Pharmacotherapy and Borderline Personality Disorder

Psychiatric medications are frequently prescribed for patients with Borderline Personality Disorder (BPD; Zanarini, Frankenburg, Hennen, et al., 2004). Although many such patients may be taking medications to address the symptoms of a comorbid Axis I disorder, it is often the case that pharmacotherapy is initiated in response to one or more core features of BPD. Yet, the empirical support for pharmacotherapy for BPD is extremely limited. Although several Randomized Control Trials (RCTs) have examined different medications for BPD, methodological problems – including very small sample sizes – and variable findings limit the conclusiveness of any recommendations stemming from these studies (Leichsenring, Leibung, Kruse, et al., 2011; Silk, 2011). In many cases, the agent being studied did not perform any better than placebo (Gunderson, 2011; Leichsenring, Leibung, Kruse, et al., 2011).

Thus, pharmacotherapy interventions are largely considered as adjuncts to psychotherapy, the mainstay treatment for BPD. Indeed, major treatment guidelines such as the National Institute for Health and Clinical Excellence (NICE, 2009) guideline for BPD recommend against the use of medications other than for the treatment of comorbid disorders. Specifically, these guidelines state that “drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour, and transient psychotic symptoms).” (NICE, 2009).

As mentioned, BPD is often associated with other Axis I disorders (See section on BPD comorbodities on our page on Associated Features) such as major depressive disorder. When considering the pharmacotherapy for depression in BPD, careful consideration must be given regarding whether the depression reflects a true major depressive disorder as opposed to depressive affect associated with emotion dysregulation (Silk, 2011). A recent Cochrane review recommends the use of SSRI antidepressants only in the event of concurrent major depressive disorder (Lieb, Volm, Rucker, et al., 2010).

There is some evidence to support the use of second generation antipsychotics (e.g. olanzapine) and mood stabilizers (e.g. lamotrigine, divalproex) in order to target very specific symptoms such as affect instability, impulsivity, and aggression (Leichsenrigh et al., 2011; Lieb et al., 2010). However, there is very little in the way of long-term follow up data regarding these agents, and no research regarding the ongoing use of such medications in patients with BPD.

An important issue to consider with regards to pharmacotherapy for BPD is the fact that side effects are associated with these medications. One notable side effect is weight gain. Aside from associated health morbidity, this can be particularly problematic for many patients with BPD who may already struggle with self esteem and body image difficulties (Silk, 2011). Another concern is the tendency for patients with BPD to receive multiple medications (Gunderson, 2011). This may occur as clinicians – in response to patients’ distress – earnestly seek to ameliorate troublesome symptoms by adding different agents to the patient’s medication regimen. Unfortunately, this practice increases the risk of drug-drug interactions and other adverse effects (Silk, 2011). Further research is required to better establish pharmacological interventions for BPD, and to assist clinicians in their decision-making regarding this challenging aspect of treating BPD.