Medication Summary
In the treatment of borderline personality disorder (BPD), selective serotonin reuptake inhibitors (SSRIs) are greatly preferred to the other classes of antidepressants. Benzodiazepines are contraindicated in this population because they reduce inhibitions and are therefore likely to increase impulsivity. Antipsychotic agents and opiate receptor antagonists may also be considered.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Class Summary
SSRIs are chemically unrelated to the tricyclic, tetracyclic, and other available antidepressants. They inhibit neuronal reuptake of serotonin in the central nervous system (CNS) and may have a weak effect on neuronal reuptake of norepinephrine and dopamine. SSRIs are also used to treat anxiety, phobias, and obsessive-compulsive disorder (OCD).
At high dosages, SSRIs appear to reduce impulsivity and aggression; however, their antidepressant effects are less impressive than those of other drugs. 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.
Fluoxetine (Prozac)
Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on norepinephrine or dopamine uptake. It was the first available SSRI and remains the prototype. Of all the SSRIs, it has the longest half-life (72 hours). Commonly reported adverse effects (eg, general insomnia, agitation, and gastrointestinal [GI] disturbance) are generally well tolerated, and discontinuance by the patient is rare.
The dosage should be increased only if improvement is not evident. A trial of 6-8 weeks may be required before resistance is inferred. Higher dosages are generally more effective in BPD. Fluoxetine is approved by the US Food and Drug Administration (FDA) for treatment of depression and OCD in children and adolescents.
Sertraline (Zoloft)
Sertraline has a shorter half-life (25 hours) and fewer reported adverse effects than fluoxetine. It does not increase plasma levels of other psychotropic medications to the same extent that fluoxetine does. The most commonly reported adverse effects are generally well tolerated; discontinuance by the patient is rare. Sertraline is FDA-approved for OCD in children older than 6 years and for posttraumatic stress disorder (PTSD) in adults. An oral liquid concentrate is available.
Paroxetine (Paxil, Pexeva)
Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake.
Escitalopram (Lexapro)
This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may occur after 1-2 weeks, which is faster than the relief obtained from other antidepressants.
Fluvoxamine (Luvox CR)
Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs do. In the treatment of BDD, higher doses than those used for depression generally are needed. Fluvoxamine is FDA-approved for children with OCD.
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.
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.
Risperidone (Risperdal)
Risperidone binds to dopamine D2 receptors with an affinity 20 times lower than its affinity for the serotonin 5-HT2 receptor. It improves negative symptoms of psychoses and reduces the incidence of extrapyramidal adverse effects. Risperidone is FDA-approved for several indications in pediatric patients: schizophrenia in adolescents (13-17 years), bipolar mania in children and adolescents (10-17 years), and irritability associated with autistic disorder in children (5-16 years). It is available as an oral solution.
Olanzapine (Zyprexa)
Olanzapine may inhibit the effects of serotonin, muscarine, and dopamine.
Quetiapine (Seroquel)
Quetiapine may act by antagonizing the effects of dopamine and serotonin. Its efficacy is similar to that of risperidone and olanzapine. This agent causes fewer dose-dependent adverse effects and less concern regarding weight gain.
Opiate Receptor Antagonists
Class Summary
In small studies and case reports, opiate receptor antagonists have been reported to reduce the duration and intensity of dissociative symptoms in patients with BPD and to decrease self-injurious behavior. Evidence suggests that alterations of the endogenous opiate systems contribute to dissociative symptoms in patients with BPD.
Naltrexone (ReVia, Vivitrol)
Naltrexone is a cyclopropyl derivative of oxymorphone that acts as a competitive antagonist at opioid receptors.
