Evidence-based pharmacotherapy for personality disorders

Abstract

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.

The Multi-Circuit Neuronal Hyperexcitability Hypothesis of Psychiatric Disorders

“…From the perspective of the MCNH hypothesis, the close relationship between personality disorders and their related Axis I disorders is not coincidental; it's as if the brain were training the mind to habitually mimic and permanently adopt the thoughts, feelings, and behaviors that are driven by the related circuit-specific imbalances. The relatively high severity and chronicity of the circuit-specific imbalances in personality-disordered individuals would also explain why antidepressants, which can further excite parts of the brain [84][85][86][87][88], tend to be much less effective for personalitydisordered individuals than anticonvulsant and antipsychotic drugs [89][90][91]. This, taken together with the high level of comorbidity and large overlap in symptomatology between personality disorders and Axis I disorders, strongly suggests that the two disorder-types are rooted in the same biological vulnerability trait; namely, neuronal hyperexcitability.…”

“…Beyond that, both the benzodiazepine and nonbenzodiazepine anticonvulsants have a long history of adjunctive use in the treatment of schizophrenia [163][164][165], and the non-benzodiazepine anticonvulsants are increasingly being used in the treatment of migraine headaches [166], fibromyalgia [167], chronic pain [168], and a host of other disorders that have been linked to a hypersensitivity of the central nervous system [99]. Lastly, both benzodiazepine and non-benzodiazepine anticonvulsants can assist in the treatment of ADHD [169,170], and they can be an indispensable adjunct in the treatment of personality disorders, particularly when mood and anxiety symptoms are prominent [89][90][91].…”

The Use of Psychotropic Medication in Patients With Emotionally Unstable Personality Disorder Under the Care of UK Mental Health Services

“…Evidence supports only the use of mood stabilizers. 17 The APA 3 recommends symptom-specific algorithms for managing impulsivity and aggression; these behaviors have been shown in a variety of electrophysiologic, endocrine, and neuroimaging studies to have demonstrable neurobiological correlates 26 and so may be considered potentially legitimate targets for drug treatments. However, while the use of a mood stabilizer to reduce impulsivity was supported by a recent review 18 of the evidence, the APA recommendation to use an antipsychotic for such a purpose was not.…”

Specific Pharmacological Effects of Paroxetine Comprise Psychological but Not Somatic Symptoms of Depression

“…This conclusion, however, is based exclusively on reported changes in total scores on depression outcome measures and treatment effects may differ by symptom clusters. The effectiveness of SSRIs for a wide range of mental disorders [ 5 – 8 ] indicates that they provide relief on diverse sets of psychological symptoms, or, alternatively, that they may alter broader dispositions, such as maladaptive personality traits [ 9 – 11 ]. Secondly, patients in depression studies rarely present exclusively with a “pure” set of depression symptoms, but nearly always have clinical or subclinical manifestations of other disorders, particularly anxiety [ 12 ], which may also be altered by SSRI treatment [ 13 ].…”