Personality Disorders Medication

Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.

The focus is on treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol. These symptoms may complicate almost all personality disorders to varying degrees, but all of them have been noted in borderline personality disorder.^{[10, 11, 12, 13, 14, 15]}

The assumption is that neurotransmitter abnormalities underlie these symptom clusters that transcend the concepts of Axis I and Axis II disorders. The strongest evidence for pharmacologic treatment of personality disorders has been for borderline personality disorder, but even this is based on a fairly small database of studies.

Class Summary

Because of overdose risk, tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are usually not prescribed for patients with personality disorders. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe and reasonably effective. However, because the depression of most patients with personality disorders stems from their limited range of coping capacities, antidepressants are usually less effective than in patients with uncomplicated major depression.

Antidepressants are most often prescribed for a limited time in patients with serious depressive episodes lasting longer than a few weeks.

Sertraline (Zoloft)

Selectively inhibits presynaptic serotonin reuptake.

Paroxetine (Paxil)

Potent selective inhibitor of neuronal serotonin reuptake. Also has weak effect on norepinephrine and dopamine neuronal reuptake.

Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.

Escitalopram (Lexapro)

Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane.

Selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in central nervous system resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.

Nefazodone (Serzone)

Antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. Also has negligible affinity for cholinergic and histaminergic receptors.

Mirtazapine (Remeron)

Increases availability of serotonin and norepinephrine.

Class Summary

Useful in stabilizing the affective extremes in patients with bipolar disorder but are less effective for that purpose in patients with personality disorders. They have some demonstrated efficacy in suppressing impulsive and particularly aggressive behavior in patients with personality disorder.

Valproic acid (Depakote)

Most widely used agent in its class. Modestly effective and generally well tolerated.

Class Summary

Some personality disorders produce transient psychotic periods (especially borderline personality disorder), while others (eg, schizotypal personality disorder) feature chronic idiosyncratic ideation of nearly psychotic proportions.

Response to antipsychotics is less dramatic than in true psychotic Axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced. Antipsychotics are typically used for a short time while the symptoms are active.

The atypical antipsychotics have almost completely replaced the traditional neuroleptics because of their safety margin, but neurologic risks (including tardive dyskinesia and neuroleptic malignant syndrome) are never absent. Risperidone and olanzapine are described here; however, quetiapine and ziprasidone may also be used. No evidence indicates that any of these has superior efficacy, and each one may have advantages and disadvantages from the standpoint of adverse effects.

Risperidone (Risperdal)

Binds to dopamine D2 receptor with a 20-times lower affinity than for the 5-HT2 receptor. Improves negative symptoms of psychoses and reduces incidence of extrapyramidal adverse effects.

Olanzapine (Zyprexa)

May inhibit serotonin, muscarinic, and dopamine effects.

Quetiapine (Seroquel)

May act by antagonizing dopamine and serotonin effects. Efficacy similar to risperidone and olanzapine. Fewer dose-dependent adverse effects and less concern of weight gain.