Borderline personality disorder: current drug treatments and future prospects

Neurobiology, Molecular Pathways, and Environmental Influences in Antisocial Traits and Personality Disorders

Personality disorders (PDs) are psychiatric conditions characterized by enduring patterns of cognition, emotion, and behaviour that deviate significantly from cultural norms, causing distress or impairment. The aetiology of PDs is complex, involving both genetic and environmental factors. Genetic studies estimate the heritability of PDs at 30% to 60%, implicating genes involved in neurotransmitter regulation, such as those for serotonin transporters and dopamine receptors. Environmental factors, including childhood trauma and chronic stress, interact with genetic predispositions to induce epigenetic modifications like DNA methylation and histone modifications, contributing to PD development. Neurobiological research has identified structural and functional abnormalities in brain regions related to emotional regulation and social cognition, such as the amygdala, prefrontal cortex, and limbic system. These abnormalities are linked to impaired emotion processing and interpersonal functioning in PDs. This review focuses on how environmental factors shape maladaptive behaviours and endophenotypes central to many PDs. It explores the interaction between the Ras-ERK, p38, and mTOR molecular pathways in response to environmental stimuli, and examines the role of oxidative stress and mitochondrial metabolism in these processes. Also reviewed are various types of PDs and existing animal models that replicate key endophenotypes, highlighting changes in neurotransmitters and neurohormones. Identifying molecular biomarkers can lead to the development of "enviromimetic" drugs, which mimic environmental influences to activate molecular pathways, facilitating targeted, personalized treatments based on the molecular profiles of individuals with PDs. Ultimately, understanding the molecular mechanisms of PDs promises to enhance diagnostic accuracy, prognosis, and therapeutic outcomes for affected individuals.

Borderline Personality Disorder: A Comprehensive Review of Current Diagnostic Practices, Treatment Modalities, and Key Controversies

Borderline personality disorder (BPD) is a complex psychiatric condition characterized by pervasive patterns of instability in emotions, interpersonal relationships, and self-image. This comprehensive review explores the current diagnostic practices, treatment modalities, and ongoing controversies surrounding BPD. We discuss established and proposed diagnostic criteria, highlight the limitations of current assessment tools, and examine the epidemiology of the disorder, including its prevalence and comorbidities. The effectiveness of psychotherapeutic approaches such as dialectical behavior therapy, mentalization-based treatment, transference-focused psychotherapy, and schema-focused psychotherapy is evaluated alongside the role of pharmacological interventions. Furthermore, we address critical controversies, including misdiagnosis, the impact of trauma, stigma, and the ongoing debate regarding the treatability and recovery potential for individuals with BPD. By synthesizing these facets, we aim to provide a nuanced understanding of BPD and inform future research and clinical practice.

The endocannabinoid system in borderline personality disorder and antisocial personality disorder: A scoping review

Individuals with borderline personality disorder (BPD) or antisocial personality disorder (ASPD) are overrepresented in forensic settings. Yet, despite the burden these disorders place on healthcare and criminal justice systems, there remains a lack of evidence-based pharmacological treatments. Epidemiological data have shown that comorbid cannabis use disorders are common in BPD and ASPD. ∆9 -Tetrahydrocannabinol, the primary psychoactive constituent of cannabis, is an exogenous cannabinoid that stimulates the endocannabinoid system (ECS). Hence, an investigation of the ECS in these conditions is warranted. This scoping review screened 105 records and summarized the extant research on the ECS in ASPD (n = 69) and BPD (n = 61) participants. Preliminary results suggest that alterations of the ECS may be present in these disorders. Although research examining the ECS in personality disorders is still in its infancy, more research is warranted given initial positive findings.

Neuropsychological deficits correlate with symptoms severity and cortical thickness in Borderline Personality Disorder

BACKGROUND

Neuropsychological abnormalities have been proposed to contribute to the development and maintenance of Borderline Personality Disorder (BPD). Previous meta-analyses and reviews confirmed deficits in a broad range of cognitive domains, including attention, cognitive flexibility, memory, executive functions, planning, information processing, and visuospatial abilities, often suggested to underlie brain abnormalities. However, no study directly explored the structural neural correlates of these deficits in BPD, also accounting for the possible confounding effect of pharmacological treatments, often used as adjunctive symptom-targeted therapy in clinical setting.

METHODS

In this study we compared the performance of 24 BPD patients to 24 healthy controls obtained at the neuropsychological battery "Brief Assessment and Cognition in Schizophrenia", exploring the relationship between the cognitive impairments and current symptomatology, brain grey matter volumes and cortical thickness, controlling for medications load.

RESULTS

Data revealed deficits in verbal memory and fluency, working memory, attention and speed of information processing and psychomotor speed and coordination when medication load was not in the model. Correcting for this variable, only the impairment in psychomotor abilities remained significant. A multiple regression confirmed the effect of this neuropsychological domain on the severity of BPD symptomatology (Borderline Evaluation of Severity Over Time). In BPD, the performance at psychomotor speed and coordination was also directly associated to cortical thickness in postcentral gyrus.

LIMITATIONS

Relatively small sample size, especially for neuroimaging.

CONCLUSIONS

Our study highlighted an influence of BPD neuropsychological impairments on symptomatology, and cortical thickness, prompting the potential clinical utility of a cognitive remediation program in BPD.

A short screening tool for borderline personality disorder (Short-Bord): Validated by Rasch analysis

The study aimed to development a short screening scale for borderline personality disorder (Short-Bord), and to validate its psychometric properties using Rasch analysis. Ninety-eight outpatients undergoing psychotherapy were evaluated using a semistructured diagnostic interview for DSM-IV Personality disorders. Correlational analysis and Rasch analysis were used to identify the best-fitted items for the shorter scale. Rasch analysis identified three underfitted items. The best five items were selected for the Short-Bord using two analyses, resulting in two sets of Short-Bord which included item 1 (becoming frantic when someone left), item 2 (up- and- down relationships), item 3 (sudden change of sense of self), item 8 (self-harm or suicide), item 9 (self-mutilation), item 10 (sudden mood change) and item 11 (feeling empty inside). Each set of the five-item Short-Bord were tested against the original 15-item BPD scale. Results showed that both sets of the Short-Bord yielded minimally lower in area under curve (AUC = 0.95 and 0.96, respectively) compared with the total score of 15 items (AUC = 0.97), but none significantly differed (chi-square = 0.89-2.87, df 1, p >.05). Internal consistency for the set from Rasch analysis was slightly higher than correlation methods (Cronbach's alpha = 0.80, and 0.78, respectively). The Short-Bord presents promising tool to screen for borderline personality disorder. Its diagnostic validity was comparable to the total 15 items despite completing in a shorter time. The Short-Bord derived from Rasch analysis was, however, preferable as all items were shown to have unidimensional construct with good fit statistics and good internal consistency.

Current Knowledge on Gene-Environment Interactions in Personality Disorders: an Update

PURPOSE OF REVIEW

We review the existing literature on gene-environment interactions (G×E) and epigenetic changes primarily in borderline personality disorder (BPD) but also in antisocial, schizotypal, and avoidant personality disorders.

RECENT FINDINGS

Research supports that susceptibility genes to BPD or its underlying traits may be expressed under certain environmental conditions such as physical or childhood sexual abuse. Epigenetic modifications of neurodevelopment- and stress-related genes are suggested to underlie the relationship between early life adversary and borderline personality disorder. Only limited studies have investigated the role of gene-environment interactions and epigenetic changes in the genesis of antisocial, schizotypal, and avoidant personality disorders. Considering the lack of pharmacological treatment for most personality disorders, the emerging evidence on the critical role of G×E and epigenetic changes in the genesis of personality disorders could help develop more biologically oriented therapeutic approaches. Future studies should explore the potential of this new therapeutic dimension.

A Focused Systematic Review of Pharmacological Treatment for Borderline Personality Disorder

BACKGROUND

Medicines are routinely prescribed to treat borderline personality disorder (BPD) despite a relative lack of high-quality evidence and in breach of some treatment guidelines. An earlier Cochrane review of pharmacotherapy in BPD underlined the lack of evidence, encouraged the replication of earlier studies, but also emphasised the pressing need for more randomised placebo-controlled trials, and for those studies to employ broadened inclusion criteria.

METHOD

The authors searched bibliographic databases, reference lists of articles and trials registers. Records were screened to identify those that met the inclusion criteria. Full-text articles were screened and assessed for eligibility. On-going trials of pharmacotherapy in BPD were also identified.

RESULTS

Fifteen new studies of pharmacotherapy for BPD were identified since the earlier review. Eight of those examined second generation antipsychotics, two investigated mood stabilisers, three investigated antidepressants and two studied the effectiveness of opioid antagonists. Results for the effectiveness of antipsychotics appeared to be mixed. There has been little recent evidence to support the use of mood stabilisers. There is a lack of new placebo-controlled, randomised controlled trials investigating antidepressants and limited new evidence to support the use of opioid antagonists.

CONCLUSIONS

The review revealed that there remains a dearth of high-quality research evidence to help patients, carers and clinicians make sound and safe evidence-based decisions about medicines to treat BPD.

Second-generation antipsychotic use in borderline personality disorder: What are we targeting?

Introduction:

Borderline personality disorder (BPD) is a personality disorder plagued with high rates of psychotropic polypharmacy. Estimates show that second-generation antipsychotics (SGAs) are used in most of these patients; however, they are being prescribed off label.

Methods:

A literature review was conducted via PubMed in search for studies evaluating SGA use in BPD.

Results:

There are available data investigating 8 of 11 SGAs and their use in BPD. Of N = 269 potential articles, N = 34 evaluating the use of SGAs in BPD were included.

Discussion:

Strong evidence supporting SGAs in BPD is lacking. Potential target symptoms in which a SGA may be useful include depression, anxiety, anger, impulsivity, and paranoia/dissociative behavior.

Childhood trauma, midbrain activation and psychotic symptoms in borderline personality disorder

Childhood trauma is believed to contribute to the development of borderline personality disorder (BPD), however the mechanism by which childhood trauma increases risk for specific symptoms of the disorder is not well understood. Here, we explore the relationship between childhood trauma, brain activation in response to emotional stimuli and psychotic symptoms in BPD. Twenty individuals with a diagnosis of BPD and 16 healthy controls were recruited to undergo a functional MRI scan, during which they viewed images of faces expressing the emotion of fear. Participants also completed the childhood trauma questionnaire (CTQ) and a structured clinical interview. Between-group differences in brain activation to fearful faces were limited to decreased activation in the BPD group in the right cuneus. However, within the BPD group, there was a significant positive correlation between physical abuse scores on the CTQ and BOLD signal in the midbrain, pulvinar and medial frontal gyrus to fearful (versus neutral) faces. In addition there was a significant correlation between midbrain activation and reported psychotic symptoms in the BPD group (P<0.05). These results show that physical abuse in childhood is, in individuals with BPD, associated with significantly increased activation of a network of brain regions including the midbrain in response to emotional stimuli. Sustained differences in the response of the midbrain to emotional stimuli in individuals with BPD who suffered childhood physical abuse may underlie the vulnerability of these patients to developing psychotic symptoms.