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Medications

Discoveries in the exploding fields of genetics and brain physiology have led to new drugs for many physical and mental conditions. Great advances have been achieved in pharmacology, especially in the area of biotechnology; in short, numerous psychotherapeutic drugs have been developed in the last twenty years, and the evidence suggests that some have proved effective in treating BPD. Although no medication is targeted specifically for BPD, research has demonstrated that three primary classes of medicines—antidepressants, mood stabilizers, and neuroleptics (antipsychotics)—ameliorate many of the maladaptive behaviors associated with the disorder.9

Antidepressants

Most research has examined the use of antidepressants, particularly serotonin reuptake inhibitors (SSRIs or SRIs). These medicines include Prozac (fluoxetine), Zoloft (sertraline), Paxil or Pexeva (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram—related to citalopram). Predictably, these drugs have been effective for mood instability and related symptoms of depression, such as feelings of emptiness, rejection sensitivity, and anxiety. Additionally, SRIs have been shown to decrease inappropriate anger and temper outbursts, aggressive behavior, destructive impulsivity, and self-mutilating actions, even in the absence of depressive symptoms. In many studies, higher than usual doses of these medicines (for example, >80 mg of Prozac; >200 mg of Zoloft per day) were necessary to have a positive effect. A related group of drugs, serotonin-norepinephrine reuptake inhibitors (SNRIs), have not been as extensively studied, but may have similar positive effects. These include Effexor (venlafaxine), Pristiq (desvenlafaxine—related to venlafaxine), and Cymbalta (duloxetine).

Older antidepressants, such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), have also been studied. TCAs include Elavil (amitriptylene), Tofranil (imipramine), Pamelor or Aventyl (nortriptylene), Vivactil (protriptylene), Sinequan (doxepin), Norpramin (desipramine), Asendin, (amoxapine), Surmontil (trimipramine), and others. These drugs have generally been less effective and in some cases have decreased emotional control. Therefore, the patient diagnosed with BPD should be wary of prescribed drugs in the TCA class.

MAOIs—Nardil (phenelzine) and Parnate (tranylcypromine) being the most commonly used in the United States—have shown efficacy in BPD comparable to that of SRIs. However, MAOIs tend to have more side effects, are more dangerous in overdose, and require dietary and concurrent medication restrictions, and are therefore utilized much less.

Mood Stabilizers

This group of medications includes Lithium, a naturally occurring element, and antiseizure drugs—Depakote (valproate), Tegretol (carbamazepine), Trileptal (oxcarbazepine—related to carbamazepine), Lamictal (lamotrigine), and Topamax (topiramate). APA guidelines recommend this group as adjunctive treatment when SRIs or other interventions are ineffective or only partially effective. These medicines, in typical doses, help stabilize mood, decrease anxiety, and better control impulsivity, aggression, irritability, and anger. Neurontin (gabapentin), Dilantin (phenytoin), Gabatril (tiagabine), Keppra (levetiracetam), and Zonegran (zonisamide) are also in this class of drugs, but studies testing their effectiveness in BPD patients have been limited.

Neuroleptics

These drugs are recommended for initial treatment of cognitive-perceptual distortions in borderline patients. Paranoia, dissociative symptoms, and feelings of unreality (criteria 9 in the DSM-IV-TR—see chapter 2) are primary targets. In combination with SRIs, these medicines, usually in lower than common doses, relieve feelings of anger and aggressiveness; stabilize mood; and decrease anxiety, obsessional thinking, impulsivity, and interpersonal sensitivity.

Early studies were done with older neuroleptics,