A clinical approach to pharmacotherapy for personality disorders

Donald W. Black, MD

Curr Psychiatr. 2021;20(4):27-32.

Abstract and Introduction

Introduction

DSM-5 defines personality disorders (PDs) as the presence of an enduring pattern of inner experience and behavior that “deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adulthood, is stable over time, and leads to distress or impairment.”^[1] As a general rule, PDs are not limited to episodes of illness, but reflect an individual’s long-term adjustment. These disorders occur in 10% to 15% of the general population; the rates are especially high in health care settings, in criminal offenders, and in those with a substance use disorder (SUD).^[2] PDs nearly always have an onset in adolescence or early adulthood and tend to diminish in severity with advancing age. They are associated with high rates of unemployment, homelessness, divorce and separation, domestic violence, substance misuse, and suicide.^[3]

Psychotherapy is the first-line treatment for PDs, but there has been growing interest in using pharmacotherapy to treat PDs. While much of the PD treatment literature focuses on borderline PD,^{[4,5,6,7,8,9]} this article describes diagnosis, potential pharmacotherapy strategies, and methods to assess response to treatment for patients with all types of PDs

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Next Section

Abstract and Introduction
Recognizing and diagnosing personality disorders
The PD clusters
Why consider pharmacotherapy for personality disorders?
Principles for prescribing
Strategies to guide prescribing
What to do before prescribing
Take-home points
Bottom Line
References

Table 1 Questions from the Iowa Personality Disorder Screen
Do you often have days when your mood is constantly changing? How do you feel when you are not the center of attention? Do you frequently insist on having what you want right now? Are you concerned that certain friends or coworkers are not really loyal or trustworthy? Are you concerned about saying the wrong things in front of other people? How often do you avoid getting to know someone because you are worried he or she may not like you?

Source: Reference 12

Table 2 Potential PD symptom dimensions to target
Mood instability Depression/anxiety Psychotic-like symptoms/dissociation/ identity disturbance Anger/hostility Self-harm Impulsivity

PD: personality disorder

Table 3 What to consider before prescribing for a patient with a PD
Potential for overdose. Many patients with PDs are at risk for suicide or self-harm; for such patients, consider prescribing a medication that is not dangerous in overdose Potential for habituation or abuse. Benzodiazepines are not recommended because they might increase acting-out behaviors and self-harm, nor should they be prescribed to patients with a history of substance use disorders Sensitivity for adverse effects. Because many patients with PDs are exquisitely sensitive to medication adverse effects, start with very low doses Concerns about weight gain and metabolic adverse effects. Patients with borderline PD are often obese and at risk for metabolic adverse effects such as glucose intolerance or diabetes; in these patients, some second-generation antipsychotics could cause weight gain or increase their risk for metabolic syndrome³⁴ Treatment compliance. Emphasizing compliance with treatment will help assure a successful medication trial Referral for psychotherapy. Psychotherapy can help patients by targeting their many psychosocial issues (low self-esteem, difficult interpersonal relationships, magical thinking, etc.). A patient with borderline PD should be referred to an evidence-based treatment program

PD: personality disorder

Table 4 Validated scales that could be used to measure PD symptom dimensions
Brief Psychiatric Rating Scale³⁶ Modified Overt Aggression Scale³⁷ State-Trait Anger Expression Inventory³⁸ Beck Depression Inventory³⁹ Positive and Negative Syndrome Scale⁴⁰ Affective Lability Scale⁴¹

PD: personality disorder

Table 5 Sample questions from the ZAN-BPD ⁴² and BEST ⁴³
ZAN-BPD
During the past week, have you… felt very angry? found that your mood has changed suddenly? been unsure of who you are or what you’re really like? had episodes where you felt spaced out or numb? felt as though you were being abandoned though you really weren’t? deliberately hurt yourself without meaning to kill yourself? • felt hatred towards someone you care about and need?
BEST
During the past week, how much has each of the following caused distress, relationship problems, or interfered in getting things done: worrying that someone important in your life is tired of you or planning to leave you severe mood swings several times a day feeling angry feeling of emptiness feeling suicida going to extremes to keep someone from leaving you

BEST: Borderline Evaluation of Severity Over Time; ZAN-BPD: Zanarini Rating Scale for Borderline Personality Disorder

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A clinical approach to pharmacotherapy for personality disorders

Abstract and Introduction

Introduction

Tables

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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