Topiramate treatment for women with borderline personality disorder: a double-blind, placebo-controlled study

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

Personality Disorders in Older Age

Personality disorders are among the most common mental disorders in older age and are associated with a range of negative outcomes in physical and emotional health as well as in interpersonal functioning. Several screening tools have been validated with older patients and can aid in diagnosis. The presence of a personality disorder is associated with increased risk of cognitive decline, and cognitive disorders may mimic personality disorders. As a result, an evaluation of cognitive function is an essential part of assessing for a personality disorder. Emerging evidence points to the promise of dialectical behavioral therapy and schema therapy for older patients with personality disorders. Second-generation antipsychotics and mood stabilizers have been found to be effective for some personality disorders in the general adult population, but no such studies have been conducted with older adults.

Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Borderline personality disorder (BPD) is a debilitating psychiatric disorder that affects 0.4-3.9% of the population in Western countries. Currently, no medications have been approved by regulatory agencies for the treatment of BPD. Nevertheless, up to 96% of patients with BPD receive at least one psychotropic medication.

OBJECTIVES

The objective of this systematic review was to assess the general efficacy and the comparative effectiveness of different pharmacological treatments for BPD patients.

METHODS

We conducted systematic literature searches limited to English language in MEDLINE, EMBASE, the Cochrane Library, and PsycINFO up to April 6, 2021, and searched reference lists of pertinent articles and reviews. Inclusion criteria were (i) patients 13 years or older with a diagnosis of BPD, (ii) treatment with anticonvulsive medications, antidepressants, antipsychotic medications, benzodiazepines, melatonin, opioid agonists or antagonists, or sedative or hypnotic medications for at least 8 weeks, (iii) comparison with placebo or an eligible medication, (iv) assessment of health-relevant outcomes, (v) randomized or non-randomized trials or controlled observational studies. Two investigators independently screened abstracts and full-text articles and graded the certainty of evidence based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. For meta-analyses, we used restricted maximum likelihood random effects models to estimate pooled effects.

RESULTS

Of 12,062 unique records, we included 21 randomized controlled trials (RCTs) with data on 1768 participants. Nineteen RCTs compared pharmacotherapies with placebo; two RCTs assessed active treatments head-to-head. Out of 87 medications in use in clinical practice, we found studies on just nine. Overall, the evidence indicates that the efficacy of pharmacotherapies for the treatment of BPD is limited. Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD. Low-certainty evidence indicates that anticonvulsants can improve specific symptoms associated with BPD such as anger, aggression, and affective lability but the evidence is mostly limited to single studies. Second-generation antipsychotics had little effect on the severity of specific BPD symptoms, but they improved general psychiatric symptoms in patients with BPD.

CONCLUSIONS

Despite the common use of pharmacotherapies for patients with BPD, the available evidence does not support the efficacy of pharmacotherapies alone to reduce the severity of BPD.

REGISTRATION

PROSPERO registration number, CRD42020194098.

Randomized Controlled Trial of Web-Based Psychoeducation for Women With Borderline Personality Disorder

OBJECTIVE

To determine if internet-based psychoeducation for borderline personality disorder is effective in reducing symptom severity and improving psychosocial functioning.

METHODS

Eighty women who met DSM-IV criteria for borderline personality disorder were randomly assigned either to the internet-based psychoeducation treatment group (n = 40) or to the internet-based control group with no psychoeducation (n = 40). Recruitment was conducted from July 2013 to March 2015. Subjects participated in 15 assessment periods that were divided into an acute phase (weeks 1-12) and a maintenance phase (months 6, 9, and 12). Main outcomes were assessed using the Zanarini Rating Scale for Borderline Personality Disorder.

RESULTS

In the acute phase, women in the treatment group were found to have a significant decline in their scores on all 10 outcomes studied, while women in the control group had a significant decline on 7 of these outcomes. Two between-group differences were found to be significant-those in the treatment group reported a significantly greater decline in their impulsivity (z = -1.98, P = .048) and a significantly greater increase in their psychosocial functioning (z = -1.97, P = .049) than those in the control group. In the maintenance phase, those in the treatment group were found to have a significant decline in their scores on 9 of the 10 outcomes studied, while those in the control group had a significant decline in 3 of these outcomes. In terms of between-group differences, those in the treatment group reported a significantly greater decline in all 5 studied areas of borderline psychopathology: affective symptoms (z = -2.31, P = .021), cognitive symptoms (z = -3.20, P = .001), impulsivity (z = -2.44, P = .015), interpersonal difficulties (z = -2.15, P = .032), and overall borderline personality disorder symptoms (z = -2.11, P = .035).

CONCLUSIONS

Taken together, these results suggest that internet-based psychoeducation is an effective form of early treatment for reducing the symptom severity of borderline personality disorder for periods up to 1 year.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01719731.

Pharmacotherapy of personality disorders: what we know and what we have to search for

Pharmacotherapy for personality disorders is in the early stage of development because the evidence base for effective drug treatment is insufficient, biased toward borderline personality disorder and rampant with methodological issues. In this paper, we reviewed randomized, placebo-controlled trials of drugs efficacy in patients with personality disorders published between 1990 and 2016. Overwhelming majority of studies focused on borderline personality disorder, and the accumulation of evidence resulted in seven meta-analyses, which are interpreted into better strategies for evidence-based practice. Little research attention was given to schizotypal and antisocial personality disorders, with only indirect treatment efficacy evidence for the obsessive–compulsive and avoidant personality disorders. Some avenues for future efficacy research are indicated.

Patients with Borderline Personality Disorder in Emergency Departments

Borderline personality disorder (BPD) patients, when in crisis, are frequent visitors of emergency departments (EDs). When these patients exhibit symptoms such as aggressiveness, impulsivity, intense anxiety, severe depression, self-harm, and suicidal attempts or gestures, diagnosis, and treatment of the BPD becomes challenging for ED doctors. This review will, therefore, outline advice to physicians and health-care providers who face this challenging patient population in the EDs. Crisis intervention should be the first objective of clinicians when dealing with BPD in the emergency. For the patients with agitation, symptom-specific pharmacotherapy is usually recommended, while for non-agitated patients, short but intensive psychotherapy especially dialectical behavior therapy (DBT) has a positive effect. Although various psychotherapies, either alone or integrated, are preferred modes of treatment for this group of patients, the effects of psychotherapies on BPD outcomes are small to medium. Proper risk management along with developing a positive attitude and empathy toward these patients will help them in normalizing in an emergency setting after which treatment course can be decided.

What Influences Treatment Satisfaction in Patients with Personality Disorders? A Naturalistic Investigation in a Hospitalization Setting

Treatment satisfaction of different mental disorders is still poorly understood, but of high clinical interest. Inpatients of a general psychiatric care hospital were asked to fill out questionnaires on satisfaction and clinical variables at admission and discharge. On the basis of an exploratory approach, differences in treatment satisfaction among diagnostic groups were examined by means of one-way analysis of variance. Potential associated clinical and socio-demographic variables were studied using multi/univariate tests. Patients with personality disorders (n=18) showed a significantly lower treatment satisfaction (ZUF-8, Zurich Satisfaction Questionnaire) and a slightly lower improvement of symptoms (CGI, Clinical Global Impression) and global functioning (GAF, Global Assessment of Functioning scale) than that of other diagnostic groups (n=95). Satisfaction in patients with personality disorders correlated much stronger with the symptom improvement and slightly with the functioning level than in patients without personality disorders. Interestingly, in patients with personality disorders psychopharmacological treatment in general (present versus not present) was independent from satisfaction. This exploratory investigation suggests that a lower satisfaction of patients with personality disorders in a general psychiatric hospital is mainly based on a reduced improvement of the symptoms and of the global functioning level.

Increased Prevalence of Intermittent Rhythmic Delta or Theta Activity (IRDA/IRTA) in the Electroencephalograms (EEGs) of Patients with Borderline Personality Disorder

INTRODUCTION

An increased prevalence of pathological electroencephalography (EEG) signals has been reported in patients with borderline personality disorder (BPD). In an elaborative case description of such a patient with intermittent rhythmic delta and theta activity (IRDA/IRTA), the BPD symptoms where linked to the frequency of the IRDAs/IRTAs and vanished with the IRDAs/IRTAs following anticonvulsive therapy. This observation raised a question regarding the prevalence of such EEG abnormalities in BPD patients. The aim of this retrospective study was to identify the frequency of EEG abnormalities in a carefully analyzed psychiatric collective. Following earlier reports, we hypothesized an increased prevalence of EEG abnormalities in BPD patients.

PARTICIPANTS AND METHODS

We recruited 96 consecutive patients with BPD from the archive of a university clinic for psychiatry and psychotherapy, and compared the prevalence of EEG abnormalities to those of 76 healthy controls subjects. The EEGs were rated by three different blinded clinicians, including a consultant specializing in epilepsy from the local epilepsy center.

RESULTS

We found a significant increase in the prevalence of IRDAs and IRTAs in BPD patients (14.6%) compared to the control subjects (3.9%; p = 0.020).

DISCUSSION

In this blinded retrospective case-control study, we were able to confirm an increased prevalence of pathological EEG findings (IRDAs/IRTAs only) in BPD patients. The major limitation of this study is that the control group was not matched on age and gender. Therefore, the results should be regarded as preliminary findings of an open uncontrolled, retrospective study. Future research performing prospective, controlled studies is needed to verify our findings and answer the question of whether such EEG findings might predict a positive response to anticonvulsive pharmacological treatment.

Complex Trauma in Adolescents and Adults: Effects and Treatment

Complex trauma involves multiple exposures to adverse events over the lifespan. Such experiences are associated with a variety of psychological outcomes, including a decreased threshold for the development of posttraumatic stress disorder as well as self-capacity problems and dysfunctional behaviors. Psychological interventions that increase affect regulation, support titrated processing of memories and cognitions, and emphasize the therapeutic relationship seem to be most helpful for complex trauma effects. Pharmacologic treatments have some efficacy in the treatment of the posttraumatic stress components of complex posttraumatic outcomes but are generally less successful in reducing self-related problems and symptoms.

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.

Effect of topiramate on hippocampus-dependent spatial memory in rats

BACKGROUND

Topiramate, a new generation antiepileptic agent with a complex mechanism of action, has a broad pharmacological profile which includes a neuroprotective effect. It has been proven to be efficacious in treating alcohol dependence through a previously confirmed association with memory processes.

METHODS

Topiramate was administered in single doses of 120 and 40 mg/kg and multiple doses of 60 mg/kg for 12 days. Its influence on the spatial memory of rats was evaluated using the Morris water maze test. The time needed to localize the platform, the distance travelled and time spent in the platform zone were recorded.

RESULTS

Single doses of topiramate induce deterioration of spatial memory, with high doses having more pronounced and longer lasting effects. Multiple administration of a medial dose does not significantly affect the learning process.

CONCLUSIONS

The influence of topiramate on the hippocampus-related memory processes may play a key role in its "anti-alcohol" effect.

Psychopharmacologic treatment of borderline personality disorder

The best available evidence for psychopharmacologic treatment of borderline personality disorder (BPD) is outlined here. BPD is defined by disturbances in identity and interpersonal functioning, and patients report potential medication treatment targets such as impulsivity, aggression, transient psychotic and dissociative symptoms, and refractory affective instability Few randomized controlled trials of psychopharmacological treatments for BPD have been published recently, although multiple reviews have converged on the effectiveness of specific anticonvulsants, atypical antipsychotic agents, and omega-3 fatty acid supplementation. Stronger evidence exists for medication providing significant improvements in impulsive aggression than in affective or other interpersonal symptoms. Future research strategies will focus on the potential role of neuropeptide agents and medications with greater specificity for 2A serotonin receptors, as well as optimizing concomitant implementation of evidence-based psychotherapy and psychopharmacology, in order to improve BPD patients' overall functioning.

Topiramate: Effects on cognition in patients with epilepsy, migraine headache and obesity

This paper reviews the clinical implications of topiramate (TPM)-induced cognitive deficits in patients with epilepsy, migraine headache, obesity, and in normal populations, followed by reviews of the literature describing the reversal of such deficits upon medication discontinuation. It also discusses animal investigations of TPM's role of neuroprotection in brain injury. TPM's most intolerable adverse effects (AEs) are on verbal fluency and reaction time, resulting in high discontinuation rates in patients taking it for epilepsy and migraine headache. However, because TPM is so effective in the treatment of epilepsy and migraine headache, its use is expected to continue. There appears to be greater tolerance of TPM's cognitive AEs when it is used in the treatment of obesity, perhaps because of the lower doses required. Research attempting to predict the populations most vulnerable to the cognitive effects caused by TPM is ongoing. Studies suggest that one such population may include patients with a past psychiatric history. Slow titration and administration of the lowest possible doses may decrease risk of cognitive deficits.

Borderline personality disorder: current drug treatments and future prospects

Individuals with borderline personality disorder (BPD) suffer from marked affective disturbance, an unstable sense of self, difficulty in interpersonal relationships and heightened impulsivity, leading to high rates of self-harm and suicide. Patients are often refractory to treatment and are at high risk for acute or dangerous presentations, with a serious impact on mental health services. There has been much debate on the effectiveness of pharmacotherapy in treating different facets of the psychopathology of the disorder. Several guidelines recommend the use of antidepressant agents, mood stabilizers for affective dysregulation and impulsive-behavioural dyscontrol, and antipsychotics for cognitive-perceptual symptoms. However, concerns have recently been raised regarding the strength of evidence for these treatment recommendations in BPD. Here, we review the evidence for efficacy of the main psychotropic medications used in BPD, drawing, in particular, on evidence from randomized controlled trials and meta-analyses. Overall, meta-analysis provides little evidence to support the use of antidepressant medication in BPD outside episodes of major depression. However, there is evidence for the use of both mood stabilizers and antipsychotic medications for the treatment of specific aspects of the disorder. Most existing studies have been conducted on small numbers of patients, and there is a requirement for further large-scale trials to substantiate these findings. In addition, given the limitations of current pharmacological treatment of BPD, there is a pressing need to investigate potential new therapeutic targets, including neuropeptides, such as the opioids and vasopressin, and drugs targeted at ameliorating the biological effects of early life stress.

Psychopharmacologic management of aggression

This article is designed to provide an overview of the existing literature on pharmacologically managing aggression, with a specific focus on psychiatric diagnoses commonly associated with increased aggression. Self-injurious behaviors and suicide are sometimes classified as forms of aggression, but information presented here focuses primarily on aggression toward others (physical and/or verbal).

The psychopharmacology of aggressive behavior: a translational approach: part 2: clinical studies using atypical antipsychotics, anticonvulsants, and lithium

Patients experiencing mental disorders are at an elevated risk for developing aggressive behavior. In the past 10 years, the psychopharmacological treatment of aggression has changed dramatically owing to the introduction of atypical antipsychotics on the market and the increased use of anticonvulsants and lithium in the treatment of aggressive patients.This review (second of 2 parts) uses a translational medicine approach to examine the neurobiology of aggression, discussing the major neurotransmitter systems implicated in its pathogenesis (serotonin, glutamate, norepinephrine, dopamine, and γ-aminobutyric acid) and the neuropharmacological rationale for using atypical antipsychotics, anticonvulsants, and lithium in the therapeutics of aggressive behavior. A critical review of all clinical trials using atypical antipsychotics (aripiprazole, clozapine, loxapine, olanzapine, quetiapine, risperidone, ziprasidone, and amisulpride), anticonvulsants (topiramate, valproate, lamotrigine, and gabapentin), and lithium are presented. Given the complex, multifaceted nature of aggression, a multifunctional combined therapy, targeting different receptors, seems to be the best strategy for treating aggressive behavior. This therapeutic strategy is supported by translational studies and a few human studies, even if additional randomized, double-blind, clinical trials are needed to confirm the clinical efficacy of this framework.

Clinical psychopharmacology of borderline personality disorder: an update on the available evidence in light of the Diagnostic and Statistical Manual of Mental Disorders - 5

PURPOSE OF REVIEW

Clinical considerations for evidence-based treatment of borderline personality disorder (BPD) are outlined in the context of the best available evidence, discussed with reference to BPD traits currently identified in the upcoming Diagnostic and Statistical Manual of Mental Disorders - 5 (DSM-5) revision. The DSM-5 will highlight refractory affective, interpersonal, and identity symptoms in BPD as potential treatment targets. In addition to providing a framework for clinical decision-making, future research strategies will also focus on neurotransmitter systems of greater relevance to understanding overall personality functioning.

RECENT FINDINGS

Although only a few randomized controlled trials of psychopharmacological treatments for BPD have been published recently, several meta-analyses and systematic reviews converge on the consensus effectiveness of lamotrigine, topiramate, valproate, aripiprazole, olanzapine, and omega-3 fatty acid supplementation. Stronger evidence exists for treating disinhibition and antagonism than negative affectivity, particularly interpersonal facets of such traits. In addition, basic research suggests a future role for modifying glutamatergic, opioid, and oxytocinergic neurotransmitter systems to treat BPD.

SUMMARY

Clinicians should utilize omega-3, anticonvulsants, and atypical antipsychotic agents in treating specific DSM-5 BPD traits, notably disinhibition, antagonism, and some aspects of negative affectivity. Future research will focus on normalizing opioid and oxytocin dysregulation, as an adjunct to evidence-based psychotherapy, in an effort to improve interpersonal functioning.

Antipsychotics, antidepressants, anticonvulsants, and placebo on the symptom dimensions of borderline personality disorder: a meta-analysis of randomized controlled and open-label trials

The aim of this study was to quantitatively review randomized controlled trials (RCTs) and open-label trials analyzing the efficacy of antidepressants, mood stabilizers, and antipsychotics for the treatment of the core symptoms of borderline personality disorder (BPD). Using a similar meta-analytic approach, the efficacy of placebo on the same core symptoms of BPD was evaluated. The risk of discontinuation of each of the medication classes reported in the studies was also analyzed to establish the major causes of discontinuation. MEDLINE (1966 to June 2010) and EMBASE (1980 to June 2010) databases were systematically searched to identify relevant RCTs and open studies. The primary outcome was improvement in the specific core symptoms of the disorder: affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual symptoms. Evidence from RCTs and open studies suggests that drug treatment, especially with mood stabilizers and antipsychotics, may be effective for treating affective dysregulation and impulsive-behavioral dyscontrol. Antipsychotics were also effective in reducing cognitive-perceptual symptoms. Antidepressants failed to show efficacy in treating BPD symptom dimensions other than affective dysregulation. Our analyses of the placebo arm of RCTs showed a significant improvement of symptomatology in these patients also. There were no significant differences in overall dropout rates between patients on medications and those on placebo. In conclusion, the efficacy of pharmacological treatment on the symptom dimensions of BPD has been shown by various independent meta-analyses, with a positive effect of drug treatment on the core symptoms of BPD and some documentable differences in terms of efficacy between different drug classes in each of the symptom domains.

Evidence-based pharmacotherapy for personality disorders

Patients with personality disorders are prescribed psychotropic medications with greater frequency than almost any other diagnostic group. Prescribing practices in these populations are often based on anecdotal evidence rather than rigorous data. Although evidence-based psychotherapy remains an integral part of treatment, Axis II psychopathology is increasingly conceptualized according to neurobiological substrates that correspond to specific psychopharmacological strategies. We summarize the best available evidence regarding medication treatment of personality disordered patients and provide optimal strategies for evidence-based practice. Most available evidence is concentrated around borderline and schizotypal personality disorders, with some additional evidence concerning the treatment of avoidant and antisocial personality disorders. Although maladaptive personality symptoms respond to antidepressants, antipsychotics, mood stabilizers, and other medications, evidence-based pharmacotherapy is most useful in treating circumscribed symptom domains and induces only partial improvement. Most available evidence supports use of medication in reducing impulsivity and aggression, characteristic of borderline and antisocial psychopathology. Efforts have also begun to reduce psychotic-like symptoms and improve cognitive deficits characteristic of schizotypy. Indirect evidence is also provided for psychopharmacological reduction of social anxiety central to avoidant personality disorder. Evidence-based practice requires attention to domains of expected clinical improvement associated with a medication, relative to the potential risks. The development of future rational pharmacotherapy will require increased understanding of the neurobiological underpinnings of personality disorders and their component dimensions. Increasing efforts to translate personality theory and social cognitive neuroscience into increasingly specific neurobiological substrates may provide more effective targets for pharmacotherapy.

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

State of the art in the pharmacologic treatment of borderline personality disorder

This article reviews the most recent studies of the pharmacologic treatment of borderline personality disorder (BPD). Although research continues using randomized controlled trials with a placebo arm as well as active medication, meta-analyses and systematic reviews have revealed that the use of any specific medication or medication class in BPD remains at best uncertain and inconclusive. Studies indicate that the selective serotonin reuptake inhibitors have fallen out of favor, and researchers have turned their attention to the study of mood stabilizers and atypical antipsychotics. Thus, it is not surprising that trends in prescribing appear to be shifting toward the use of these two classes over the selective serotonin reuptake inhibitors; yet we remain without any medication that has a specific indication for treatment of BPD or an indication for any symptom that is seen as part of the BPD syndrome.

A naturalistic study of changes in pharmacological prescription for borderline personality disorder in clinical practice: from APA to NICE guidelines

Although no psychotropic agents are specifically licensed for the management of borderline personality disorder (BPD), pharmacological treatment appears to be common. This study aimed to examine the drug prescriptions for patients with BPD in clinical practice, analyze the prescription patterns from the appearance of the American Psychiatric Association guidelines in 2001 until the National Institute for Health and Clinical Excellence guidelines in 2009, and identify the factors associated with such prescription of each type of drug. Naturalistic study on 226 consecutive BPD patients admitted to an outpatient BPD program. Socio-demographic, clinical and pharmacological treatment information was collected; factors associated with drug prescription were examined using logistic regression analyses for dichotomous outcomes measures. Changes in prescription patterns over time were also evaluated. Patients received an average of 2.7 drugs; only 6% were drug-free; 56% were taking ≥3 drugs and 30% ≥4 drugs. Over the past 8 years, prescription of antidepressants has remained stable; there has been a significant reduction in prescription of benzodiazepines and an increase in the use of mood stabilizers and atypical antipsychotics. Comorbidity with Axis I disorders was the main factor associated with drug prescription. Drug prescription and polypharmacy are common in the management of BPD in clinical practice.

Nervous system adverse responses to topiramate in the treatment of neuropsychiatric disorders

IMPORTANCE OF THE FIELD

Nervous system adverse drug reactions (NS-ADRs), such as cognitive complaints and paresthesia, are among the most frequent and clinically important ADRs of topiramate. Studying ADR profiles across disorders is clinically relevant because treatment decision-making in neuropsychiatry is highly guided by ADR profiles.

AREAS COVERED IN THIS REVIEW

We used medline searches (until July 2009) to review the NS-ADRs of topiramate across the most investigated topiramate indications: alcohol dependence, essential tremor, binge-eating disorder, bulimia nervosa, migraine and epilepsy. We compared NS-ADRs between these disorders but did not carry out meta-analysis.

WHAT THE READER WILL GAIN

ADR profiles greatly differed between disorders. Drop-outs due to ADRs highly varied between disorders: from 2% in the bulimia nervosa group to 29% in the migraine group. Paresthesia was the most common NS-ADR for all disorders but frequencies also differed between disorders. Cognitive complaints were frequent and were reported in comparable proportions.

TAKE HOME MESSAGE

When prescribing topiramate in neuropsychiatry, physicians should be aware that NS-ADR profiles have been found to differ between disorders. Differences in drop-out rates due to ADRs and in frequencies of specific NS-ADRs across disorders must be taken into account when evaluating the potential harm of topiramate in clinical practice.

Pharmacological interventions for borderline personality disorder

BACKGROUND

Drugs are widely used in borderline personality disorder (BPD) treatment, chosen because of properties known from other psychiatric disorders ("off-label use"), mostly targeting affective or impulsive symptom clusters.

OBJECTIVES

To assess the effects of drug treatment in BPD patients.

SEARCH STRATEGY

We searched bibliographic databases according to the Cochrane Developmental, Psychosocial and Learning Problems Group strategy up to September 2009, reference lists of articles, and contacted researchers in the field.

SELECTION CRITERIA

Randomised studies comparing drug versus placebo, or drug versus drug(s) in BPD patients. Outcomes included total BPD severity, distinct BPD symptom facets according to DSM-IV criteria, associated psychopathology not specific to BPD, attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

Two authors selected trials, assessed quality and extracted data, independently.

MAIN RESULTS

Twenty-eight trials involving a total of 1742 trial participants were included. First-generation antipsychotics (flupenthixol decanoate, haloperidol, thiothixene); second-generation antipsychotics (aripirazole, olanzapine, ziprasidone), mood stabilisers (carbamazepine, valproate semisodium, lamotrigine, topiramate), antidepressants (amitriptyline, fluoxetine, fluvoxamine, phenelzine sulfate, mianserin), and dietary supplementation (omega-3 fatty acid) were tested. First-generation antipsychotics were subject to older trials, whereas recent studies focussed on second-generation antipsychotics and mood stabilisers. Data were sparse for individual comparisons, indicating marginal effects for first-generation antipsychotics and antidepressants.The findings were suggestive in supporting the use of second-generation antipsychotics, mood stabilisers, and omega-3 fatty acids, but require replication, since most effect estimates were based on single studies. The long-term use of these drugs has not been assessed.Adverse event data were scarce, except for olanzapine. There was a possible increase in self-harming behaviour, significant weight gain, sedation and changes in haemogram parameters with olanzapine. A significant decrease in body weight was observed with topiramate treatment. All drugs were well tolerated in terms of attrition.Direct drug comparisons comprised two first-generation antipsychotics (loxapine versus chlorpromazine), first-generation antipsychotic against antidepressant (haloperidol versus amitriptyline; haloperidol versus phenelzine sulfate), and second-generation antipsychotic against antidepressant (olanzapine versus fluoxetine). Data indicated better outcomes for phenelzine sulfate but no significant differences in the other comparisons, except olanzapine which showed more weight gain and sedation than fluoxetine. The only trial testing single versus combined drug treatment (olanzapine versus olanzapine plus fluoxetine; fluoxetine versus fluoxetine plus olanzapine) yielded no significant differences in outcomes.

AUTHORS' CONCLUSIONS

The available evidence indicates some beneficial effects with second-generation antipsychotics, mood stabilisers, and dietary supplementation by omega-3 fatty acids. However, these are mostly based on single study effect estimates. Antidepressants are not widely supported for BPD treatment, but may be helpful in the presence of comorbid conditions. Total BPD severity was not significantly influenced by any drug. No promising results are available for the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment. Conclusions have to be drawn carefully in the light of several limitations of the RCT evidence that constrain applicability to everyday clinical settings (among others, patients' characteristics and duration of interventions and observation periods).

Volitional disorders: a proposal for DSM-V

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

Antiepileptics for aggression and associated impulsivity

BACKGROUND

Aggression is a major public health issue and is integral to several mental health disorders. Antiepileptic drugs may reduce aggression by acting on the central nervous system to reduce neuronal hyper-excitability associated with aggression.

OBJECTIVES

To evaluate the efficacy of antiepileptic drugs in reducing aggression and associated impulsivity.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, metaRegister of Controlled Trials (mRCT) and ClinicalTrials.gov to April 2009. We also searched Cochrane Schizophrenia Group's register of trials on aggression, National Research Record and handsearched for studies.

SELECTION CRITERIA

Prospective, placebo-controlled trials of antiepileptic drugs taken regularly by individuals with recurrent aggression to reduce the frequency or intensity of aggressive outbursts.

DATA COLLECTION AND ANALYSIS

Three authors independently selected studies and two authors independently extracted data. We calculated standardised mean differences (SMDs), with odds ratios (ORs) for dichotomous data.

MAIN RESULTS

Fourteen studies with data from 672 participants met the inclusion criteria. Five different antiepileptic drugs were examined. Sodium valproate/divalproex was superior to placebo for outpatient men with recurrent impulsive aggression, for impulsively aggressive adults with cluster B personality disorders, and for youths with conduct disorder, but not for children and adolescents with pervasive developmental disorder. Carbamazepine was superior to placebo in reducing acts of self-directed aggression in women with borderline personality disorder, but not in children with conduct disorder. Oxcarbazepine was superior to placebo for verbal aggression and aggression against objects in adult outpatients. Phenytoin was superior to placebo on the frequency of aggressive acts in male prisoners and in outpatient men including those with personality disorder, but not on the frequency of 'behavioral incidents' in delinquent boys.

AUTHORS' CONCLUSIONS

The authors consider that the body of evidence summarised in this review is insufficient to allow any firm conclusion to be drawn about the use of antiepileptic medication in the treatment of aggression and associated impulsivity. Four antiepileptics (valproate/divalproex, carbamazepine, oxcarbazepine and phenytoin) were effective, compared to placebo, in reducing aggression in at least one study, although for three drugs (valproate, carbamazepine and phenytoin) at least one other study showed no statistically significant difference between treatment and control conditions. Side effects were more commonly noted for the intervention group although adverse effects were not well reported. Absence of information does not necessarily mean that the treatment is safe, nor that the potential gains from the medication necessarily balance the risk of an adverse event occurring. Further research is needed.

Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials

BACKGROUND

Many patients with borderline personality disorder receive pharmacological treatment, but there is uncertainty about the usefulness of such therapies.

AIMS

To evaluate the evidence of effectiveness of pharmacotherapy in treating different facets of the psychopathology of borderline personality disorder.

METHOD

A Cochrane Collaboration systematic review and meta-analysis of randomised comparisons of drug v. placebo, drug v. drug, or single drug v. combined drug treatment in adult patients with borderline personality disorder was conducted. Primary outcomes were overall disorder severity as well as specific core symptoms. Secondary outcomes comprised associated psychiatric pathology and drug tolerability.

RESULTS

Twenty-seven trials were included in which first- and second-generation antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids were tested. Most beneficial effects were found for the mood stabilisers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine. However, the robustness of findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness.

CONCLUSIONS

The current evidence from randomised controlled trials suggests that drug treatment, especially with mood stabilisers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

Psychopharmakotherapie einer ambulanten und stationären Inanspruchnahmepopulation adoleszenter Patienten mit Borderline-Persönlichkeitsstörung

Fragestellung: Ein Großteil erwachsener Patienten mit Borderline-Persönlichkeitsstörung (BPS) wird mit Psychopharmaka behandelt. Über die Psychopharmakotherapie bei Adoleszenten mit BPS liegen bisher keine Daten vor. Ziel dieser Studie ist die Untersuchung der Häufigkeit des Störungsbildes und des Verschreibungsverhaltens bei adoleszenten ambulanten und stationären Patienten mit BPS. Methoden: 58 adoleszente Patienten mit BPS (16.7 ± 2.5 Jahre) einer Inanspruchnahmepopulation während eines 7-jährigen Beobachtungszeitraums wurden retrospektiv hinsichtlich der Medikation und verschiedener Risikovariablen in der Erstbehandlungsepisode untersucht. Ergebnisse: 37 Patienten wurden stationär und 21 ambulant behandelt, entsprechend einer Prävalenz von 2.1 %, bezogen auf die Inanspruchnahmepopulation. Stationäre Patienten waren insgesamt stärker durch Risikofaktoren belastet (ca. 68 % mit komorbiden Störungen, ca. 49 % mit selbstverletzendem Verhalten, signifikant (p < .001) mehr Suizidversuche in der Vorgeschichte) und wurden häufiger (p < .001) psychopharmakologisch behandelt. Am häufigsten wurden Antidepressiva verschrieben (SSRI und NaSSA), gefolgt von Neuroleptika. Über die Hälfte der medizierten Patienten erhielten mehrere Medikamente gleichzeitig. Schlussfolgerungen: Psychopharmakotherapie bei BPS hat inzwischen einen hohen Stellenwert, ist in erster Linie symptomorientiert und komorbide Störungen sollten gleichermaßen miteinbezogen werden. Auch für Adoleszente gewinnt die Medikation bei BPS an Bedeutung. Stationär behandelte Patienten sind durch psychiatrische Risikofaktoren stärker belastet und werden häufiger mediziert.

Multivariate therapeutic approach to binge-eating disorder: combined nutritional, psychological and pharmacological treatment

Treatment for binge-eating disorder (BED) is directed towards either the physical or psychopathological impairments, and often does not cover all the alterations characterizing the disease. In 30 BED patients, we monitored the effects of three types of 6-month treatment, randomly assigned to one of the three treatment groups, each consisting of 10 patients. Group 1 received a 1700-kcal diet (21% proteins, 27% lipids, 52% carbohydrate), cognitive-behavioural therapy (CBT), sertraline (50-150 mg/day) and topiramate (25-150 mg/day); group 2 received the same diet, CBT, sertraline; and group 3 received nutritional counselling and CBT. Binge frequency and weight were assessed every month. The Eating Disorder Inventory-2, the Symptoms Check List-90-Revised (SCL-90-R) and the Personality Diagnostic Questionnaire-4-Revised (PDQ-4-R) were administered before and after treatment. Binge frequency and excessive weight decreased significantly only in group 1 patients, in whom improvement was noted in total Eating Disorder Inventory-2 scores and the subitems 'bulimia', 'drive for thinness', 'maturity fear', 'ascetism', in total SCL-90-R scores and in the subitem 'somatization', in PDQ-4-R subitems 'schizotypic personality' and 'dependent personality'. Group 2 patients improved on the SCL-90-R subitems 'depression' and 'interpersonal relationship' and in the PDQ-4-R 'schizoid personality'. Combination therapy seems to be the only fully effective treatment in BED patients.

Personality trait dimensions and the pharmacological treatment of borderline personality disorder

The number of well-designed placebo-controlled studies on pharmacological treatment of borderline personality disorder has been small. We present a breakdown of results of placebo-controlled pharmacological studies, sorting target symptoms into the trait dimensions of affective instability, anxiety inhibition, cognitive-perceptual disturbances, and impulsivity-aggression. Twenty randomized placebo-controlled pharmacological trials studying typical and atypical antipsychotics, selective serotonin reuptake and monoamine oxidase inhibitors, tricyclic antidepressants, mood stabilizers, and benzodiazepines were included. A relative measure of the weight of an outcome was determined by (1) dividing the number of positive comparisons for a drug class by the total number of comparisons of all drugs of all classes for each dimension and (2) dividing the number of positive comparisons for a drug class by the total number of comparisons for that particular drug class for that trait dimension. Antipsychotics (neuroleptics and atypicals) had the most evidence for each of the traits with both methods. Our results are compared with the results of 2 meta-analyses, 1 guideline set, and 1 other systematic review. We found little concordance across these studies. We propose a consortium to discuss guidelines for future studies, including agreement as to what should be measured to determine the outcome and adoption of standardized instruments to measure that outcome.

A preliminary study of lamotrigine in the treatment of affective instability in borderline personality disorder

The objective of this study was to evaluate the effectiveness of lamotrigine in reducing affective instability in borderline personality disorder (BPD). We conducted a 12-week, double-blind, placebo-controlled study of 28 patients who met Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for BPD. Patients could not meet Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for bipolar disorder. Patients could be taking one antidepressant during the study. Patients were randomly assigned to treatment with flexible-dose lamotrigine or placebo in a 1 : 1 manner. The primary outcome measures were: (i) the Affective Lability Scale total score; and (ii) the Affective Instability Item of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). The study randomized 15 patients to receive lamotrigine and 13 patients to receive placebo. Patients in the lamotrigine group had significantly greater reductions in the total Affective Lability Scale scores (P<0.05) and significantly greater reductions in scores on the affective instability item of the ZAN-BPD (P<0.05). A secondary finding was that patients in the lamotrigine group had significantly greater reductions in scores on the ZAN-BPD impulsivity item (P = 0.001). Results from the study suggest that lamotrigine is an effective treatment for affective instability and for the general impulsivity characteristic of BPD.

Treatment with aripiprazole and topiramate in an obese subject with borderline personality disorder, obsessive-compulsive symptoms and bulimia nervosa: a case report

Introduction

Borderline personality disorder is a chronic mental disorder associated with severe psychosocial impairment and morbidity, greater usage of mental health resources, and a high mortality rate. Although there is no drug with an approved indication for this disorder, pharmacological treatment is a common practice based on the specific benefit of the drugs on the remission of the core symptoms of the disease.

Case presentation

Authors reported the case of a 37-year-old obese woman with borderline personality disorder, obsessive-compulsive symptoms and bulimia nervosa treated with aripiprazole and topiramate. Co-administration of aripiprazole and topiramate produced a significant improvement of all psychopathological dimensions, obsessive-compulsive symptoms, and eating disorder.

Conclusion

Co-administration of aripiprazole and topiramate could be a safe and effective long-term treatment for improving not only the symptoms of borderline personality disorder but also the associated health-related quality of life and interpersonal problems.

The treatment of borderline personality disorder: implications of research on diagnosis, etiology, and outcome

The treatment of patients with borderline personality disorder (BPD) is challenging. Making a diagnosis is necessary to plan therapy. But since we do not know the etiology of BPD, treatment cannot be based on a well-established theory. Outcome research shows that most patients recover with time. A series of clinical trials show that a variety of psychotherapies are effective in BPD and that the effects of medication are unimpressive.

Lamotrigine treatment of aggression in female borderline patients, Part II: an 18-month follow-up

Borderline patients often display pathological aggression. We previously tested lamotrigine, an anti-convulsant, in therapy for aggression in women with borderline personality disorder (BPD) (J Psychopharmacol 2005; 19: 287-291), and found significant changes on most scales of the State-Trait Anger Expression Inventory (STAXI) after eight weeks. To assess the longer-term efficacy of lamotrigine in therapy for aggression in women with BPD, this 18-month follow-up observation was carried out, in which patients (treated with lamotrigine: n = 18; former placebo group: n = 9) were tested every six months. According to the intent-to-treat principle, significant changes on all scales of the STAXI were observed in the lamotrigine-treated subjects. All subjects tolerated lamotrigine relatively well. Lamotrigine appears to be an effective and relatively safe agent in the longer-term treatment of aggression in women with BPD.

Clinical trials of treatment for personality disorders

The objective of this review is to examine clinical trials of the treatment of personality disorders (PDs). The method is a narrative review of published controlled trials of psychotherapy and pharmacotherapy. Results show that a variety of methods reduce impulsivity, with less striking results for affective instability. There is good support for well-structured methods of psychotherapy, mainly in borderline personality disorder (BPD), but evidence for the efficacy of pharmacotherapy is weak. Research on other PD categories is sparse.

The effectiveness of anticonvulsants in psychiatric disorders

Anticonvulsant drugs are widely used in psychiatric indications. These include mainly alcohol and benzodiazepine withdrawal syndromes, panic and anxiety disorders, dementia, schizophrenia, affective disorders, bipolar affective disorders in particular, and, to some extent, personality disorders, A further area in which neurology and psychiatry overlap is pain conditions, in which some anticonvulsants, and also typical psychiatric medications such as antidepressants, are helpful. From the beginning of their psychiatric use, anticonvulsants have also been used to ameliorate specific symptoms of psychiatric disorders independently of their causality and underlying illness, eg, aggression, and, more recently, cognitive impairment, as seen in affective disorders and schizophrenia. With new anticonvulsants currently under development, it is likely that their use in psychiatry will further increase, and that psychiatrists need to learn about their differential efficacy and safety profiles to the same extent as do neurologists.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders

These practical guidelines for the biological treatment of personality disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the biological treatment of three specific personality disorders, namely borderline, schizotypal and anxious/avoidant personality disorder in addition to some general recommendations for the whole field. The guidelines cover disease definition, classification, epidemiology, course and current knowledge on biological underpinnings, and provide a detailed overview on the state of the art of clinical management. They deal primarily with biological treatment (including antidepressants, neuroleptics, mood stabilizers and some further pharmacological agents) and discuss the relative significance of medication within the spectrum of treatment strategies that have been tested for patients with personality disorders, up to now. The recommendations should help the clinician to evaluate the efficacy spectrum of psychotropic drugs and therefore to select the drug best suited to the specific psychopathology of an individual patient diagnosed for a personality disorder.

[Psychopathology and treatment of borderline personality disorder]

Borderline personality disorder (BPD) is a severe psychiatric disorder accounting for about 30% of the total cost for psychiatric inpatient care in the Federal Republic of Germany. Suicidality, self-harm, and severe deterioration of self-esteem lead to chronic suffering for patients and the social environment. With a prevalence rate of 1.5%, BPD is more frequent than schizophrenic disorders. Within the last years, empirically based knowledge concerning the psychopathology, etiopathogenesis, and treatment of BPD have significantly improved. Today most researchers postulate pervasive affective dysregulation at the core of borderline symptomatology and see it as the consequence of an interplay between genetic vulnerability, sociobiographic experience, and dysfunctional behavior. Disorder-specific psychotherapeutic treatments, especially dialectical behavior therapy, show significant improvements in both in- and outpatient settings. Studies on psychopharmacological treatment with promising results have also recently been published. Sufficient outpatient treatment by trained psychotherapists is underdeveloped. Hence, specialized inpatient centers assume this task.

Controversies in diagnosis, classification and treatment of borderline personality disorder

PURPOSE OF REVIEW

Borderline personality disorder is the most widely researched single personality disorder, and much research activity continues. This review covers empirical literature on diagnosis, classification and treatment of borderline personality disorder published during 2006 and 2007. Several of the issues that concern borderline personality disorder also concern personality disorders in general, and so the review is broadened in the diagnostic section to include the latter.

RECENT FINDINGS

Integration of categorical and dimensional approaches to personality disorders is actively being sought for inclusion in the next revision of the psychiatric classifications. Although there are few new studies on pharmacotherapy for borderline personality disorder, many new findings on psychotherapy have been reported. They indicate that a variety of treatment modalities can influence borderline personality disorder, but the role of spontaneous improvement over time and established prognostic factors have not received sufficient attention. New modalities of psychotherapy have been tested by less stringent designs.

SUMMARY

Research into classification, diagnosis and psychotherapy of borderline personality disorder is flourishing, but research activity in pharmacotherapy is limited.