A trial of carbamazepine in borderline personality disorder

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

Impulsivity and its Therapeutic Management in Borderline Personality Disorder: a Systematic Review

No treatment has been approved and recognized as effective in borderline personality disorder (BPD). Impulsivity is a key dimension because it is a predictor of remission but also suicide. The purpose of this review is to establish an inventory on the management of impulsivity in BPD and determine the effective treatments. A systematic review on the PubMed and Ovid databases was conducted up to September 2019 to December 2019 using the PRISMA guidelines. The inclusion criteria were: studies with patients with borderline personality disorder, were published between 1989 and 2019, used English-language and evaluated impulsivity before and after treatment. 41 articles selected were included for pharmacological treatment. 24 articles were found for psychotherapeutic management and one randomized study of transcranial magnetic stimulation. Based on this review, we must focus on psychotherapy in BPD, particularly the schema therapy, dialectical behavioral therapy, psychoeducation, system training of emotional predictability and problem solving and psychotherapy using mentalisation. The use of neuroleptics and mood stabilizers appears to be more effective than antidepressants. Another approach, such as transcranial magnetic stimulation, may prove useful in the near future if this technique is studied further.

The Limits between Bipolar Disorder and Borderline Personality Disorder: A Review of the Evidence

Bipolar disorder and borderline personality disorder are among the most frequently diagnosed psychiatric conditions. However, the nosological aspects and diagnostic boundaries of both conditions have historically been the object of considerable controversy. The present paper critically analyzes this debate, in light of available evidence. Clinical and neurobiological differences between bipolar disorder and borderline personality disorder are discussed, as well as the factors possibly involved in the overlap between both conditions and the potential implications of this.

Drug treatment for personality disorders

There is some evidence that antidepressants, particularly the selective serotonin reuptake inhibitors and the monoamine oxidase inhibitors, have some benefits in the management of borderline personality disorder, and lesser evidence (partly because of limited trial data) for the benefits of antipsychotic drugs and mood stabilisers. There is not sufficient distinction between the different personality disorders to recommend that any one disorder should be treated by any one drug, and successful treatment is dependent on careful management, sensitive to the patient's expectations.

Pharmacotherapy of personality disorders: what we know and what we have to search for

Pharmacotherapy for personality disorders is in the early stage of development because the evidence base for effective drug treatment is insufficient, biased toward borderline personality disorder and rampant with methodological issues. In this paper, we reviewed randomized, placebo-controlled trials of drugs efficacy in patients with personality disorders published between 1990 and 2016. Overwhelming majority of studies focused on borderline personality disorder, and the accumulation of evidence resulted in seven meta-analyses, which are interpreted into better strategies for evidence-based practice. Little research attention was given to schizotypal and antisocial personality disorders, with only indirect treatment efficacy evidence for the obsessive–compulsive and avoidant personality disorders. Some avenues for future efficacy research are indicated.

Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: A comparison with other psychiatric disorders

Patients with borderline personality disorder (BPD) are usually prescribed a variety of psychotropic drugs; however, none is recommended in the guidelines nor has any been approved for this indication. As data on drug prescriptions for BPD are sparse, cross-sectional data from the European Drug Safety Project AMSP were used to analyse drug prescriptions of 2195 in-patients with BPD between 2001 and 2011, and the mean values, confidence intervals and regression analyses were calculated. 70% of all BPD patients were medicated with antipsychotics and/or antidepressants, 33% with anticonvulsants, 30% with benzodiazepines, and 4% with lithium; 90% received at least one, 80%≥2, and 54%≥3 psychotropic drugs concomitantly (mean: 2.8). Prescription rates for quetiapine, the single drug most often used in BPD (22%), increased significantly over time. In view of the high percentage of young females with BPD, 18-40 year-old female patients with BPD were compared with patients of the same age but with depression (unipolar and bipolar) and schizophrenia. Typical sedative antipsychotics and anticonvulsants were prescribed more often in BPD than in the other diagnostic groups, with the exception of bipolar depression; this was true for the single substances quetiapine, levomepromazine, chlorprothixene, carbamazepine, and valproate. A limitation of the study was the use of clinical data without verifying the diagnoses by structured interviews. Contrary to the guidelines, about 90% of in-patients with BPD received psychotropic drugs. Polypharmacy was common, and antipsychotics with sedative profiles such as quetiapine and mood-stabilizing anticonvulsants such as valproate appear to be preferred.

Pharmacotherapy for borderline personality disorder--current evidence and recent trends

Drug treatment of patients with borderline personality disorder (BPD) is common but mostly not supported by evidence from high-quality research. This review summarises the current evidence up to August 2014 and also aims to identify research trends in terms of ongoing randomised controlled trials (RCTs) as well as research gaps. There is some evidence for beneficial effects by second-generation antipsychotics, mood stabilisers and omega-3 fatty acids, while the overall evidence base is still unsatisfying. The dominating role SSRI antidepressants usually play within the medical treatment of BPD patients is neither reflected nor supported by corresponding evidence. Any drug treatment of BPD patients should be planned and regularly evaluated against this background of evidence. Research trends indicate increasing attention to alternative treatments such as dietary supplementation by omega-3 fatty acids or oxytocin.

Psychopharmacologic treatment of borderline personality disorder

The best available evidence for psychopharmacologic treatment of borderline personality disorder (BPD) is outlined here. BPD is defined by disturbances in identity and interpersonal functioning, and patients report potential medication treatment targets such as impulsivity, aggression, transient psychotic and dissociative symptoms, and refractory affective instability Few randomized controlled trials of psychopharmacological treatments for BPD have been published recently, although multiple reviews have converged on the effectiveness of specific anticonvulsants, atypical antipsychotic agents, and omega-3 fatty acid supplementation. Stronger evidence exists for medication providing significant improvements in impulsive aggression than in affective or other interpersonal symptoms. Future research strategies will focus on the potential role of neuropeptide agents and medications with greater specificity for 2A serotonin receptors, as well as optimizing concomitant implementation of evidence-based psychotherapy and psychopharmacology, in order to improve BPD patients' overall functioning.

Borderline personality disorder: current drug treatments and future prospects

Individuals with borderline personality disorder (BPD) suffer from marked affective disturbance, an unstable sense of self, difficulty in interpersonal relationships and heightened impulsivity, leading to high rates of self-harm and suicide. Patients are often refractory to treatment and are at high risk for acute or dangerous presentations, with a serious impact on mental health services. There has been much debate on the effectiveness of pharmacotherapy in treating different facets of the psychopathology of the disorder. Several guidelines recommend the use of antidepressant agents, mood stabilizers for affective dysregulation and impulsive-behavioural dyscontrol, and antipsychotics for cognitive-perceptual symptoms. However, concerns have recently been raised regarding the strength of evidence for these treatment recommendations in BPD. Here, we review the evidence for efficacy of the main psychotropic medications used in BPD, drawing, in particular, on evidence from randomized controlled trials and meta-analyses. Overall, meta-analysis provides little evidence to support the use of antidepressant medication in BPD outside episodes of major depression. However, there is evidence for the use of both mood stabilizers and antipsychotic medications for the treatment of specific aspects of the disorder. Most existing studies have been conducted on small numbers of patients, and there is a requirement for further large-scale trials to substantiate these findings. In addition, given the limitations of current pharmacological treatment of BPD, there is a pressing need to investigate potential new therapeutic targets, including neuropeptides, such as the opioids and vasopressin, and drugs targeted at ameliorating the biological effects of early life stress.

Antipsychotics, antidepressants, anticonvulsants, and placebo on the symptom dimensions of borderline personality disorder: a meta-analysis of randomized controlled and open-label trials

The aim of this study was to quantitatively review randomized controlled trials (RCTs) and open-label trials analyzing the efficacy of antidepressants, mood stabilizers, and antipsychotics for the treatment of the core symptoms of borderline personality disorder (BPD). Using a similar meta-analytic approach, the efficacy of placebo on the same core symptoms of BPD was evaluated. The risk of discontinuation of each of the medication classes reported in the studies was also analyzed to establish the major causes of discontinuation. MEDLINE (1966 to June 2010) and EMBASE (1980 to June 2010) databases were systematically searched to identify relevant RCTs and open studies. The primary outcome was improvement in the specific core symptoms of the disorder: affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual symptoms. Evidence from RCTs and open studies suggests that drug treatment, especially with mood stabilizers and antipsychotics, may be effective for treating affective dysregulation and impulsive-behavioral dyscontrol. Antipsychotics were also effective in reducing cognitive-perceptual symptoms. Antidepressants failed to show efficacy in treating BPD symptom dimensions other than affective dysregulation. Our analyses of the placebo arm of RCTs showed a significant improvement of symptomatology in these patients also. There were no significant differences in overall dropout rates between patients on medications and those on placebo. In conclusion, the efficacy of pharmacological treatment on the symptom dimensions of BPD has been shown by various independent meta-analyses, with a positive effect of drug treatment on the core symptoms of BPD and some documentable differences in terms of efficacy between different drug classes in each of the symptom domains.

Evidence-based pharmacotherapy for personality disorders

Patients with personality disorders are prescribed psychotropic medications with greater frequency than almost any other diagnostic group. Prescribing practices in these populations are often based on anecdotal evidence rather than rigorous data. Although evidence-based psychotherapy remains an integral part of treatment, Axis II psychopathology is increasingly conceptualized according to neurobiological substrates that correspond to specific psychopharmacological strategies. We summarize the best available evidence regarding medication treatment of personality disordered patients and provide optimal strategies for evidence-based practice. Most available evidence is concentrated around borderline and schizotypal personality disorders, with some additional evidence concerning the treatment of avoidant and antisocial personality disorders. Although maladaptive personality symptoms respond to antidepressants, antipsychotics, mood stabilizers, and other medications, evidence-based pharmacotherapy is most useful in treating circumscribed symptom domains and induces only partial improvement. Most available evidence supports use of medication in reducing impulsivity and aggression, characteristic of borderline and antisocial psychopathology. Efforts have also begun to reduce psychotic-like symptoms and improve cognitive deficits characteristic of schizotypy. Indirect evidence is also provided for psychopharmacological reduction of social anxiety central to avoidant personality disorder. Evidence-based practice requires attention to domains of expected clinical improvement associated with a medication, relative to the potential risks. The development of future rational pharmacotherapy will require increased understanding of the neurobiological underpinnings of personality disorders and their component dimensions. Increasing efforts to translate personality theory and social cognitive neuroscience into increasingly specific neurobiological substrates may provide more effective targets for pharmacotherapy.

A comparison of UK and US guidelines for drug treatment in borderline personality disorder

The UK and USA differ considerably in their guidance regarding the use of drug treatment for borderline personality disorder, but generally agree over the use of psychological treatment. The 2009 UK guidelines from the National Institute for Health and Clinical Excellence (NICE) do not recommend any form of drug treatment except in a crisis with the intention of ceasing such treatment shortly afterwards. The US guidelines from the American Psychiatric Association (APA), published in 2001, are much more positive and suggest that there is a place for selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and antipsychotic drugs as adjunctive treatments in borderline personality disorder. The guidelines are summarized and two main reasons for the differences identified. First, the separation of the borderline personality group into those with 'affective dysregulation', 'impulsive behaviour dyscontrol' and 'cognitive-perceptual' symptoms in the US guidelines was felt by the guideline development group for the NICE guideline to be a post hoc classification not supported by any other evidence. Second, the threshold of evidence necessary for making recommendations was much higher for the UK than the US guideline. Both guidelines recognize that we need more substantial trials, preferably independent of the pharmaceutical industry, before we can have any real confidence in our recommendations.

Pharmacological treatments for personality disorders

Abstract This paper presents a systematic review of clinical trials of drugs for patients with personality disorders. Almost all trials have concerned the treatment of borderline personality disorder (BPD). Research yields some evidence for symptomatic improvement with antidepressants, mood stabilizers, and antipsychotics. However, drug treatment does not produce remission of BPD. Routine prescription of these agents for these patients is not evidence-based.

Borderline personality disorder

Recent research findings have contributed to an improved understanding and treatment of borderline personality disorder. This disorder is characterised by severe functional impairments, a high risk of suicide, a negative effect on the course of depressive disorders, extensive use of treatment, and high costs to society. The course of this disorder is less stable than expected for personality disorders. The causes are not yet clear, but genetic factors and adverse life events seem to interact to lead to the disorder. Neurobiological research suggests that abnormalities in the frontolimbic networks are associated with many of the symptoms. Data for the effectiveness of pharmacotherapy vary and evidence is not yet robust. Specific forms of psychotherapy seem to be beneficial for at least some of the problems frequently reported in patients with borderline personality disorder. At present, there is no evidence to suggest that one specific form of psychotherapy is more effective than another. Further research is needed on the diagnosis, neurobiology, and treatment of borderline personality disorder.

Pharmacological interventions for borderline personality disorder

BACKGROUND

Drugs are widely used in borderline personality disorder (BPD) treatment, chosen because of properties known from other psychiatric disorders ("off-label use"), mostly targeting affective or impulsive symptom clusters.

OBJECTIVES

To assess the effects of drug treatment in BPD patients.

SEARCH STRATEGY

We searched bibliographic databases according to the Cochrane Developmental, Psychosocial and Learning Problems Group strategy up to September 2009, reference lists of articles, and contacted researchers in the field.

SELECTION CRITERIA

Randomised studies comparing drug versus placebo, or drug versus drug(s) in BPD patients. Outcomes included total BPD severity, distinct BPD symptom facets according to DSM-IV criteria, associated psychopathology not specific to BPD, attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

Two authors selected trials, assessed quality and extracted data, independently.

MAIN RESULTS

Twenty-eight trials involving a total of 1742 trial participants were included. First-generation antipsychotics (flupenthixol decanoate, haloperidol, thiothixene); second-generation antipsychotics (aripirazole, olanzapine, ziprasidone), mood stabilisers (carbamazepine, valproate semisodium, lamotrigine, topiramate), antidepressants (amitriptyline, fluoxetine, fluvoxamine, phenelzine sulfate, mianserin), and dietary supplementation (omega-3 fatty acid) were tested. First-generation antipsychotics were subject to older trials, whereas recent studies focussed on second-generation antipsychotics and mood stabilisers. Data were sparse for individual comparisons, indicating marginal effects for first-generation antipsychotics and antidepressants.The findings were suggestive in supporting the use of second-generation antipsychotics, mood stabilisers, and omega-3 fatty acids, but require replication, since most effect estimates were based on single studies. The long-term use of these drugs has not been assessed.Adverse event data were scarce, except for olanzapine. There was a possible increase in self-harming behaviour, significant weight gain, sedation and changes in haemogram parameters with olanzapine. A significant decrease in body weight was observed with topiramate treatment. All drugs were well tolerated in terms of attrition.Direct drug comparisons comprised two first-generation antipsychotics (loxapine versus chlorpromazine), first-generation antipsychotic against antidepressant (haloperidol versus amitriptyline; haloperidol versus phenelzine sulfate), and second-generation antipsychotic against antidepressant (olanzapine versus fluoxetine). Data indicated better outcomes for phenelzine sulfate but no significant differences in the other comparisons, except olanzapine which showed more weight gain and sedation than fluoxetine. The only trial testing single versus combined drug treatment (olanzapine versus olanzapine plus fluoxetine; fluoxetine versus fluoxetine plus olanzapine) yielded no significant differences in outcomes.

AUTHORS' CONCLUSIONS

The available evidence indicates some beneficial effects with second-generation antipsychotics, mood stabilisers, and dietary supplementation by omega-3 fatty acids. However, these are mostly based on single study effect estimates. Antidepressants are not widely supported for BPD treatment, but may be helpful in the presence of comorbid conditions. Total BPD severity was not significantly influenced by any drug. No promising results are available for the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment. Conclusions have to be drawn carefully in the light of several limitations of the RCT evidence that constrain applicability to everyday clinical settings (among others, patients' characteristics and duration of interventions and observation periods).

Antiepileptics for aggression and associated impulsivity

BACKGROUND

Aggression is a major public health issue and is integral to several mental health disorders. Antiepileptic drugs may reduce aggression by acting on the central nervous system to reduce neuronal hyper-excitability associated with aggression.

OBJECTIVES

To evaluate the efficacy of antiepileptic drugs in reducing aggression and associated impulsivity.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, metaRegister of Controlled Trials (mRCT) and ClinicalTrials.gov to April 2009. We also searched Cochrane Schizophrenia Group's register of trials on aggression, National Research Record and handsearched for studies.

SELECTION CRITERIA

Prospective, placebo-controlled trials of antiepileptic drugs taken regularly by individuals with recurrent aggression to reduce the frequency or intensity of aggressive outbursts.

DATA COLLECTION AND ANALYSIS

Three authors independently selected studies and two authors independently extracted data. We calculated standardised mean differences (SMDs), with odds ratios (ORs) for dichotomous data.

MAIN RESULTS

Fourteen studies with data from 672 participants met the inclusion criteria. Five different antiepileptic drugs were examined. Sodium valproate/divalproex was superior to placebo for outpatient men with recurrent impulsive aggression, for impulsively aggressive adults with cluster B personality disorders, and for youths with conduct disorder, but not for children and adolescents with pervasive developmental disorder. Carbamazepine was superior to placebo in reducing acts of self-directed aggression in women with borderline personality disorder, but not in children with conduct disorder. Oxcarbazepine was superior to placebo for verbal aggression and aggression against objects in adult outpatients. Phenytoin was superior to placebo on the frequency of aggressive acts in male prisoners and in outpatient men including those with personality disorder, but not on the frequency of 'behavioral incidents' in delinquent boys.

AUTHORS' CONCLUSIONS

The authors consider that the body of evidence summarised in this review is insufficient to allow any firm conclusion to be drawn about the use of antiepileptic medication in the treatment of aggression and associated impulsivity. Four antiepileptics (valproate/divalproex, carbamazepine, oxcarbazepine and phenytoin) were effective, compared to placebo, in reducing aggression in at least one study, although for three drugs (valproate, carbamazepine and phenytoin) at least one other study showed no statistically significant difference between treatment and control conditions. Side effects were more commonly noted for the intervention group although adverse effects were not well reported. Absence of information does not necessarily mean that the treatment is safe, nor that the potential gains from the medication necessarily balance the risk of an adverse event occurring. Further research is needed.

Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials

BACKGROUND

Many patients with borderline personality disorder receive pharmacological treatment, but there is uncertainty about the usefulness of such therapies.

AIMS

To evaluate the evidence of effectiveness of pharmacotherapy in treating different facets of the psychopathology of borderline personality disorder.

METHOD

A Cochrane Collaboration systematic review and meta-analysis of randomised comparisons of drug v. placebo, drug v. drug, or single drug v. combined drug treatment in adult patients with borderline personality disorder was conducted. Primary outcomes were overall disorder severity as well as specific core symptoms. Secondary outcomes comprised associated psychiatric pathology and drug tolerability.

RESULTS

Twenty-seven trials were included in which first- and second-generation antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids were tested. Most beneficial effects were found for the mood stabilisers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine. However, the robustness of findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness.

CONCLUSIONS

The current evidence from randomised controlled trials suggests that drug treatment, especially with mood stabilisers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

Psychopharmakotherapie einer ambulanten und stationären Inanspruchnahmepopulation adoleszenter Patienten mit Borderline-Persönlichkeitsstörung

Fragestellung: Ein Großteil erwachsener Patienten mit Borderline-Persönlichkeitsstörung (BPS) wird mit Psychopharmaka behandelt. Über die Psychopharmakotherapie bei Adoleszenten mit BPS liegen bisher keine Daten vor. Ziel dieser Studie ist die Untersuchung der Häufigkeit des Störungsbildes und des Verschreibungsverhaltens bei adoleszenten ambulanten und stationären Patienten mit BPS. Methoden: 58 adoleszente Patienten mit BPS (16.7 ± 2.5 Jahre) einer Inanspruchnahmepopulation während eines 7-jährigen Beobachtungszeitraums wurden retrospektiv hinsichtlich der Medikation und verschiedener Risikovariablen in der Erstbehandlungsepisode untersucht. Ergebnisse: 37 Patienten wurden stationär und 21 ambulant behandelt, entsprechend einer Prävalenz von 2.1 %, bezogen auf die Inanspruchnahmepopulation. Stationäre Patienten waren insgesamt stärker durch Risikofaktoren belastet (ca. 68 % mit komorbiden Störungen, ca. 49 % mit selbstverletzendem Verhalten, signifikant (p < .001) mehr Suizidversuche in der Vorgeschichte) und wurden häufiger (p < .001) psychopharmakologisch behandelt. Am häufigsten wurden Antidepressiva verschrieben (SSRI und NaSSA), gefolgt von Neuroleptika. Über die Hälfte der medizierten Patienten erhielten mehrere Medikamente gleichzeitig. Schlussfolgerungen: Psychopharmakotherapie bei BPS hat inzwischen einen hohen Stellenwert, ist in erster Linie symptomorientiert und komorbide Störungen sollten gleichermaßen miteinbezogen werden. Auch für Adoleszente gewinnt die Medikation bei BPS an Bedeutung. Stationär behandelte Patienten sind durch psychiatrische Risikofaktoren stärker belastet und werden häufiger mediziert.

Personality trait dimensions and the pharmacological treatment of borderline personality disorder

The number of well-designed placebo-controlled studies on pharmacological treatment of borderline personality disorder has been small. We present a breakdown of results of placebo-controlled pharmacological studies, sorting target symptoms into the trait dimensions of affective instability, anxiety inhibition, cognitive-perceptual disturbances, and impulsivity-aggression. Twenty randomized placebo-controlled pharmacological trials studying typical and atypical antipsychotics, selective serotonin reuptake and monoamine oxidase inhibitors, tricyclic antidepressants, mood stabilizers, and benzodiazepines were included. A relative measure of the weight of an outcome was determined by (1) dividing the number of positive comparisons for a drug class by the total number of comparisons of all drugs of all classes for each dimension and (2) dividing the number of positive comparisons for a drug class by the total number of comparisons for that particular drug class for that trait dimension. Antipsychotics (neuroleptics and atypicals) had the most evidence for each of the traits with both methods. Our results are compared with the results of 2 meta-analyses, 1 guideline set, and 1 other systematic review. We found little concordance across these studies. We propose a consortium to discuss guidelines for future studies, including agreement as to what should be measured to determine the outcome and adoption of standardized instruments to measure that outcome.

Evidenced-based pharmacologic treatment of borderline personality disorder: a shift from SSRIs to anticonvulsants and atypical antipsychotics?

OBJECTIVE

The authors performed a review of double-blind, controlled studies of psychotropic drugs to evaluate the evidence base supporting their use in treatment of borderline personality disorder.

METHODS

English language literature cited in Medline and published between 1970 and 2006 was searched using the following terms: anticonvulsants, antidepressants, antipsychotics, anxiolytics, benzodiazepines, borderline personality disorder, lithium, medication, mood stabilizers, pharmacotherapy, and psychotropics. Only reports of double-blind, randomized, controlled trials were included.

RESULTS

Twenty eight double-blind, randomized, controlled trials were identified which included anticonvulsants, classical neuroleptics, the benzodiazepine alprazolam, lithium, monoamine oxidase inhibitors, the novel antipsychotic olanzapine, selective serotonin reuptake inhibitors, tricyclic antidepressants, and omega-3 fatty acids. All but three were placebo-controlled. With the exception of alprazolam and tricyclics, the data from these trials revealed evidence of improvements, although often circumscribed and variable. The novel antipsychotic olanzapine appeared to have the most empirical support for having a favorable effect on borderline personality disorder.

CONCLUSION

A growing body of data suggests that there are psychotropic agents which appear to be well tolerated, and which to varying degrees may be expected to ameliorate the domains of psychopathology associated with borderline personality disorder. The research literature, on which practice should be optimally based, appears to suggest a need for a shift from antidepressants to anticonvulsants and atypical antipsychotics.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders

These practical guidelines for the biological treatment of personality disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the biological treatment of three specific personality disorders, namely borderline, schizotypal and anxious/avoidant personality disorder in addition to some general recommendations for the whole field. The guidelines cover disease definition, classification, epidemiology, course and current knowledge on biological underpinnings, and provide a detailed overview on the state of the art of clinical management. They deal primarily with biological treatment (including antidepressants, neuroleptics, mood stabilizers and some further pharmacological agents) and discuss the relative significance of medication within the spectrum of treatment strategies that have been tested for patients with personality disorders, up to now. The recommendations should help the clinician to evaluate the efficacy spectrum of psychotropic drugs and therefore to select the drug best suited to the specific psychopathology of an individual patient diagnosed for a personality disorder.

[Psychopathology and treatment of borderline personality disorder]

Borderline personality disorder (BPD) is a severe psychiatric disorder accounting for about 30% of the total cost for psychiatric inpatient care in the Federal Republic of Germany. Suicidality, self-harm, and severe deterioration of self-esteem lead to chronic suffering for patients and the social environment. With a prevalence rate of 1.5%, BPD is more frequent than schizophrenic disorders. Within the last years, empirically based knowledge concerning the psychopathology, etiopathogenesis, and treatment of BPD have significantly improved. Today most researchers postulate pervasive affective dysregulation at the core of borderline symptomatology and see it as the consequence of an interplay between genetic vulnerability, sociobiographic experience, and dysfunctional behavior. Disorder-specific psychotherapeutic treatments, especially dialectical behavior therapy, show significant improvements in both in- and outpatient settings. Studies on psychopharmacological treatment with promising results have also recently been published. Sufficient outpatient treatment by trained psychotherapists is underdeveloped. Hence, specialized inpatient centers assume this task.

Epidemiology, risk factors, and psychopharmacological management of suicidal behavior in borderline personality disorder

Borderline personality disorder (BPD) is a chronic psychiatric condition characterized by a pervasive pattern of instability in affect regulation and impulse control. These maladaptive coping strategies predispose individuals with BPD to suicidal behavior, and this diagnosis increases the risk for completed suicide. Empirical data indicate that adverse life events; a history of childhood trauma; and the presence of comorbid psychiatric conditions, in particular major depressive disorder and substance use disorders; confer an elevated risk of suicidal behavior in patients with BPD. Psychopharmacological interventions, including the use of antidepressants, anti-psychotics, and mood stabilizers, are considered in this review in terms of the evidence for their utility in reducing the risk of suicidal behavior in BPD.

Medications in the treatment of borderline personality disorder 2006

This review covers all significant randomized controlled trials and open trials of medications for the treatment of borderline personality disorder. New developments in the effectiveness of mood stabilizers and antipsychotics are discussed. Differences were found in the effectiveness of medications based on the presence or absence of depression and significant anger symptoms. Medications continue to be recommended as adjuncts to psychotherapy. Most of the trials discussed require replication, and more trials that investigate the effectiveness of medications in combination with psychotherapy are recommended.

Efficacy of pharmacotherapy against core traits of borderline personality disorder: meta-analysis of randomized controlled trials

We conducted a meta-analysis of published randomized, placebo-controlled clinical trials that evaluated the effect of pharmacotherapy in patients with borderline personality disorder. Comprehensive searches of the MEDLINE, EMBASE, PsychLIT and Cochrane Central Register of Controlled Trials databases were performed using web-based search engines. Twenty articles, reporting 22 placebo-controlled comparisons, were included in the meta-analysis: eight involved antipsychotics, seven antidepressants and seven mood stabilizers. Antidepressants (four studies, standardized mean difference -0.55, 95% confidence interval -0.92, -0.17) and mood stabilizers (six studies, standardized mean difference -1.74, 95% confidence interval -2.76, -0.73) were effective against affective instability and anger, but did not produce significant benefits against impulsivity and aggression, unstable relationships, suicidality and global functioning. Antipsychotics as a class had a positive effect in terms of impulsivity and aggression (three studies, standardized mean difference -0.31, 95% confidence interval -0.63, -0.003), interpersonal relationships (three studies, standardized mean difference -0.52, 95% confidence interval -0.87, -0.17) and global functioning (seven studies, standardized mean difference -0.56, 95% confidence interval -1.00, -0.11). No difference was observed between pharmacotherapy and placebo in terms of participants leaving the study early. Pharmacotherapy can exert a modest beneficial effect on some core traits of borderline personality disorder.

Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders

OBJECTIVES

The Diagnostic and Statistical Manual of Mental Disorders guidelines provide only a partial solution to the nosology and treatment of bipolar disorder in that disorders with common symptoms and biological correlates may be categorized separately because of superficial differences related to behavior, life history, and temperament. The relationship is explored between extremely rapid switching forms of bipolar disorder, in which manic and depressive symptoms are either mixed or switch rapidly, and forms of borderline personality disorder in which affective lability is a prominent symptom.

METHODS

A MedLine search was conducted of articles that focused on rapid cycling in bipolar disorder, emphasizing recent publications (2001-2004).

RESULTS

Studies examined here suggest a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders. We propose a model for the development of 'borderline' behaviors on the basis of unstable mood states that sheds light on how the psychological and somatic interventions may be aimed at 'breaking the cycle' of borderline personality disorder development. A review of pharmacologic studies suggests that anticonvulsants may have similar stabilizing effects in both borderline personality disorder and rapid cycling bipolar disorder.

CONCLUSIONS

The same mechanism may drive both the rapid mood switching in some forms of bipolar disorder and the affective instability of borderline personality disorder and may even be rooted in the same genetic etiology. While continued clinical investigation of the use of anticonvulsants in borderline personality disorder is needed, anticonvulsants may be useful in the treatment of this condition, combined with appropriate psychotherapy.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is prevalent (2% in the general population, 20% among psychiatry in-patients) and has a major impact on health facilities as those affected often present in crisis but then make poor use of further attempts to help them.

OBJECTIVES

To evaluate the effects of pharmacological interventions for people with borderline personality disorder.

SEARCH STRATEGY

We conducted a systematic search of 26 specialist and general bibliographic databases (October 2002) and searched relevant reference lists for further trials.

SELECTION CRITERIA

We included all randomised clinical trials comparing any psychoactive drugs with any other treatment for people with borderline personality disorder.

DATA COLLECTION AND ANALYSIS

We independently selected, quality assessed and data extracted studies. For binary outcomes we calculated a standard estimation of the risk ratio (RR), its 95% confidence interval (CI), and where possible the number need to help/harm (NNT/H). For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were synthesised using a weighted mean difference (WMD).

MAIN RESULTS

We found ten small (total n=554), short, randomised studies involving eight comparisons from which we could extract usable data. Studies comparing antidepressants with placebo were small (total n=79, 2 RCTs) but for ratings of anger fluoxetine may offer some improvement for those on antidepressant therapy over placebo (n=22, 1 RCT, RR anger not improved 0.30 CI 0.10 to 0.85, NNT 2 CI 2 to 9). The one small study investigating the important outcome of attempted suicide found no difference between mianserin and placebo (n=38, 1 RCT, RR 0.82 CI 0.44 to 1.54). Haloperidol may be better than antidepressants for symptoms of hostility and psychotism. There were few differences between MAOIs and placebo except that people given MAOIs were less hostile (n=62, 1 RCT, MD -9.19 CI -16.12 to -2.26). Although some ratings were statistically significant the comparison of MAOIs with antipsychotics did not show convincing differences. Antipsychotics may effect some mental state symptoms more effectively than placebo but results are difficult to interpret clinically and there is little evidence of advantage of one antipsychotic over another. Finally mood stabilisers such as divalporex may help mental state (n=16, 1 RCT, RR no improvement in mental state 0.58 CI 0.36 to 0.94, NNT 3 CI 2 to 17) but data are far from conclusive.

AUTHORS' CONCLUSIONS

Pharmacological treatment of people with BPD is not based on good evidence from trials and it is arguable that future use of medication should be from within randomised trials. Current trials suggest that the positive effect of antidepressants, in particular, could be considerable. Well designed, conducted and reported clinically meaningful trials are possible and needed with, perhaps, the question of antidepressant versus placebo being addressed first.

Is the biological nature of depressive symptoms in borderline patients without concomitant Axis I pathology idiosyncratic? Sleep EEG comparison with recurrent brief, major depression and control subjects

The relationship between borderline personality disorder (BPD) and the affective disorders is controversial, and we have previously compared BPD and major depression (MD) with endocrinological measures and sleep electroencephalography (S-EEG). We have also compared BPD, MD and recurrent brief depression (RBD) using endocrine tests. We have proposed that depressive symptoms in BPD might have a biological substrate that is distinct from those in depressive illness without comorbid BPD. BPD has been proposed to overlap with RBD, which has been found to share perturbed biological substrates with MD, but we have not found the same biological pattern in BPD. When endocrinological data in BPD, MD and RBD were compared, we did not find evidence of biological linkage between BPD and RBD. To clarify the biological nature of depressive symptoms in BPD, we examined S-EEG characteristics in BPD, RBD, MD and controls. Among 20 BPD patients, 12 were also diagnosed as having clinical RBD. BPD patients showed differences in sleep continuity and especially in sleep architecture compared with RBD, MD and controls. BPD with or without clinical RBD did not show significant differences in any parameter. BPD with or without clinical RBD had less slow sleep activity not only than MD but also than non-borderline RBD patients. We propose that although BPD patients can have concomitant MD, they often exhibit a specific BPD-associated affective syndrome that is different from both MD and non-borderline RBD in the quality and duration of symptoms and the biological substrate.

Borderline personality disorder

Borderline personality disorder is characterised by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image. Clinical signs of the disorder include emotional dysregulation, impulsive aggression, repeated self-injury, and chronic suicidal tendencies, which make these patients frequent users of mental-health resources. Causal factors are only partly known, but genetic factors and adverse events during childhood, such as physical and sexual abuse, contribute to the development of the disorder. Dialectical behaviour therapy and psychodynamic partial hospital programmes are effective treatments for out-of-control patients, and drug therapy can reduce depression, anxiety, and impulsive aggression. More research is needed for the understanding and management of this disabling clinical condition. Current strategies are focusing on the neurobiological underpinnings of the disorder and the development and dissemination of better and more cost-effective treatments to clinicians.

Psychopharmacology of borderline personality disorder

Psychopharmacology is widely used in the treatment of borderline personality disorder. However, support for this form of treatment has been largely based on case reports, case series, and open-label clinical trials. This evidence-based review examines the most recent randomized controlled trials of psychopharmacology in the treatment of borderline personality disorder, with a goal of highlighting the most promising pharmacotherapy for use in current clinical practice, as well as for future large-scale research testing. The results and limitations of the randomized controlled trial data are presented along with case vignettes illustrating the complexity of the disorder and the heterogeneity of its treatment. To date, there is at least some evidence-based support for the use of antipsychotics (conventional and atypical), monoamine oxidase inhibitors, serotonin reuptake inhibitors, and omega-3 fatty acids in the treatment of borderline personality disorder.

Effects of carbamazepine on dexamethasone suppression and sleep electroencephalography in borderline personality disorder

The pathophysiology of borderline personality disorder (BPD) remains obscure, but there is mounting evidence of brain dysfunction without focal abnormality. The dexamethasone suppression test (DST) and sleep electroencephalography (sleep EEG) have been studied in BPD, but the findings seem to be related to a concomitant axis I diagnosis of major depression (MD) rather than to BPD itself. There is no effective treatment for BPD. Carbamazepine (CBZ) has shown contradictory results and in a previous study, our results were negative. In this study, we investigated the effects of CBZ versus placebo on the DST and sleep EEG in a sample of 20 BPD patients without concomitant MD. CBZ given at doses that are therapeutic for epilepsy and affective disorders may have an effect on the DST and sleep EEG in BPD. CBZ significantly increased the postdexamethasone plasma cortisol values. This did not parallel MD or an increase in the Hamilton depression rating scores. CBZ also increased slow wave sleep (SWS). The mechanisms by which CBZ increased postdexamethasone plasma cortisol levels and SWS in BPD are discussed.

Psychobiology and treatment of borderline personality disorder

Borderline personality disorder can be characterized in terms of a profile of abnormal deviations on multiple personality dimensions using the temperament and character inventory (TCI). Borderline patients show poor character development, including low TCI self-directedness (irresponsible, blaming) and low TCI cooperativeness (hostile, intolerant). Their temperament is explosive or unstable due to a combination of high TCI harm avoidance (anxious, shy), high TCI novelty seeking (impulsive, quick-tempered), and low reward dependence (cold, aloof). Consequently they are usually dysthymic with an admixture of anxiety and anger, and regulate their social problems and intense emotions in immature ways. Genetic and psychobiological studies have led to identification of biological correlates of each of the TCI dimensions of personality, including individual differences in regional brain activity, psychophysiological variables, neuroendocrine abnormalities and specific gene polymorphisms. Each dimension of personality involves complex non-linear interaction of multiple genetic and environmental factors and, in turn, each personality dimension interacts with the others in influencing the way an individual directs and adapts to his or her life experiences. Systematic clinical trials have shown that these personality variables predict the response to pharmacological and psychotherapeutic treatments. For example, high harm avoidance and low self-directedness predict slower response and more rapid relapse with both antidepressants and cognitive-behavioral therapy. Treatment with drugs and/or psychotherapy can be individually matched to the patient's profile of temperament and character traits, rather than treating a heterogeneous group of patients as if they had a discrete, homogeneous illness. Fundamental change in cognitive schemas depends on attention to all aspects of character, especially self-transcendence, which has previously been neglected in cognitive-behavioral therapy. Personality integration requires non-resistance to our natural intuitive awareness, rather than intensified intellectual and emotional defenses.

Psychopharmacology of personality disorders: review and emerging issues

Progress with the development of models and general principles of psychopharmacologic management of personality disordered patients is reviewed. Recent research using mood stabilizers and novel antipsychotics are discussed. The effects of these medications on impulsive aggressiveness are supported and the effects are evident early and are independent of the effects on mood, including depression. Research is needed with other personality disorders beyond just borderline personality disorder. Future research must develop measurable outcomes and delineate the causal and temporal relationships between the psychopathologic features of personality disorders.

Modeling the relationship between affective lability, impulsivity, and suicidal behavior in patients with borderline personality disorder

This article reviews the concept of affective lability and suggests that new models are needed to characterize the relationship between affective states such as affective lability, impulsivity, and suicidal behavior. The association of affective lability, impulsivity, and suicidal behavior is most relevant to understanding the risk of suicide in individuals with borderline personality disorder. The relationship between affective lability and suicide might be explained as 1) a form of bipolarity, 2) a form of impulse dyscontrol, 3) a quantitative disorder of affect, or 4) an environmental reactivity. Our opinion of the relevant literature suggests that a quantitative disorder of affect accompanied by the inability to control these affects are the essential components leading to the risk of suicidal behavior. Characterizing the dyscontrol and high intensity of affect leads to a reconceptualization of depression in patients with borderline personality disorder and to a re-examination of the causal chain of events leading to suicidal behavior. The implications for clinical practice resulting from the proposed model are discussed.

Psychopharmacology of borderline personality disorder

Pharmacotherapy for patients with borderline personality disorder is directed against the psychobiology of cognitive-perceptual, affective, and impulsive-behavioral symptoms. A symptom-specific method using current empiric evidence for drug efficacy in each symptom domain is proposed. Drugs in each medication class have some potential utility against specific symptoms in patients with borderline personality disorder.

Electroencephalographic abnormalities in borderline personality disorder

Epilepsy and non-localized brain dysfunction have been invoked, among others, as underlying factors in borderline personality disorder. We have recorded 58 electroencephalograms in 20 borderline patients, first after complete drug washout and then under carbamazepine or placebo double-blind treatment. Taking into account only definite abnormal tracings, we found a 40% incidence of abnormal diffuse slow activity. No patient disclosed focal or epileptiform EEG features. Carbamazepine did not appear to modify the electroencephalogram.

Dimensional classification and behavioral pharmacology of personality disorders; a review and hypothesis

Nosological orientation in psychiatry has severely hampered the progress of research in biological psychiatry, especially in the case of personality disorders. Dimensional approaches have redefined the characteristics of these disorders and their possible pathogenetic factors. The significance of arousal and stress, so far relatively neglected in clinical research, and its important function in adaptive and coping strategies has to be included in the study of the behavioral pharmacology of personality disorders. Some preliminary clinical data are available suggesting the potential therapeutic use of serotonin modulating agents in the key symptomatology of certain personality disorders such as disturbed impulsive regulation and increased stress reactivity.