What pharmacologic treatments are recommended for borderline personality disorder?

Pharmacologic Treatment for Borderline Personality Disorder

Primary Recommendation

Psychotherapy is the treatment of choice for borderline personality disorder, and there is no evidence that any psychoactive medication consistently improves the core symptoms of BPD. 1

Medications should only be prescribed as adjuncts to BPD-specific psychotherapy and should target specific comorbid psychiatric disorders or acute crisis situations, not the personality disorder itself. 1, 2

Treatment Algorithm for BPD with Comorbidities

Step 1: Establish Psychotherapy as Foundation

• Dialectical behavior therapy (DBT) or psychodynamic therapy are first-line treatments, with medium effect sizes (standardized mean difference -0.60 to -0.65) compared to usual care. 1
• Pharmacotherapy should never replace psychotherapy but may be added for discrete comorbid conditions. 1, 2

Step 2: Identify and Treat Specific Comorbid Disorders

For Comorbid Major Depressive Disorder (present in 83% of BPD patients): 1

• Sertraline is the preferred SSRI due to its FDA approval for both panic disorder and PTSD (commonly comorbid with BPD), and equivalent efficacy to other SSRIs for depression. 3
• Alternative SSRIs include escitalopram or fluoxetine. 1
• Allow 6-8 weeks at therapeutic dose before declaring treatment failure. 3
• Continue for 4-9 months minimum after satisfactory response. 3

For Comorbid Anxiety Disorders (present in 85% of BPD patients): 1

• Sertraline shows equivalent efficacy to other second-generation antidepressants for anxiety symptoms comorbid with depression. 3
• SSRIs are effective in decreasing severity of anxiety and anger, particularly when concomitant affective disorder is present. 4

Step 3: Target Specific BPD Symptom Clusters (Only When Severe)

For Affective Dysregulation and Impulsive-Behavioral Dyscontrol:

• Mood stabilizers show the most beneficial effects: topiramate, lamotrigine, or valproate semisodium. 5, 4
• Second-generation antipsychotics: aripiprazole or olanzapine. 5, 4
• Important caveat: These findings are based mostly on single, small studies with low robustness. 5

For Cognitive-Perceptual Symptoms:

• Second-generation antipsychotics significantly improve cognitive symptoms. 4

Step 4: Acute Crisis Management

For short-term treatment of suicidal behavior, extreme anxiety, or psychotic episodes:

• Low-potency antipsychotics (quetiapine) are preferred. 1
• Off-label sedative antihistamines (promethazine) may be used. 1
• Avoid benzodiazepines (diazepam, lorazepam) due to safety concerns in this population. 1, 2

Critical Pitfalls to Avoid

• Polypharmacy must be avoided in BPD patients, as medications do not treat core BPD symptoms and increase risk of adverse effects. 2
• Avoid unsafe drugs with overdose risk given the high rate of suicidal behavior in this population. 2
• SSRIs lack high-level evidence of effectiveness for core BPD symptoms; their use should be restricted to treating comorbid major depression or anxiety disorders. 5, 1
• Effects of antidepressants on impulsive behaviors are uncertain and should not be the primary indication. 4
• Approximately 38% of patients do not achieve treatment response with initial antidepressant treatment. 3

Monitoring Strategy

• Use standardized scales: PHQ-9 for depression, PCL-5 for PTSD at each visit. 3
• Monitor for sexual dysfunction with sertraline (intermediate rates among SSRIs—higher than bupropion but lower than paroxetine). 3
• For PTSD comorbidity, continuation treatment for 6-12 months decreases relapse rates. 3

Evidence Quality Considerations

The current evidence does not support pharmacotherapy effectiveness for overall severity of borderline personality disorder. 5 Pharmacotherapy should be targeted at specific comorbid psychiatric disorders or discrete symptom clusters, not prescribed routinely for the personality disorder diagnosis itself. 5, 1, 2