Pharmacotherapy of borderline outpatients

Rates of psychotropic medication use reported by borderline patients and axis II comparison subjects over 16 years of prospective follow-up

The purpose of this study was to assess the classes and types of psychotropic medication reported by borderline patients and axis II comparison subjects over 16 years of prospective follow-up. Medication use was assessed at baseline using a semistructured interview of proven reliability and validity as well as its follow-up analog at 8 contiguous 2-year follow-up periods. A significantly higher percentage of borderline patients than axis II comparison subjects reported taking an antidepressant, an anxiolytic, an antipsychotic, and a mood stabilizer over time. They also reported more commonly taking 7 of the 10 more specific types of medication studied (ie, all but tricyclic antidepressants, monoamine oxidase inhibitor antidepressants, and atypical antipsychotics). The rates over time of taking antipsychotics and mood stabilizers were stable, whereas there was a significant decline in the rates of antidepressants and anxiolytics from baseline to 8-year follow-up (but not from 8- to 16-year follow-up) reported by those in both study groups. In terms of specific medications, rates of atypical antidepressants and anticonvulsants were the most stable. In contrast, nonbenzodiazepine anxiolytics declined the most steadily over time, whereas rates of atypical antipsychotics increased significantly over the 16 years of prospective follow-up. Taken together, the results of this study suggest that a substantial percentage of borderline patients continue to use the major classes of medication over time. They also suggest that the declining rates of use tend to stabilize less than a decade after index admission.

Efficacy and tolerability of pharmacotherapies for borderline personality disorder

Borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, affects and self-image, as well as marked impulsivity. Although psychotherapy is needed to attain lasting improvements in a patient's personality and overall functioning, practice guidelines state that pharmacotherapy is indicated to manage state symptoms and trait vulnerabilities. Three psychopathological dimensions are the main targets for pharmacotherapy of borderline personality disorder: affective dysregulation, impulsive-behavioural dyscontrol and cognitive-perceptual symptoms. Guidelines recommend the use of antidepressant agents and mood stabilizers for affective dysregulation and impulsive-behavioural dyscontrol, and antipsychotics for cognitive-perceptual symptoms. This review aims to report and discuss data from clinical trials, reviews and meta-analyses concerning drug efficacy and tolerability in the treatment of borderline personality disorder. Investigations that considered antidepressant agents mainly focused on SSRIs, which are recommended as first-line treatments for affective instability and impulse dyscontrol. Both open-label and randomized controlled studies have been performed, predominantly concerning the efficacy of fluoxetine and fluvoxamine. Other classes of antidepressants, such as TCAs and MAOIs, were investigated as alternative treatments for borderline personality disorder, but the risk of adverse effects and toxicity is a limitation to their use in clinical practice. Increasing amounts of data have recently been collected on the use of mood stabilizers to control mood instability and impulsivity in patients with borderline personality disorder. More substantial data were derived from controlled trials of valproate semisodium, although other drugs such as lithium, carbamazepine, oxcarbazepine and lamotrigine were tested with promising results. Several first-generation antipsychotics were studied in open-label and controlled trials, with good effects on behavioural dyscontrol and psychotic-like symptoms. Selection biases and heterogeneity of drugs and methods somewhat limited the value of these results. More recent investigations have examined atypical antipsychotics, with most of these studies being open-label trials with small sample sizes; however, a few controlled studies have been performed using olanzapine, showing improvements in impulsivity, anger and hostility. In conclusion, a large number of different drugs have been evaluated in the treatment of patients with borderline personality disorder. Initial findings are encouraging for many of these drugs. However, data need to be replicated in further controlled studies with head-to-head comparisons and long-term follow-ups. Many questions remain to be answered.

Sociodemography of borderline personality disorder (PD): a comparison with Axis II PDs and psychiatric symptom disorders convergent validation

A theoretical objective of the present meta-analysis based upon data derived from a previously reported review (Taub, 1995), was to test two inductive hypotheses empirically regarding educational background and social class across different criteria for the DSM-III diagnosis of borderline personality disorder (PD). A secondary purpose was to determine whether comorbidity of borderline PD with other Axis II PDs would significantly delineate socioeducational variables. Across 7/8 pairwise contrasts which represented five studies, distribution of Hollingshead Redlich (H-R) social classes II-IV borderline PD (N = 326) significantly exceeded that in 457 diagnostic controls with Axis II PDs and psychiatric symptom disorders. Although average differences, as well as, interactions reflected by values of the H-R two-factor scale attained statistical significance these were were less consistent in magnitude and direction versus outcomes yielded by distribution of social classes. For the borderline PD diagnosis, the inductive hypotheses were substantiated by findings of significantly advanced scholastic achievement, as well as the younger age of most cohorts versus diagnostic controls with Axis II PDs and psychiatric symptom disorders; and in pairwise contrasts of outpatients with hospitalized cohorts. Comorbidity of the borderline PD diagnosis was associated with significantly lower social class, scholastic achievement and to a lesser extent, more severe psychopathology. Evidence for predominantly convergent validation relative to the socioeducational variables was substantiated by comparisons with (a) cohorts selected by criteria of the DSM-III-R, Gunderson's DIB and Borderline Personality Scale: (b) Norwegian females admitted to Gaustad Hospital and (c) patients with the DSM-III diagnosis of borderline PD attending an outpatient clinic in Norway.

Demography of DSM-III borderline personality disorder (PD): a comparison with Axis II PDs, affective illness and schizophrenia convergent and discriminant validation

Demographic characteristics of borderline personality disorder (PD) defined according to DSM-III criteria were compared with those found for schizophrenia, affective illness, and other Axis II PDs. Borderline PD, unlike affective illness and most other Axis II PDs, usually occurs before the age of 30. By contrast to antisocial PD and schizophrenia, borderline PD usually occurs after the age of 25. For borderline PD (N = 280) average age was significantly more homogeneous compared with affective illness (N = 157) and Axis II PDs (N = 71) across 9 studies. By contrast, variability for 63 predominantly male schizophrenics in 3 studies was significantly less, reflecting the younger age at admission compared with borderline PD (N = 84). According to predictions based upon an age-of-risk hypothesis (Dahl, 1985) for 106 borderline PD patients, a significantly lower percentage were > or = 40 years of age than diagnostic controls (N = 181) predominantly with DSM-III affective illness. Borderline PD is predominantly diagnosed in females either single or who have been divorced compared with Axis II PDs and affective illness, to a lesser extent. Unlike antisocial PD, as well as schizophrenia, the preponderance of male and single/divorced patients usually occur significantly less than for borderline PD. Borderline PD usually occur significantly less than Axis II PDs, affective illness and schizophrenia and ethnic minorities, particularly Afro-Americans. These differences in ethnic/racial distribution are explained in terms of two hypotheses. From the perspective of demographic variables, borderline PD closely converges with neither (a) schizophrenia, (b) antisocial PC, (c) other Axis II PDs, nor (d) affective illness. Evidence for discriminant and convergent validation of these data is provided by (a) cluster analyses and intersample pairwise contrasts, as well as comparisons with (b) clinical samples selected on the basis of DSM-III-R and criteria of the (c) Diagnostic Interview for Borderline Patients, (d) a longitudinal case registry study conducted in Denmark, and (e) prospective surveys conducted among (i) North Carolina community residents and (ii) first degree (nonpatients) relatives of psychiatric patients in Iowa.

Clozapine treatment of borderline patients: a preliminary study

Clinicians frequently encounter patients who present with borderline personality disorder (BPD) and prolonged and/or pronounced psychotic symptoms of an atypical nature. Fifteen such patients were treated with clozapine and rerated blind to baseline symptomatology and functional level from 2 to 9 months after beginning treatment (mean = 4.2 +/- 2.1). The overall symptomatology of these patients as rated on the Brief Psychiatric Rating Scale (BPRS) decreased significantly from a mean of 57.0 +/- 10.4 to a mean of 37.8 +/- 7.7 (t = 7.03, df = 14, P = .001). Their positive, negative, and general symptoms as rated by the BPRS also decreased significantly. Additionally, their Global Assessment Scale (GAS) score increased significantly from a mean of 30.8 +/- 4.7 to a mean of 43.1 +/- 8.6 (t = 5.19, df = 14, P = .001). These results suggest that clozapine may be an effective antipsychotic agent for this subset of BPD patients. However, double-blind, placebo-controlled studies are necessary to confirm these preliminary results.

Psychotherapy in borderline and narcissistic personality disorder

Psychodynamic concepts about borderline personality disorder are reviewed and the literature concerning psychotherapeutic treatment of this group is examined. The treatment contexts considered include: psychoanalysis and intensive (expressive) psychoanalytic psychotherapy, supportive psychotherapy, group psychotherapy, family therapy, in-patient treatment, the therapeutic community, cognitive-behavioural approaches, and combinations of drugs and psychotherapy. The practical implications of recent follow-up studies for intervention strategies are considered.