Medications for Borderline Personality Disorder
Psychotherapy is the treatment of choice for borderline personality disorder, and no psychoactive medication consistently improves the core symptoms of BPD. 1
Primary Treatment Approach
Psychotherapy, specifically dialectical behavior therapy (DBT) or psychodynamic therapy, should be the first-line treatment for BPD, with medium effect sizes (standardized mean difference -0.60 to -0.65) compared to usual care. 1
Medications should only be prescribed as adjuncts to BPD-specific psychotherapy, not as standalone treatment for the core personality disorder symptoms. 2
Polypharmacy should be avoided or strictly limited in patients with BPD. 2, 3
When to Consider Pharmacotherapy
Medications may be considered in two specific clinical scenarios:
1. Treatment of Discrete Comorbid Mental Disorders
For comorbid major depressive disorder, prescribe selective serotonin reuptake inhibitors (SSRIs):
- Escitalopram, sertraline, or fluoxetine are the recommended agents. 1
- These should only be used when a clear, severe comorbid depressive episode is present, not for depressive symptoms alone. 1
For patients with family history suggesting genetic link to bipolar disorder:
- Lithium or lamotrigine in modest doses may be particularly beneficial, more so than conventional antidepressants. 4
- Always obtain a careful and extensive family history extending to grandparents, aunts, uncles, and cousins to identify mood disorder patterns. 4
2. Acute Crisis Management
For short-term treatment of acute crises (suicidal behavior/ideation, extreme anxiety, psychotic episodes, or extreme behavior endangering patient or others):
- Low-potency antipsychotics such as quetiapine are preferred. 1
- Off-label sedative antihistamines (e.g., promethazine) may be used. 1
- Benzodiazepines such as diazepam or lorazepam should be avoided in favor of the above options. 1
Critical Caveats
Avoid prescribing antidepressants for depressive symptoms in the absence of a current moderate or severe depressive episode, as there is unlikely to be clinically important difference from placebo in patients with depressive symptoms alone. 5
Recognize that antidepressants are unlikely to be effective when BPD symptoms are the primary issue, particularly when personality disorder traits were documented as independent and antecedent to any mood symptoms. 5
Be cautious with substance abuse history: Patients with severe substance use disorder not currently in remission require specialized consideration, though mild to moderate active substance use does not automatically preclude treatment. 5
Symptom-Targeted Approach (When Psychotherapy Insufficient)
If specific symptom dimensions require additional management beyond psychotherapy:
- Affective instability and mood symptoms: Consider SSRIs or mood stabilizers (lithium, lamotrigine) if family history suggests bipolar spectrum. 4, 6
- Impulsive-aggressive behaviors: Mood stabilizers may be considered. 6
- Cognitive-perceptive symptoms: Low-dose antipsychotics for transient stress-related paranoid ideation. 6
The prescription should target prominent symptom clusters in an individualized manner, but remember that no medication treats the global psychopathology of BPD. 3