Borderline personality disorder (BPD) is a difficult to treat condition that can cause significant distress for those living with it. While the gold standard for treatment is psychotherapy, specifically dialectical behaviour therapy (DBT), medications may also play a supporting role, and that’s what this post will focus on.
Antidepressants, particularly SSRIs, are some of the most commonly used medications in BPD, but research has demonstrated only moderate effectiveness. The tricyclic antidepressant amitriptyline has shown somewhat better results, but it can be lethal in overdose, which is not necessarily the best fit for an illness that often combines impulsivity with suicidality.
The mood stabilizers topiramate, lamotrigine, and valproic acid have shown some benefit in research studies. Additionally, valproic acid may be able to reverse some of the changes in gene expression that result from childhood trauma. When there is a family history of bipolar disorder suggesting a genetic predisposition, a mood stabilizer like lithium or lamotrigine may be helpful.
The atypical antipsychotic olanzapine has demonstrated effectiveness in reducing impulsivity, hostility, mood lability, and psychotic symptoms. However, there appears to be an increase in the risk of self-harming behaviour. The older antipsychotic haloperidol may be useful for anger, although for the most part it’s newer antipsychotics that have shown the most benefit in BPD.
Benzodiazepines, e.g. clonazepam and lorazepam, are not recommended for use in BPD because they can worsen impulsivity and suicidality. People with BPD may also be at increased risk for becoming dependent on benzos.
It’s been proposed that in BPD there may be dysfunction in the body’s natural opioid system. The opioid antagonist naltrexone has shown some benefit for dissociative symptoms. Further research in this area may turn up some new potential treatment options.
Some studies have suggested that irritability and aggression may be related to changes in levels of the hormone vasopressin. These changes in the regulation of vasopressin, as well as the feel-good hormone oxytocin, may be the result of changes in gene expression that result from early life trauma. The administration of vasopressin to manage symptoms of BPD is an area for future research.
Overall, there’s not a lot of research evidence when it comes to medication use in BPD. Even when drugs have shown some benefit, there are many core symptoms of BPD that they do not address, and they do not appear to decrease the overall severity of the illness. It’s recommended that medications only be used on a time-limited basis as adjuncts to psychotherapy, and polypharmacy (aka being on multiple medications at the same time) should be avoided. Medications that are added during a time of crisis should be withdrawn in possible when the crisis is over.
It seems unlikely that BPD could ever be treated with medication alone, but people living with BPD certainly deserve better than the under-researched hodgepodge that is the current state of affairs. It’s hard not to wonder if the type of research that’s been done has been influenced by thinking that BPD is “just” a personality disorder.
If you have BPD, what has your experience with medication been?
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- Stoffers, J., et al. (2010). Drug treatment for borderline personality disorder. Cochrane Review.
- Stone, M.H. (2019). Borderline personality disorder: Clinical guidelines for treatment. Psychodynamic Psychiatry, 47(1), 5-26.