I Hate You--Don't Leave Me - Jerold J. Kreisman [90]
Anxiolytics
Antianxiety agents, although acutely helpful for anxiety, have been shown to increase impulsivity and can be abused and addictive. These tranquilizers, primarily in the class known as benzodiazepines, include Xanax (alprazalom), Ativan (lorazepam), Valium (diazepam), and Librium (chlordiazepoxide), among others. Klonopin (clonazepam), a longer-acting benzodiazepine that may have greater effect on serotonin, has had success in treating symptoms of aggression and anxiety and so is perhaps the only benzodiazepine that may be useful for BPD.
Opiate Antagonists
Revia (naltrexone) blocks the body’s release of its own endorphins, which induce analgesia and euphoric feelings. Some reports suggest that this medicine may inhibit self-mutilating behavior.
Other Treatments
Homeopathic or herbal treatments have generally been unsuccessful, with the exception of omega-3 fatty acid preparation. One small study found that the substance did decrease aggressiveness and depression among women.10
Two substances that modulate the neurotransmitter glutamate have been investigated in BPD. The amino acid N-acetylcysteine and Rilutek (riluzole)—a drug used for the treatment of amyotrophic lateral sclerosis (Lou Gehrig’s disease)—were reported to significantly diminish self-injurious behavior in two borderline patients.11
The APA’s Practice Guideline recommends that medications target a specific symptom cluster. Guidelines divide BPD symptoms into three primary groups: Mood Instability, Impulse Dyscontrol, and Cognitive-Perceptual Distortions. An algorithm of recommended treatment approaches, with alternative tactics if the previous choice is ineffective, is summarized in Table 9-1.
TABLE 9-1. Pharmacotherapy for treating BPD symptoms
A Word About “Off-Label” Use
The FDA (Food and Drug Administration) has not formally approved any drug for the treatment of BPD, so all of the medicines commonly used for treating BPD are considered “off-label.” Though the term “off-label” may be off-putting, if not seem downright risky to the uninitiated, off-label prescribing is quite common for a wide variety of conditions. Because a pharmaceutical company spends almost $1 billion on average to bring a drug to market, many companies do not seek approval for a wide range of conditions or outside narrow dosage ranges, as these strategies might narrow the chances for FDA approval and greatly increase the cost of development. For example, even though it is known that SRIs benefit several conditions, including depression, PTSD, anxiety illnesses, and some pain disorders, the drug manufacturer may not want to absorb the extra expense of gaining FDA approval—nor risk FDA rejection—by applying for label use for all of these indications and/or broad dosage ranges. Whenever a physician prescribes a medicine for an unapproved condition, or at a dose outside of recommendations, it is considered “off-label.” Unfortunately, managed care agencies may refuse approval of these (sometimes expensive) “off-label” prescriptions.
Generic Drugs
In simplest terms, a generic drug contains the same primary or active ingredient as the original formulation; generally speaking, it is almost always less expensive. However, this does not mean that a generic medication is identical to its brand-name counterpart. The FDA considers a generic drug “equivalent” to a branded medicine if blood levels in healthy volunteers are within 20 percent variation,