The Borderline Personality Disorder diagnosis has been a favorite label for patients of Freudian psychiatrists for many years.  The name makes is sound like its right on the edge of going psychotic and needs lots of therapy.  In fact, the word borderline is a misnomer.  While a few patients may indeed have very brief episodes of paranoia or psychosis, this is not a necessary feature and there is no indication that these patients are any more likely to develop a true psychotic disorder than any other personality disorder. 

The central feature of the diagnosis is a "pervasive pattern of instability of interpersonal relationships, self-image, and moods, and marked impulsivity that begins by early adulthood and is present in a variety of contexts."  Since many of the same symptoms can occur in mood disorders, the borderline symptoms should be of early onset and have a long-standing and separate course.  Borderline symptoms in depressed patients usually decrease considerably with treatment of the depression.

For the diagnosis, patients must have five or more of the following: 1) frantic efforts to avoid real or imagined abandonment, 2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, 3) identity disturbance: markedly and persistently unstable self-image or sense of self, 4) impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). 5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior, 6) affective instability due to a marked reactivity of mood (intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days), 7) chronic feelings of emptiness, 8) inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights), 9) transient, stress-related paranoid ideation or severe dissociative symptoms.

Counseling vs. medication has very little research.  However, medication research is not very extensive or promising.  While psychiatrists give lots of medication to Borderline patients, the research does not inspire confidence in medication management other than for treating the depression.  Of course, everyone should take fish oil and folate.  Cognitive-behavioral counseling might be a good idea.  Other than that, any medication treatment is just guessing as this point.  Certainly, one should be hesitant to give any psychiatric medication unless the patient has a severe borderline disorder.  Then, a trial of an atypical anti-psychotic, lithium, or an anti-depressant might be cautiously undertaken. 

Medication Treatment

Study Finds Psychiatrists Treat Patients With Everything: 96 women in a partial hospital program who had borderline features were interviewed. Of those with four or more BPD criteria, 62% were on an SSRI, 40% a benzodiazepine, 12% a tricyclic, 43% trazodone for sleep, 10% venalafazine, 15% a neuroleptic, 19% an anticonvulsant, and 5% lithium. The more features present, the more different meds they were on. Karen Rosen, Butler Hosp, Providence, APA 5/30/98

Amitriptyline Helped Only Depression; Haldol Also Helped Hostility: A 5-week DB PC trial of 90 patients with 4 years of follow-up. Haldol was at 4-16 mg/d and amitriptyline at 100-175 mg/d. Haloperidol helped depression, hostility, impulsivity, and schizotypal symptoms. Univ. Pittsburgh. Amitriptyline versus haloperidol in borderlines: final outcomes and predictors of response. Soloff PH, George A, Nathan S, Schulz PM, Cornelius JR, Herring J, Perel JM. J Clin Psychopharmacol. 1989 Aug;9(4):238-46

Atypical Anti-Psychotic Helped in Small DB: A DB PC study of 28 Borderline Personality women for six months using olanzapine or placebos. On SCL-90 scores, olanzapine patients had a significantly (p < .05) greater rate of improvement over time than placebo in all of the symptom areas studied except depression.  Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebo-controlled pilot study. Zanarini MC, Frankenburg FR. J Clin Psychiatry. 2001 Nov;62(11):849-54. Harvard.

Carbamazepine No Benefit in Very Small DB: 20 pt. 31 days DB PC. A trial of carbamazepine in borderline personality disorder. de la Fuente JM, Lotstra F. Eur Neuropsychopharmacol 1994 Dec;4(4):479-86

Divalproex Might Help Borderline-BADs: 30 women comorbid for Bipolar Affective Disorder and Borderline Personality Disorder were treated in a very small DB PC study for 6 months to blood level of 50-100 microg/ml. Symptoms decreased 35% vs. 15% for placebo. Improvements in interpersonal sensitivity and anger/hostility and overt aggression. High (65%) drop out rate in study for both, especially after 3 months make any conclusion from this report impossible. Harvard (Abbott), J Clin Psych 02;63:442.

Fish Oil EPA Helped Borderlines: A small DB PC study of 30 patients (20 on E-EPA 1000mg/d) for 8 weeks. None had Major Depressive Disorder or substance abuse. Both groups improved markedly, but the EPA group improved significantly (and slightly) more. Modified Overt Aggression Scale and MADRS were used. Recruited via newspaper ad. Not on psychiatric meds. No side-effects. Harvard. Omega-3 Fatty Acid Treatment of Women With Borderline Personality Disorder: A Double-Blind, Placebo-Controlled Pilot Study. Mary C. Zanarini, Ed.D., and Frances R. Frankenburg, M.D. Am J Psychiatry 160:167-169, January 2003

Fluoxetine (Prozac) or Olanzapine (Zyprexa) Helped Borderlines: In an 8-week DB PC study of 45 women with borderline personality disorder, fluoxetine was compared to olanzapine and both drugs. Olanzapine monotherapy and the combination were associated with a significantly greater rate of improvement than fluoxetine on both outcome measures. However, fluoxetine by itself led to a substantial reduction in impulsive aggression and severity of depression. Weight gain was greater with olanzapine. A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. Zanarini MC, Frankenburg FR, Parachini EA. Harvard-McLean, J Clin Psychiatry. 2004 Jul;65(7):903-7

Lamotrigine May Have Helped Anger in Borderlines: Anger and aggression are typical in borderline patients. In an 8-week DB PC study of 27 female borderlines, those taking lamotrigine had a significant (p < 0.01) change on four STAXI scales (State-Anger, Trait-Anger, Anger-Out, Anger-Control) but not the Anger-In scale, where a difference of only 8.5% (p < 0.2) was found. Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo-controlled study. Tritt K, et al. University Clinic, Regensburg, Germany. J Psychopharmacol. 2005 May;19(3):287-91.

MAO Inhibitor Modest Benefit, Anti-Psychotic Even Less: A 108-patient, 5-week DB PC trial of phenelzine 60mg/d vs. haloperidol 4 mg/d vs. placebo found benefit only from the phenelzine. Benefit occurred in depression, anxiety, and Borderline symptoms. Efficacy of phenelzine and haloperidol in borderline personality disorder. Soloff PH, Cornelius J, George A, Nathan S, Perel JM, Ulrich RF. Arch Gen Psychiatry. 1993 May;50(5):377-85. Univ. Pittsburgh. In a 16-week continuation study of some of these patients, haloperidol to 6 mg/d, and phenelzine to 90 mg/d found haldol benefiting only irritability and phenelzine of only modest benefit to irritability and depression. Continuation pharmacotherapy of borderline personality disorder with haloperidol and phenelzine. Cornelius JR, Soloff PH, Perel JM, Ulrich RF. Am J Psychiatry. 1993 Dec;150(12):1843-8. Haloperidol drop-out rate of 64% vs. 28% with placebo.

SSRI Fluvoxamine Helps Mood Swings Only: One study with SSRIs inconclusive due to high placebo effect. This DB PC 6 weeks followed by a blind half-crossover for 6 weeks and an open follow-up for another 12 weeks was conducted with 38 nonschizophrenic, nonbipolar female patients with borderline personality disorder. The outcome measures were the rapid mood shift, impulsivity, and aggression subscales from the Borderline Personality Disorder Severity Index. RESULTS: Fluvoxamine but not placebo produced a robust and long-lasting reduction in the scores on the subscale for rapid mood shifts. In contrast, no difference between the fluvoxamine and placebo groups was observed in the effect on the impulsivity and aggression scores. SSRI Treatment of Borderline Personality Disorder: A Randomized, Placebo-Controlled Clinical Trial for Female Patients With Borderline Personality Disorder. Rinne T, Van Den Brink W, Wouters L, Van Dyck R. Am J Psychiatry 2002 Dec;159(12):2048-54

SSRIs No Value for Borderline Personality Impulsivity and Aggression: Although SSRIs are frequently given to BPD patients based on open trial reports, the only two PC DB studies, using fluvoxamine (Luvox) or fluoxetine (Prozac), have found benefit only for mood symptoms. Rinne T et al: SSRI treatment of borderline personality disorder: a randomized, placebo-controlled trial for female patients with borderline personality disorder. Am J Psychiatry 2002;159:2048-2054, U Leiden. and Salzman C, et al: Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder. J Clin Psychopharm 1995;15:23-9

SSRI: Fluoxetine Helped Anger in Very Small DB: A 13-week DB PC 21-patient Harvard study found a significant decrease in anger in the fluoxetine patients. Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder. Salzman C, Wolfson AN, Schatzberg A, Looper J, Henke R, Albanese M, Schwartz J, Miyawaki E. J Clin Psychopharmacol. 1995 Feb;15(1):23-9

Anti-Convulsants: Impulsive Aggression Reduced in Borderlines: In an 8-week DB PC study of 42 male borderlines, those on topiramate had decreases in State Anger, p < .01; Trait Anger, p < .05; Anger Out, p < .01; Anger Control, p < .01, but not on the Anger In scale (p = .86). Treatment of aggression with topiramate in male borderline patients: a double-blind, placebo-controlled study. Nickel MK, et al. Simbach/Inn, Germany. Biol Psychiatry. 2005 Mar 1;57(5):495-9. Ed: Several anti-convulsants have been shown to reduce aggression (carbamazepine, valproic acid, lamotrigine, topiramate.  There are no comparative studies.  Carbamazepine is the least expensive with a more favorable side-effect profile than valproic acid or topiramate.

Thomas E. Radecki, M.D., J.D.

modern-psychiatry.com

Email: [email protected]