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Psychopharmacological Treatments for Emotion Dysregulation in Borderline Personality Disorder

Elena I Nica1 and Paul S Links2 Affiliations: 1Faculty of Medicine, University of Toronto, Ontario, Canada and 2Arthur Sommer Rotenberg Chair in Suicide Studies at St. Michael’s Hospital, Toronto, Ontario, Canada and Professor of Psychiatry in the Department of Psychiatry, Faculty of Medicine, University of Toronto, and the Centre for Research in Inner City Health in The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada.


The drug treatment of affective symptoms in borderline personality disorder (BPD) has been the subject of four recent meta-analyses of randomized controlled studies (RCTs). This paper reviews the current evidence-based recommendations for the psychopharmacological treatment of the affective symptoms in BPD: affective instability, anger, depression, and anxiety. There was not enough data on affective instability as an outcome measure to make a good conclusion. Most of the evidence point to a large reduction of anger with mood stabilizers and antipsychotics. Mood stabilizers are also moderately effective against depressed mood and anxiety. Contrary to prior guidelines, selective serotonin reuptake inhibitors (SSRIs) were shown to be minimally effective against depression in BPD. Omega 3 fatty acids helped reduce depression. These results suggest that clinicians should raise their threshold for prescribing medication for affective instability, anxiety, and depression, but not for anger. Clinicians must also weigh the benefits of medication over their side effects in the neurologic and metabolic domains. The meta-analyses were limited by the heterogeneity in methodology, by the small number of RCTs for each drug and small sample sizes, and by the exclusion of patients with comorbidities that are common in this population.

Keywords: borderline personality disorder, affective instability, emotion dysregulation, anger, anxiety, depression, drug therapy, evidence based practice Correspondence: Elena I. Nica, Faculty of Medicine, University of Toronto, St. Michael’s Hospital, 30 Bond Street, Shutter Wing, Room

2010d, Toronto, Ontario M5B1W8, Canada. Tel.: 416 997 1605; Fax: 1 416 864 5996; e-mail: Affective instability is part of the core pathology in border-

line personality disorder (BPD; alongside other symptom domains such as impulsivity, unstable interpersonal relation- ships, and cognitive defects), and the underlying cause for severe clinical manifestations such as impulsive behaviors, self-injury, and suicide.14

As a DSMIV diagnostic criterion for BPD, affective instability is described as ‘‘marked reactivity of mood (ie, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).’’5 The DSMV revision of BPD diagnostic criteria proposes describing affective instability as ‘‘rapidly changing, intense, unpredictable, and reactive emotions’’ including shifts into extreme anxiety, depression, and anger.6 This definition shares the view that affective instability is a dynamic process characterized by multiple parameters: intensity of affect, frequent shifts in affect, magnitude of mood change, rapid raise emotion time with slow return to baseline, reactivity to external triggers, and reactivity to endogenous stimuli.710

Given the complexity and the clinical significance of affective instability, the treatment of patients with severely dysregulated affect is challenging. While psychotherapy is considered the standard of care for the management of BPD,1113 many patients with BPD are treated with psycho- tropic medications. Most of the data on treatment utilization comes from US studies, and they show that the use of 45

psychotropic medication is higher in BPD than in major depressive disorder or other personality disorders.1416 In a sample of 130 participants recruited from the community in an American study, patients with BPD had an average lifetime use of 3.58 psychiatric medications. This medication usage is the highest when the BPD group is compared to groups with other personality disorders (1.58 medications), with depression (1.07 medications), or of healthy controls (0.03 medications).14 In a prospective 6-year US study of 290 patients with BPD, 70% were taking three or more psycho- tropic medications at 2-, 4-, or 6-year follow-up after discharge from a hospital admission.16 The Canadian data are similar. In a one year Canadian study of 180 patients with BPD, the average number of psychotropic medications used was 2.33, with 64% of the patients being on one or more medications (most often antidepressants and antipsychotics, followed by mood stabilizers and sedatives).17

In spite of the wide use of medications to treat patient with

BPD, there are no up-to-date clinical guidelines on drug therapy for the core symptoms of this condition. The NICE guidelines13 only recommend psychopharmacological treat- ment of comorbid depression, post-traumatic stress disorder, and anxiety. They advise against the use of medications for BPD or for individual symptoms, including for affective instability. They also specifically recommend against the use of antipsychotics for the moderate or long-term management

M&B 2011; 2:(1). July 2011

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