Until the late 20th century, personality disorders were thought to be impervious to any pharmacological interventions. Personality characteristics were perceived as chronic, ingrained, and inconsistent with neurobiological theories of intervention. At best, perhaps minor, co-occurring symptoms could be addressed, such as anxiety or depression. However, it was soon observed that treatment with the older tricyclic antidepressants (such as Elavil or Tofranil) actually worsened borderline symptoms, resulting in less, not more, emotional control. Similarly, anti-anxiety medicines (Valium, Xanax, etc.) also often lessened impulse control and exacerbated symptoms.
Antidepressants
Serotonin reuptake inhibitors (SRIs), developed for depression, did demonstrate benefit for specific borderline symptoms, even in the absence of typical depressive characteristics. In addition to relieving feelings of emptiness, mood instability, and anxiety, SRIs (such as Prozac, Zoloft, Paxil, Lexapro, etc.) have been shown to decrease rage outbursts and self-destructive impulsivity. Some studies determined that doses significantly higher than those usually effective for treating depression were optimal in treating BPD. Another, older class of antidepressants-monoamine oxidase inhibitors (MAOIs, such as Nardil or Parnate)-have also been effective in treatment.
Antipsychotics
Older (Thorazine, Haldol, Stelazine, Navane) and more recently developed (Zyprexa, Risperdal, Seroquel, Abilify) medicines in this class have been particularly useful in addressing symptoms of paranoia, dissociation, and other cognitive and perceptual distortions. Additionally, antipsychotics, usually in very low doses, can relieve feelings of anger, aggressiveness, anxiety, impulsivity, and mood instability.
Mood Stabilizers
This group of medicines includes anti-seizure drugs (Depakote, Tegretol, Lamictal, etc.) and Lithium. These drugs, in usual doses, help decrease impulsivity, aggressiveness, irritability, and mood instability.
The American Psychiatric Association's "Practice Guideline for the Treatment of Patients with Borderline Personality Disorder" (2001) recommends that when medicines are utilized to supplement psychotherapy, they should target a specific symptom cluster. Guidelines divide BPD symptoms into three primary groups:
Mood Instability,
Impulse Dyscontrol, and
Cognitive-Perceptual Distortions.
SRIs, usually in high doses, are the usual first pharmacological approach to the first two clusters. Sometimes SRIs may be supplemented with antipsychotics and/or mood stabilizers. Antipsychotics are the initial intervention for primary symptoms of distortions of cognition or perception.
Other medicines and some homeopathic preparations have also been explored. For a fuller discussion of pharmacotherapy of BPD consult the 2010 edition of I Hate You, Don't Leave Me.
