Pharmacological Management of Borderline Personality Disorder and Common Comorbidities

Abstract

Comorbidity between borderline personality disorder (BPD) and other mental disorders is common. Although no specific pharmacological treatments have been approved for the treatment of BPD, many drugs, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, second-generation antipsychotics, and even benzodiazepines, are routinely prescribed off label. Nonetheless, recommendations for off-label drugs in these patients are highly varied, with a notable lack of agreement among clinical guidelines. The most common reason for pharmacological treatment and polypharmacy in these patients is comorbidity with other psychiatric disorders. In this context, we reviewed major clinical guidelines and the available data on pharmacotherapy in patients with BPD to develop practical recommendations to facilitate decision-making in routine clinical practice, thus helping clinicians to select the optimal therapeutic approach in patients with BPD who have comorbid disorders. This review confirmed that no clear recommendations for the pharmacological treatment are available in clinical guidelines. Therefore, based on the available evidence, we have developed a series of recommendations for pharmacotherapy in patients with BPD who present the four most common comorbidities (affective, anxiety, eating, and drug use disorders). Here, we discuss the recommended treatment approach for each of these comorbid disorders. The prescription of medications should be considered only as an adjunct to BPD-specific psychotherapy. Polypharmacy and the use of unsafe drugs (i.e., with a risk of overdose) should be avoided. Our review highlights the need for more research to provide more definitive guidance and to develop treatment algorithms.

Fig. 1

Algorithm for the management of patients with borderline personality disorder and comorbid major depressive disorder. AD, antidepressants; APS, antipsychotics; BPD, borderline personality disorder; DBT, dialectical behavioral therapy; EBT, evidence-based treatment; MBT, mentalization-based treatment; MDD, major depressive disorder; SFT, schema-focused therapy; SSRI, selective serotonin reuptake inhibitor; STEPPS, systems training for emotional predictability and problem solving; TCA, tricyclic antidepressants; TFP, transference-focused psychotherapy