What medications are used to treat Borderline Personality Disorder (BPD)?

Medications for Borderline Personality Disorder (BPD)

No medications are FDA-approved specifically for treating the core symptoms of Borderline Personality Disorder, but several classes of medications are commonly prescribed off-label to target specific symptom clusters. 1, 2

Evidence-Based Medication Approaches

Second-Generation Antipsychotics

• Olanzapine and aripiprazole have shown efficacy in treating affective symptoms and impulsive-behavioral dyscontrol in BPD patients 3
• Antipsychotics significantly improve cognitive symptoms in BPD patients, including cognitive-perceptual disturbances 3
• Second-generation antipsychotics may improve general psychiatric symptoms but have limited effect on specific BPD symptoms 4
• Low-potency antipsychotics like quetiapine may be used for short-term management of acute crises, including extreme anxiety or psychotic episodes 2

Mood Stabilizers

• Topiramate, valproate, and lamotrigine have demonstrated efficacy in treating affective symptoms and impulsive-behavioral dyscontrol 3
• Low-certainty evidence suggests anticonvulsants may improve specific symptoms like anger, aggression, and affective lability 4
• Benefits from mood stabilizers are mostly limited to single studies rather than consistent findings across multiple trials 4

Antidepressants

• SSRIs (selective serotonin reuptake inhibitors) may decrease severity of depressed mood, anxiety, and anger, primarily in patients with comorbid affective disorders 3
• Escitalopram, sertraline, or fluoxetine may be prescribed for comorbid major depression 2
• Effects of antidepressants on impulsive behaviors are uncertain and not consistently demonstrated 3

Other Agents

• Omega-3 fatty acids have shown some utility in treating affective symptoms and impulsive-behavioral dyscontrol 3
• Sedative antihistamines (e.g., promethazine) may be used off-label for short-term crisis management 2
• Benzodiazepines like diazepam or lorazepam should generally be avoided due to risk of dependence and potential for misuse 2, 5

Symptom-Targeted Approach

For Affective Dysregulation

• Mood stabilizers (topiramate, valproate, lamotrigine) or second-generation antipsychotics (olanzapine, aripiprazole) should be considered first-line 3
• SSRIs may be beneficial when comorbid depression or anxiety is present 3, 2

For Impulsive-Behavioral Dyscontrol

• Mood stabilizers and second-generation antipsychotics have shown the most consistent benefits 3
• Anticonvulsants may help with anger and aggression symptoms 4

For Cognitive-Perceptual Symptoms

• Antipsychotics have demonstrated the most significant improvement for cognitive symptoms and perceptual disturbances 3
• Low-dose antipsychotics may help with transient stress-related paranoid ideation 2

Important Considerations

• Pharmacotherapy should be considered only as an adjunct to BPD-specific psychotherapy, which remains the treatment of choice 5, 2
• Polypharmacy should be avoided due to increased risk of side effects and limited evidence of additional benefit 5
• Medications with high risk of overdose should be avoided given the elevated suicide risk in BPD patients 5
• Treatment should focus on comorbid conditions when present, as these often drive medication decisions 5
• Regular reassessment of medication efficacy and side effects is essential, with discontinuation of ineffective medications 5

Limitations of Medication Treatment

• Overall evidence indicates that the efficacy of pharmacotherapies for BPD is limited 4
• Out of 87 medications used in clinical practice, studies have only evaluated nine 4
• No medication has consistently demonstrated efficacy in reducing the core features of BPD 1, 2
• Clinical guidelines lack clear consensus on medication recommendations for BPD 5

Psychotherapy remains the cornerstone of BPD treatment, with medications serving primarily as adjunctive treatments targeting specific symptom clusters or comorbid conditions.