Is Abilify (aripiprazole) effective in treating borderline personality disorder?

Efficacy of Aripiprazole (Abilify) for Borderline Personality Disorder

Aripiprazole (Abilify) shows promise for treating specific symptoms of borderline personality disorder (BPD), particularly impulsivity, anger, hostility, and cognitive-perceptual symptoms, though it is not FDA-approved for this indication.

Evidence for Aripiprazole in BPD

Atypical antipsychotics, including aripiprazole, have been investigated for treating BPD with encouraging initial results. Several studies have examined aripiprazole specifically:

• Case reports indicate that aripiprazole may have potential benefits in treating various psychopathological dimensions of BPD 1
• Aripiprazole has shown effectiveness in improving cognitive symptoms, impulsivity, anger, and hostility in patients with BPD 2
• In some cases, aripiprazole has demonstrated efficacy for psychotic-like symptoms that can occur in BPD 1

Target Symptoms for Pharmacotherapy in BPD

Pharmacotherapy for BPD typically targets three main psychopathological dimensions:

1. Affective dysregulation - mood instability, emotional reactivity
2. Impulsive-behavioral dyscontrol - impulsivity, aggression
3. Cognitive-perceptual symptoms - paranoid ideation, dissociative symptoms

Antipsychotics like aripiprazole are particularly recommended for cognitive-perceptual symptoms, while they may also help with impulsivity and mood instability 3.

Tolerability and Side Effects

Tolerability of aripiprazole in BPD patients varies:

• Some patients experience initial side effects that may necessitate dose reduction or discontinuation 1
• Others tolerate the medication well with minimal adverse effects
• Weight gain is less problematic with aripiprazole compared to some other atypical antipsychotics

Alternative Pharmacological Options for BPD

If aripiprazole is not effective or not tolerated, other medication options include:

• Mood stabilizers: Valproate, lamotrigine, and topiramate have shown promise for affective instability and impulsivity 4, 2
• SSRIs: May help with affective symptoms, particularly in patients with comorbid depression or anxiety 3
• Other atypical antipsychotics: Olanzapine has the most evidence among this class 2

Important Considerations

1. Dialectical Behavior Therapy (DBT) should be considered alongside medication, as psychotherapy remains the foundation of BPD treatment 5

2. Suicide risk assessment is crucial in BPD patients, who have high rates of self-harm and suicidal behavior 5

3. Polypharmacy should be avoided when possible, as multiple medications increase the risk of side effects without necessarily improving outcomes

4. Regular monitoring for medication effectiveness and side effects is essential

Limitations of Current Evidence

The evidence for pharmacotherapy in BPD has several limitations:

• Most studies have small sample sizes
• Many are open-label rather than controlled trials
• Long-term follow-up data is limited
• Few head-to-head comparisons between medications exist

Clinical Approach

For patients with BPD considering aripiprazole:

1. Start with a low dose (e.g., 2-5 mg daily) and titrate slowly based on response and tolerability
2. Target specific symptoms (impulsivity, anger, cognitive symptoms) rather than expecting global improvement
3. Regularly assess effectiveness using validated measures
4. Consider discontinuation if no benefit is observed after an adequate trial (8-12 weeks)
5. Combine with evidence-based psychotherapy when possible

While aripiprazole shows promise for specific BPD symptoms, larger controlled trials are needed to establish its definitive role in BPD treatment.