'Borderline' drugs: a limited role.

"Borderline' drugs: A limited role

One of the more common diagnoses of psychiatric patients in hospitals or in psychotherapy is "borderline personality disorder,' a label now estimated to include up to 20 percent of all such patients. Much about the disorder and its treatment remains uncertain and open to debate, yet drug treatments for borderline patients have proliferated in the past 10 years.

Now, the first two carefully controlled studies of several medications prescribed for borderline personality appear in the July ARCHIVES OF GENERAL PSYCHIATRY. Taken together, the reports indicate that low doses of neuroleptics (often used to treat psychotic symptoms) taken for short periods can ease some severe and longstanding borderline symptoms. But an antidepressant drug used in one study was no more effective than inactive "placebo' pills, although antidepressants are often used with borderline patients.

Neuroleptics, however, did not wipe away core features of the disorder. These features include intense and unstable relationships, self-destructive, impulsive behavior (such as drug abuse), fears of being abandoned, intolerance of being alone, suicide attempts aimed at manipulating others, persistent feelings of emptiness, and rage alternating with a childish dependency on others. An example of borderline behavior is the person who calls a crisis hotline threatening to commit suicide, then--insisting that the crisis counselor does not really care --refuses to give an address or seek help.

Many borderline personalities tend to slip into a short-lived psychosis under stress or the influence of drugs. When compared with placebos, neuroleptics used in the two new studies markedly diminished the delusions, hallucinations and disconnected thoughts typical of psychosis, as well as depression, anxiety, feelings of losing one's identity or being someone else, paranoid thoughts, phobias, obsessions and compulsions.

The findings point to "a real, albeit limited role' for neuroleptics in treating borderline patients, psychiatrist John G. Gunderson of McLean Hospital in Belmont, Mass., a leading investigator of the disorder, notes in the same issue of the journal. "In my experience,' he says, "a considerable fraction of borderline patients, especially outpatients, does not have the [symptoms] that, according to these studies, [call] for . . . drug therapy.'

In one report, Solomon C. Goldberg of the Medical College of Virginia in Richmond and his colleagues randomly assigned 50 outpatients with borderline personality disorder and, in some cases, related symptoms such as "magical thinking' and hypersensitivity to criticism, to 12 weeks of treatment with thiothixene (a neuroleptic) or a placebo. Borderline patients with the related symptoms responded best to the neuroleptic, while "pure' borderlines showed a surprising improvement in core personality features while on the placebo. This indicates, say the researchers, that the latter symptoms respond to the attention and support also available in psychotherapy.

The other report, conducted by Paul H. Soloff of the University of Pittsburgh and his colleagues, followed 61 borderline patients randomly assigned to 5-week trials of haloperidol (a neuroleptic), amitriptyline (an antidepressant) and a placebo. Haloperidol produced modest improvements in psychotic symptoms, depression and several other areas; there was no difference between amitriptyline and placebo, but a few patients actually became worse when given the antidepressant, say the researchers.

Side effects caused 10 of 47 patients given neuroleptics in the two studies to drop out. Since these drugs can cause severe movement disorders (SN: 7/20/85, p. 45), Gunderson says neuroleptic treatment should be in low doses and for short periods.