been shown in the specific depressive entity of major depressive disorder, but there is little evidence for medication effectiveness in other “depressions.” This does not mean that medications or some medication will not be tried and might even turn out to be helpful, but the benefits one might receive will usually be quite modest at best.
2.
Elaborating on the point made above, the patient needs to be told that since the research for effectiveness for these drugs reveals modest effect at best, the greatest amount of progress and improvement will come from the psychotherapeutic work. This does not mean that patients will get no benefit from pharmacologic treatment, but they should work towards not idealizing the pharmacology or any particular pharmacologic agent.
3.
There is no data that supports the use of polypharmacy, and it is best to treat with one medication, to appreciate the targeted outcome with or for that medication, and, if after the medication has been tried for a sufficient amount of time, to stop that medication before starting another one. There is no evidence for augmentation of medications in BPD.
4.
It is important that all these discussions take place an appreciation by the patient that one of the diagnoses being considered is BPD. In fact such discussions should take place at the initiation of psychopharmacologic treatment [41].
The prescriber should not assume that the patient already has this knowledge, as the patient’s prior experience may have been with a psychiatrist who believed that the patient had treatment-resistant affective illness and approached treatment from the position that finding the right combination of medications is all that the patient needed in order to improve.
References
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Deutsch H. Some forms of emotional disturbance and their relationship to schizophrenia. Psychoanal Q. 1942;11:301–21.
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Klein M. Notes on some schizoid mechanisms. Int J Psychoanal. 1946;27:99–110 (Reprinted in J Psychother Prac Res. 1996;5:164–79.).PubMed
5.
Zilboorg G. Ambulatory schizophrenia. Psychiatry. 1941;4:149–55.
6.
Chopra HD, Beatson JA. Psychotic symptoms in borderline personality disorder. Am J Psychiatry. 1986;143:1605–7.PubMed
7.
Links PS, Steiner M, Mitton J. Characteristics of psychosis in borderline personality disorder. Psychopathology. 1989;22:188–1983.PubMed
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Silk KR, Lohr NE, Westen D, Goodrich S. Psychosis in borderline patients with depression. J Personal Disord. 1989;3:92–100.
9.
Frosch J. The psychotic character. Clinical psychiatric considerations. Psychiatr Q. 1964;38:81–96.PubMed
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Barnow S, Arens EA, Sieswerda S, Dinu-Biringer R, Spitzer C, Lang S. Borderline personality disorder and psychosis: a review. Curr Psychiatry Rep. 2010;12:186–95.PubMed
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Goldberg SC, Schulz SC, Schulz PM, Resnick RJ, Hamer RM, Friedel RO. Borderline and schizotypal personality disorders treated with low-dose thiothixene vs placebo. Arch Gen Psychiatry. 1986;43:680–6.PubMed
12.
Leone NF. Response of borderline patients to loxapine and chlorpromazine. J Clin Psychiatry. 1982;43:148–50.PubMed
13.
Soloff PH, George A, Nathan RS, Schulz PM, Ulrich RF, Perel JM. Progress in pharmacotherapy of borderline disorders. A double-blind study of amitriptyline, haloperidol, and placebo. Arch Gen Psychiatry. 1986;43:691–7.PubMed
14.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.
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Schmideberg M. The treatment of psychopaths and borderline patients. Am J Psychother. 1947;1:45–70.PubMed
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Grinker RR, Werble G, Drye RC. The borderline syndrome. A behavioral study of ego functions. New York: Basic Books; 1968.
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