Drug therapy in borderline patients

Is the biological nature of depressive symptoms in borderline patients without concomitant Axis I pathology idiosyncratic? Sleep EEG comparison with recurrent brief, major depression and control subjects

The relationship between borderline personality disorder (BPD) and the affective disorders is controversial, and we have previously compared BPD and major depression (MD) with endocrinological measures and sleep electroencephalography (S-EEG). We have also compared BPD, MD and recurrent brief depression (RBD) using endocrine tests. We have proposed that depressive symptoms in BPD might have a biological substrate that is distinct from those in depressive illness without comorbid BPD. BPD has been proposed to overlap with RBD, which has been found to share perturbed biological substrates with MD, but we have not found the same biological pattern in BPD. When endocrinological data in BPD, MD and RBD were compared, we did not find evidence of biological linkage between BPD and RBD. To clarify the biological nature of depressive symptoms in BPD, we examined S-EEG characteristics in BPD, RBD, MD and controls. Among 20 BPD patients, 12 were also diagnosed as having clinical RBD. BPD patients showed differences in sleep continuity and especially in sleep architecture compared with RBD, MD and controls. BPD with or without clinical RBD did not show significant differences in any parameter. BPD with or without clinical RBD had less slow sleep activity not only than MD but also than non-borderline RBD patients. We propose that although BPD patients can have concomitant MD, they often exhibit a specific BPD-associated affective syndrome that is different from both MD and non-borderline RBD in the quality and duration of symptoms and the biological substrate.

Sleep-EEG in borderline patients without concomitant major depression: a comparison with major depressives and normal control subjects

The link between borderline personality disorder (BPD) and the affective disorders remains controversial. The aim of this study was to examine the relationships between BPD and major depression (MD) from the perspective of sleep parameters and to contribute to the characterisation of the sleep-EEG in BPD. We compared 20 off-medication BPD in-patients without co-existing MD with 20 sex- and age-matched MD patients without BPD and 20 sex- and age-matched control subjects. BPD patients had a greater prevalence of drug or alcohol abuse and suicide attempts than MD patients. MD patients had higher scores on the Hamilton Depression Rating Scale (HDRS). Both BPD and MD patients had less total sleep time, more prolonged sleep onset latency, and a greater percentage of wakefulness than control subjects. BPD patients and control subjects had more stage 2 sleep than MD patients. BPD patients had a longer duration of rapid eye movement (REM) sleep, and less stage 3, stage 4 and slow wave sleep than MD patients and control subjects. REM latency did not differentiate the three groups. BPD and MD patients shared sleep-continuity characteristics, but sleep architecture differentiated the two groups. BPD patients with a past history of MD had more wakefulness and less slow wave sleep than BPD patients without a history of MD; other sleep parameters, age, sex and HDRS scores were not statistically different in the two BPD subgroups. Although BPD and MD may coexist, the present study offers more arguments favouring the concept that they are not biologically linked and that BPD patients with depressive symptoms often experience an affective syndrome different from that in MD patients without BPD, in terms of quality and duration of symptoms and of the biological substrate.

Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder

Clinical data and uncontrolled observations have suggested that fluoxetine is helpful in some patients with borderline personality disorder. This article describes the results of a 13-week double-blind study of volunteer subjects with mild to moderately severe borderline personality disorder. Thirteen fluoxetine recipients and nine placebo recipients received treatment. Pretreatment and posttreatment measures were obtained for global mood and functioning, anger, and depression. The most striking finding from this study was a clinically and statistically significant decrease in anger among the fluoxetine recipients. This decrease was independent of changes in depression. These data support previous observations that fluoxetine may reduce anger in patients with borderline personality disorder. The number of subjects in this study was small, the placebo responsiveness was high, and the clinical characteristics of the patients were in the mild to moderate range of severity. The data cannot be extrapolated to more severely ill borderline patients, but further study of fluoxetine and other selective serotonin reuptake inhibitors is indicated in this population.

A trial of carbamazepine in borderline personality disorder

Borderline personality disorder does not have a first choice pharmacological treatment. We studied 20 borderline inpatients in a double-blind parallel placebo-controlled trial with carbamazepine for a mean of 30.9 days. No significant positive effects of the drug were found.

The quality of depression in adolescents with borderline personality disorder

OBJECTIVE

The quality of depression in borderline adolescent girls was compared with the quality of depression in depressed, nonborderline girls. Psychoanalytic theories led us to expect signs of anaclitic depression in borderlines as well as a depressive sense of being "all bad."

METHOD

Quality of depression was examined by means of Rorschach content analysis and the Depressive Experiences Questionnaire (DEQ). Borderline girls were expected to show greater Rorschach imagery pertaining to oral dependency and oral aggression than would depressed, nonborderline control girls. The borderline diagnosis was based on the Diagnostic Interview for Borderlines. DSM-III-R criteria were used to diagnose depression. Subjects were psychiatric inpatients, ages 14 to 18 years.

RESULTS

As expected, it was found that borderline girls scored significantly higher than did controls on Rorschach scales of oral dependency; borderlines scored significantly higher on DEQ factors of dependency and self-criticism. Significant DEQ items reflected the borderlines' abandonment fears.

CONCLUSIONS

This study provides empirical support for anaclitic depression in borderline adolescents, and suggests the presence of underlying fears in borderlines of being fundamentally evil or bad.

Clozapine treatment of borderline patients: a preliminary study

Clinicians frequently encounter patients who present with borderline personality disorder (BPD) and prolonged and/or pronounced psychotic symptoms of an atypical nature. Fifteen such patients were treated with clozapine and rerated blind to baseline symptomatology and functional level from 2 to 9 months after beginning treatment (mean = 4.2 +/- 2.1). The overall symptomatology of these patients as rated on the Brief Psychiatric Rating Scale (BPRS) decreased significantly from a mean of 57.0 +/- 10.4 to a mean of 37.8 +/- 7.7 (t = 7.03, df = 14, P = .001). Their positive, negative, and general symptoms as rated by the BPRS also decreased significantly. Additionally, their Global Assessment Scale (GAS) score increased significantly from a mean of 30.8 +/- 4.7 to a mean of 43.1 +/- 8.6 (t = 5.19, df = 14, P = .001). These results suggest that clozapine may be an effective antipsychotic agent for this subset of BPD patients. However, double-blind, placebo-controlled studies are necessary to confirm these preliminary results.

Drug treatment of the personality disorders

Many people with well defined borderline and schizotypal personality disorders may benefit considerably from small doses of neuroleptics. Depression that occurs with personality disorders, which is frequent, responds poorly to tricyclics but may respond better to neuroleptics, while the response to ECT is usually short lived. Selected borderline subjects may respond to MAOIs, particularly where there is a history of childhood hyperactivity. Carbamazepine and lithium may help some individuals with episodic behavioural dyscontrol and aggression, even in the absence of epileptic, affective or organic features. Drug treatments can be combined with psychotherapy, but further placebo-controlled trials are needed to clarify which drugs are most useful, and whether there are any useful clinical predictors of drug responsiveness.

Intravenous haloperidol treatment of severely regressed, nonviolent psychiatric inpatients

The use of intravenous haloperidol in five severely regressed, nonviolent, psychiatric inpatients with psychotic disorders is described. Unlike previous reports in the consultation psychiatry literature, this treatment was not instituted to control combative behavior in the medically ill. All patients had intravenous access in place for hydration. Four of five patients were discharged in complete remission of psychotic symptoms after brief hospitalizations. The indications for use, dosages, and general absence of side effects are described. Intravenous haloperidol is a viable option for treating severely ill psychiatric inpatients with psychotic disorders.

Medication consultation and split treatment during psychotherapy

In split treatment a patient simultaneously sees both a psychotherapist and a pharmacotherapist. Research indicates that medication and psychotherapy have additive value when used together in the treatment of depression and probably in other disorders as well. However, little is known about the presumably common technique of separate therapists administering these treatments. Complex interpersonal issues arise, reflecting both ideological and transferential attitudes toward medication as well as the intricacies of triangular relationships. Establishing a three-way therapeutic alliance, awareness of competitive countertransference feelings, and recognition of covert issues other than medication in the request for consultation are examples of areas where special attention can help the treatment succeed.

Transference and the vicissitudes of medication use by borderline patients

This paper discusses the psychodynamics of medication use by borderline patients who are involved in ongoing psychotherapy. Particular attention must be paid to the transference reactions that these patients have to the therapist and to the medication, and to countertransference responses as well. Shifts in the transference must be monitored, as rapidly fluctuating views of self and other may hamper borderline patients' abilities to use medication responsibly at certain points in treatment. Case examples are used to illustrate the complexities of the prescribing process in such situations. The implications for prescribing strategies are considered.

Pharmacotherapy of the borderline patient: a critical review and clinical guidelines

The literature on the pharmacotherapy of Borderline Personality Disorder (BPD) is critically reviewed, and suggestions for the appropriate clinical use of psychotropic agents and directions for future research are made.

Borderline personality disorder. When medical care is complicated by mental illness

Management of patients with borderline personality disorder on a medical ward requires the cooperation of all caregivers involved. First, it is necessary to recognize the disorder in patients who exhibit maladaptive behavior. Next, a comprehensive plan of behavioral management should be implemented that includes (1) clear communication among staff members, (2) education of staff members, (3) a consistent approach to the patient, (4) firm limits on the patient's behavior, and (5) an empathic rather than confrontational response to the patient's demands. Use of psychoactive medications may be a valuable adjunct to these approaches. A consulting psychiatrist can confirm the diagnosis and help to develop and implement the management plan.

Pharmacotherapy of borderline outpatients

The charts of 50 outpatients meeting both Diagnostic Interview for Borderlines (DIB) and DSM-III criteria for Borderline Personality Disorder (BPD), 29 outpatients meeting DSM-III criteria for Antisocial Personality Disorder (APD), and 26 outpatients meeting DSM-III criteria for Dysthymic Disorder, as well as DSM-III criteria for some other type of Axis II disorder (dysthymic other personality disorder [OPD]) were reviewed blind to proband diagnosis to determine both the percentage of those in each group who had adequate medication trials and the efficacy of those trials. Borderlines were significantly more likely than antisocial controls to have received an adequate trial of some form of medication. They were also significantly more likely than antisocial controls to have received an adequate trial of anxiolytics and antidepressants. However, they were distinguished at the trend level or better from both antisocial and dysthymic OPD controls by their greater likelihood of having received an adequate trial of neuroleptics, lithium, and polypharmacy. The percentage of adequately treated borderlines who experienced some degree of symptom relief was not significantly different than that found in either control group. However, adequately treated borderlines were significantly less likely than adequately treated dysthymic OPD controls to have had a definite response to pharmacotherapy (i.e., shown marked improvement of target symptoms).

Psychopharmacologic management of patients with borderline personality disorder

This paper reviews recent literature on the psychopharmacologic management of borderline personality disorder (BPD) patients and discusses an approach to drug therapy. Five randomized controlled trials have shown positive, but non-specific effects of antipsychotic drugs on the symptoms suffered by BPD patients. There were too few data on other types of drugs to draw any conclusion. We propose that BPD patients be treated on the basis of being in a state or episode of co-existing Axis I disorder.

Lack of effect of dopamine receptor blockade on the TSH response to TRH in borderline personality disorder

We recently reported that some patients with borderline personality disorder (BPD) exhibit a blunted thyrotropin (thyroid-stimulating hormone; TSH) response to thyrotropin-releasing hormone (TRH). Because it is known that dopamine can inhibit the TSH response to TRH and that some patients with BPD show improvement with antipsychotic (dopamine-blocking) medication, we investigated whether haloperidol could reverse the blunted TSH response in BPD. Of 12 patients with BPD, three showed a blunted TSH response that did not normalize with haloperidol. Furthermore, there were no overall group changes in TSH response with haloperidol. The present study suggests that reductions in TSH response in BPD are not secondary to dopamine.