Clozapine treatment of a borderline personality disorder with severe self-mutilating behaviours

A systematic review of the role of clozapine for severe borderline personality disorder

RATIONALE

Clozapine is a unique medication with a potential role in the treatment of severe borderline personality disorder (BPD).

OBJECTIVES

The review examines the effectiveness of clozapine as a medication for management for severe BPD with high risk of suicide, violence or imprisonment, and aims to help guide clinical practice in managing severe BPD.

METHODS

A database search of the terms "Clozapine" AND "BPD"; "Antipsychotics" AND "BPD"; "Clozapine" AND "Borderline Personality Disorder"; and "Antipsychotics" AND "Borderline Personality Disorder" were performed in CINAHL, Cochrane Library, Embase, Medline, PsychINFO, PubMed, and Web of Science. Full-text articles of clinical clozapine use for BPD were included for review.

RESULTS

A total of 24 articles consisting of 1 randomised control trial, 10 non-controlled trials, and 13 case reports were identified. Most of the studies reported benefits from clozapine when used for severe BPD. Many of the studies focused on clozapine use in BPD patients at high risk of suicide. Results from these non-controlled and case reports support the use of clozapine in patients with severe BPD at high risk of suicide.

CONCLUSION

There may be a role for clozapine in treating severe treatment refractory BPD, especially for those patients at high risk of suicide and frequent hospitalisations.

Genital Mutilation in Males

PURPOSE OF THE REVIEW

Genital mutilation in males can range from minor injuries (cuts from a blade) to severe urological emergencies (testicular or penile amputation). Due to the rarity of these events, there is a lack of extensive reports, as most of the available literature is regarding single cases. Genital mutilation has been associated with psychotic and non-psychotic causes, psychiatric conditions, drug consumption, sexual practices, or even cultural or religious beliefs. It is crucial to perform a psychiatric evaluation of these patients to obtain the best therapeutic approach. This manuscript serves as a review of the currently available knowledge regarding male genital mutilation.

RECENT FINDINGS

A great variety of reasons have been associated with genital mutilation. Previous authors have distinguished between those that present with a clear mental health precursor from cases with no psychotic background. Nevertheless, sometimes, it is difficult to make this distinction. Recently, reconstructive techniques for amputation cases have moved towards a microsurgical approach in order to improve outcomes. A holistic therapeutic approach must be performed to increase the chances of effective treatment. Close collaboration between urologists, psychiatrists, and emergency doctors is essential to ensure the best care for patients performing genital mutilation. Future publications must evaluate differences in treatment options and the impact that these have on the long-term well-being of patients undergoing genital self-mutilation.

Prevention of suicide by clozapine in mental disorders: systematic review

BACKGROUND

Previous research has investigated the efficacy of clozapine in reducing suicidality in patients with schizophrenia and schizoaffective disorder. We aimed to systematically review published evidence, including studies concerning clozapine administration to treat: (a) refractory suicidality in other mental disorders, including bipolar disorder and borderline and other personality disorders; and (b) refractory cases of non-suicidal self-injury.

METHOD

We performed a PUBMED-search (last day: July 17, 2022) of English-language studies, combining the keywords "clozapine", "suicidality", and "suicide" with various psychopathological terms (e.g. "schizophrenia"). All duplications were eliminated.

RESULTS

Fifty-one studies were eligible for inclusion in the review. Most studies suggest a superior anti-suicide effect of clozapine in schizophrenia/schizoaffective disorder, compared to other antipsychotics, or no antipsychotic therapy, which is not due to the close monitoring of patients for blood dyscrasias. No consensus exists as to whether other antipsychotic drugs share this effect. Discontinuation of clozapine is associated with increases in suicidality. Reductions in refractory suicidality/NSSI are observed in clozapine-treated patients with bipolar disorder or borderline personality disorder, but the evidence is limited. Potential biological underpinnings of the anti-suicide effect of clozapine include its unique profile of modulation of brain neurotransmitters; its non-selectivity for neurotransmitter receptors; specific genetic and hormonal factors; effects on neuroinflammation; and ability to elicit epileptiform activity.

CONCLUSION

The superior anti-suicide effect of clozapine in schizophrenia/schizoaffective disorder patients is well established. It may have a role in severe and refractory cases of suicidality and non-suicidal self-injury in patients with bipolar disorder or borderline personality disorder, but the level and quality of supporting evidence is limited.

Repeated self-injury: perspectives from general psychiatry

Patients who repeatedly injure themselves present particular management problems for general psychiatric teams. This article, the first of a series of four, examines the characteristics of those that present to adult mental health services, and the possible underlying background and trigger factors that lead to these anxiety-raising events. Suggestions are made on preventive and assessment procedures, staff reactions and management strategies aimed at helping patients deal with the overwhelming feelings that underlie self-injury.

Male genital self-mutilation: a systematic review of psychiatric disorders and psychosocial factors

OBJECTIVE

To identify psychiatric diagnoses and psychosocial factors associated with intentional male genital self-mutilation (GSM) of specific injury subtypes.

METHODS

A search of MEDLINE, EMBASE, PsycINFO, PubMed, Web of Science and CINAHL for cases of GSM was conducted until December 2015, based on GSM and related terms. Cases were examined for injury subtype, psychiatric diagnosis and psychosocial factors. Chi-square analyses were employed to determine differences in frequency of such factors across injury subtypes.

RESULTS

Data were obtained from 173 cases: genital mutilation (n=21), penile amputation (n=62), castration (n=56) and combined amputation/castration (n=34). Common psychiatric disorders included schizophrenia spectrum (49%), substance use (18.5%), personality (15.9%) and gender dysphoric disorders (15.3%). Chi-square analyses revealed that schizophrenia spectrum disorders occurred significantly more often among auto-amputates as compared with self-castrators or mutilators. Gender dysphoria occurred significantly more often among self-castrators than auto-amputates. No significant differences emerged regarding psychosocial factors across GSM subtypes. However, associations were observed between psychosocial factors and psychiatric diagnoses. Although altogether not commonly reported, experiential factors were reported in 82% of psychotic individuals. Treatment inaccessibility was noted among 71% of gender dysphorics engaging in auto-castration.

CONCLUSION

Clinicians must consider the diverse range of psychiatric disorders and psychosocial factors underlying GSM.

Use of Clozapine for Borderline Personality Disorder: A Case Report

Patients with borderline personality disorder (BPD) show significant impairment in functioning, particularly in the interpersonal and social domains. Prior reports suggest that clozapine may be effective in the management of BPD. We present the case of a patient with BPD who experienced persistent suicidal ideation and was treated with clozapine at a state psychiatric hospital. After treatment failure with other psychotropic medications, clozapine medication was initiated; not only did suicidal ideation cease, but social and professional functioning also greatly improved to the point of no longer requiring intensive levels of observation or restrictive procedures. Clozapine appears to be efficacious in the management of suicide attempts and self-injurious behavior. Moreover, it appears to be promising as a therapeutic measure for ameliorating the global functioning of patients with severe BPD. Larger, randomized, blinded, and controlled prospective studies are needed to confirm these findings and to determine optimal dosage.

Second-generation antipsychotic use in borderline personality disorder: What are we targeting?

Introduction:

Borderline personality disorder (BPD) is a personality disorder plagued with high rates of psychotropic polypharmacy. Estimates show that second-generation antipsychotics (SGAs) are used in most of these patients; however, they are being prescribed off label.

Methods:

A literature review was conducted via PubMed in search for studies evaluating SGA use in BPD.

Results:

There are available data investigating 8 of 11 SGAs and their use in BPD. Of N = 269 potential articles, N = 34 evaluating the use of SGAs in BPD were included.

Discussion:

Strong evidence supporting SGAs in BPD is lacking. Potential target symptoms in which a SGA may be useful include depression, anxiety, anger, impulsivity, and paranoia/dissociative behavior.

Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: A comparison with other psychiatric disorders

Patients with borderline personality disorder (BPD) are usually prescribed a variety of psychotropic drugs; however, none is recommended in the guidelines nor has any been approved for this indication. As data on drug prescriptions for BPD are sparse, cross-sectional data from the European Drug Safety Project AMSP were used to analyse drug prescriptions of 2195 in-patients with BPD between 2001 and 2011, and the mean values, confidence intervals and regression analyses were calculated. 70% of all BPD patients were medicated with antipsychotics and/or antidepressants, 33% with anticonvulsants, 30% with benzodiazepines, and 4% with lithium; 90% received at least one, 80%≥2, and 54%≥3 psychotropic drugs concomitantly (mean: 2.8). Prescription rates for quetiapine, the single drug most often used in BPD (22%), increased significantly over time. In view of the high percentage of young females with BPD, 18-40 year-old female patients with BPD were compared with patients of the same age but with depression (unipolar and bipolar) and schizophrenia. Typical sedative antipsychotics and anticonvulsants were prescribed more often in BPD than in the other diagnostic groups, with the exception of bipolar depression; this was true for the single substances quetiapine, levomepromazine, chlorprothixene, carbamazepine, and valproate. A limitation of the study was the use of clinical data without verifying the diagnoses by structured interviews. Contrary to the guidelines, about 90% of in-patients with BPD received psychotropic drugs. Polypharmacy was common, and antipsychotics with sedative profiles such as quetiapine and mood-stabilizing anticonvulsants such as valproate appear to be preferred.

Pharmacotherapy for borderline personality disorder--current evidence and recent trends

Drug treatment of patients with borderline personality disorder (BPD) is common but mostly not supported by evidence from high-quality research. This review summarises the current evidence up to August 2014 and also aims to identify research trends in terms of ongoing randomised controlled trials (RCTs) as well as research gaps. There is some evidence for beneficial effects by second-generation antipsychotics, mood stabilisers and omega-3 fatty acids, while the overall evidence base is still unsatisfying. The dominating role SSRI antidepressants usually play within the medical treatment of BPD patients is neither reflected nor supported by corresponding evidence. Any drug treatment of BPD patients should be planned and regularly evaluated against this background of evidence. Research trends indicate increasing attention to alternative treatments such as dietary supplementation by omega-3 fatty acids or oxytocin.

The novel use of clozapine in an adolescent with borderline personality disorder

BACKGROUND

Clozapine has been used to good effect in the treatment of adults with borderline personality disorder, but there is scant evidence of it being used in an adolescent population with these difficulties.

METHODS

Clozapine was trialled in an adolescent with a clinical presentation consistent with an emerging borderline personality disorder.

RESULTS

There was a large reduction in the number of incidents involving abuse to staff, or harm to self, in the 8 weeks after commencing clozapine therapy, compared with the 8 weeks prior, and also a large reduction in the number of episodes of the use of seclusion in the 13 weeks after commencing clozapine therapy, compared with the 13 weeks prior. The young person was also able to be reintegrated in to the ward environment once established on clozapine therapy, which had not been possible full-time, for a whole year prior.

CONCLUSIONS

Although limited by involving just one adolescent, this very preliminary data does nonetheless suggest that clozapine may have a role in treating adolescents with emerging borderline personality disorder when other treatment options have been exhausted.

Clozapine for self-injurious behavior in individuals with borderline personality disorder

Prior reports suggest that clozapine can markedly reduce aggression and self-injurious behavior in patients with borderline personality disorder (BPD). We present a series of four patients with BPD and persistent self-injurious behavior treated with clozapine at a state psychiatric hospital. After treatment with clozapine these patients ceased self-injurious behaviors and aggression, and no longer required intensive levels of observation or restrictive procedures. All were successfully discharged from the hospital soon after initiation of clozapine. Clozapine appears to be efficacious in the management of chronic suicidality, self-injurious behaviors and aggression in patients with severe BPD.

Efficacy and tolerability of aripiprazole augmentation in sertraline-resistant patients with borderline personality disorder

Information is available on aripiprazole as a treatment for borderline personality disorder (BPD), but no data have yet been presented concerning the use of this drug as an adjunctive treatment for drug-resistant BPD patients. This study investigates aripiprazole augmentation of ongoing sertraline therapy in drug-resistant BPD patients. Twenty-one outpatients with a DSM-IV-TR diagnosis of BPD who did not respond to sertraline, 100-200 mg/day for 12 weeks, were treated for 12 weeks with the addition of aripiprazole, 10-15 mg/day. Patients were assessed at baseline, week 4, and week 12 with the Clinical Global Impression Scale - Severity item (CGI-S), the Brief Psychiatric Rating Scale (BPRS), the Hamilton scales for depression and anxiety (HAM-D, HAM-A), the Social Occupational Functioning Assessment Scale (SOFAS) for social functioning, the Borderline Personality Disorder Severity Index (BPDSI), and the Barratt Impulsiveness Scale (BIS-11). Adverse effects were evaluated using the Dosage Record and Treatment Emergent Symptom Scale (DOTES). Sixteen patients completed the study. Five patients (23.8%) dropped out due to anxiety/insomnia or non-compliance. Nine patients (56.3%) were responders. Analysis of variance revealed significant changes in the following measures: CGI-S, BPRS, BPDSI total score, BPDSI "impulsivity" and "dissociation/paranoid ideation" items, and BIS-11. Adverse effects were mild headache, insomnia, and anxiety. Aripiprazole is an efficacious and well-tolerated add-on treatment for sertraline-resistant BPD patients. It acts on impulsive and psychotic-like symptoms.

Medications in the treatment of borderline personality disorder 2006

This review covers all significant randomized controlled trials and open trials of medications for the treatment of borderline personality disorder. New developments in the effectiveness of mood stabilizers and antipsychotics are discussed. Differences were found in the effectiveness of medications based on the presence or absence of depression and significant anger symptoms. Medications continue to be recommended as adjuncts to psychotherapy. Most of the trials discussed require replication, and more trials that investigate the effectiveness of medications in combination with psychotherapy are recommended.

Suicide and deliberate self-harm in personality disorders

PURPOSE OF REVIEW

This article reviews literature published over the period January 2004-May 2005 on suicidal behaviour and self-harm in personality disorders.

RECENT FINDINGS

Studies have confirmed that personality disorders and their co-morbidity with other psychiatric conditions are risk factors for both fatal and nonfatal suicidal behaviours, and self-mutilation. Negative life events, childhood sexual abuse, difficulties in social functioning, deficits in future-directed thinking and time perception, as well as familial and neurocognitive factors may be related to increased suicide risk in individuals with borderline and other personality disorders. Findings seem to confirm that suicidality and self-injurious behaviour are efficient DSM-IV diagnostic criteria for borderline personality disorder. Out of several psychosocial and pharmacological interventions for treating suicidality in personality disorders, only one randomized, controlled study has recently been published. Medico-legal concerns related to the clinical management of chronically suicidal patients, including hospitalization and alternative treatment approaches, are also discussed.

SUMMARY

Although recent studies have contributed to the theoretical knowledge and clinical practice, there are unsettled questions that should be addressed in the future. More randomized, controlled trials evaluating the efficacy of interventions in suicidal individuals with personality disorders should be conducted. As the majority of studies conducted to date have concentrated on borderline personality disorder and antisocial personality disorder, the prevalence and risk factors for suicidal behaviours and self-mutilation in other personality disorders require further clarification. The introduction of unified nomenclature related to suicidal behaviours and self-mutilation would facilitate comparability of results across studies.