Borderline Personality Disorder Medication

  • Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Sep 2, 2011
 

Medication Summary

Patients with borderline personality disorder (BPD) tend to have strong placebo responses to medication; thus, impressive short-term improvement might occur and unexpectedly fade. Impulsivity, affective instability, and psychosis are the significant manifestations of borderline pathology that might require pharmacologic treatment.

Benzodiazepines are contraindicated in this population because they reduce inhibitions and are therefore likely to increase impulsivity. Furthermore, patients with BPD are prone to sedative addiction.

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Selective serotonin reuptake inhibitors (SSRIs)

Class Summary

These antidepressant agents are chemically unrelated to the tricyclic, tetracyclic, and other available antidepressants. SSRIs inhibit CNS neuronal reuptake of serotonin (5HT). They may also have a weak effect on norepinephrine and dopamine neuronal reuptake. SSRIs are also used to treat anxiety, phobias, and obsessive-compulsive disorders (OCDs).

When used at high doses, SSRIs appear to reduce impulsivity and aggression; however, the antidepressant effects are less impressive than those of other drugs. One important advantage of SSRIs is their relative safety because patients with BPD commonly take overdoses of their prescribed medication. Therefore, the use of tricyclic antidepressants, lithium, and other mood stabilizers is usually not indicated without specific relevant symptoms and a strong, ongoing therapeutic relationship.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.[25]

Currently, evidence does associate OCD and other anxiety disorders treated with SSRIs with an increased risk of suicide.

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Fluoxetine (Prozac)

 

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect on norepinephrine or dopamine uptake. Was the first available SSRI and remains the prototype. Has longest half-life (72 h). Commonly reported adverse effects (eg, general insomnia, agitation, GI disturbance) generally well tolerated, and discontinuation by the patient is rare.

Increase dose only if improvement not evident. Trial of 6-8 wk may be required before resistance inferred. Higher doses generally more effective in BPD. FDA approved for depression and OCD in children and adolescents.

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Sertraline (Zoloft)

 

Shorter half-life (25 h) than that of fluoxetine and has fewer reported adverse effects. Does not increase plasma levels of other psychotropic medications to same extent as fluoxetine. Most commonly reported adverse effects generally well tolerated; discontinuation by the patient is rare. FDA approved for OCD in children >6 y. FDA approved for PTSD in adults. PO liquid concentrate available.

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Antipsychotics

Class Summary

Low-dose neuroleptics are effective in the short term for control of transient psychotic symptoms. Antipsychotics have long been used to control impulsivity and aggression in patients with BPD, although SSRIs are preferred because of their more benign adverse effect profile. If an antipsychotic agent is necessary, avoid butyrophenones in favor of atypical agents such as risperidone.[26, 27, 28]

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Risperidone (Risperdal)

 

Binds to dopamine D2-receptor with an affinity 20 times lower than its affinity for the 5-HT2-receptor. Improves negative symptoms of psychoses and reduces incidence of extrapyramidal adverse effects. Approved for several indications in pediatric patients. Indicated for schizophrenia in adolescents (13-17 y), for bipolar mania in children and adolescents (10-17 y), and in children (5-16 y) with irritability associated with autistic disorder. Available as PO sol.

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Opiate receptor antagonist

Class Summary

In 1999, Bohus et al reported a significant reduction in the duration and intensity of dissociative symptoms in a small number of patients with BPD during treatment with naltrexone, an opiate receptor antagonist.[29] Evidence suggests that alterations of the endogenous opiate systems contribute to dissociative symptoms in patients with BPD. In a case report, naltrexone was reported decrease self-injurious behavior in a 3 year-old boy.[30]

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Naltrexone (ReVia)

 

Cyclopropyl derivative of oxymorphone that acts as a competitive antagonist at opioid receptors.

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Contributor Information and Disclosures
Author

Roy H Lubit, MD, PhD  Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Elizabeth A Finley-Belgrad, MD and Joseph A Davies, MD to the development and writing of this article.

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