Use medication as adjunct for patients with BPD. (SSRIs, Related Agents are Drugs of Choice).

NEW YORK--Medication plays an important, if adjunctive, role in the treatment of borderline personality disorder by addressing temperamental aspects of the condition that underlie problematic behaviors, Dr. Paul H. Soloff said at a conference on borderline personality disorder sponsored by Columbia University.

Pharmacotherapy should be guided by "the medical model" of chronic illness, in which resolution of exacerbations and complications, and alleviation of disability are the goal.

"We won't cure borderline personality with medications," said Dr. Soloff, who is professor of psychiatry at University of Pittsburgh. "They are an adjunct to psychosocial interventions and psychotherapy."

Research in the area is increasing, but the evidence base for drug treatment is still far smaller for borderline than for other psychiatric disorders. When an American Psychiatric Association task force developed the first practice guideline for the condition (Am. J. Psychiatry 158[10 Supp1.1:1-52, 2001), they found 40-50 studies in this area, "which is miniscule, compared with schizophrenia or depression," he said.

No medication is approved for use in borderline personality, Dr. Soloff pointed out at the meeting, which was also sponsored by the National Education Alliance for Borderline Personality Disorder.

"Some people felt that guidelines were premature, given the small number of studies, but they came in response to demand; practitioners needed them," he said.

Personality may be said to have two dimensions--character, which is primarily learned through family and interpersonal relationships, and temperament, which is biologically determined and presumably mediated by neurotransmitters.

Interpersonal problems and pathology per se are not targets for pharmaco therapy, but the biologic substrates thought to underlie specific symptom domains--impulsive-behavioral dyscontrol, affective in- stability, and coguitive-perceptual distortions--can be addressed with the same strategies that work in other disorders, Dr. Soloff said.

"Affective instability in borderlines responds to the same medications as in manic depression, and we believe the same neurotransmitters are involved," he said.

Similarly, borderline patients under stress develop transient delusions and ideas of reference, which though milder than the psychotic symptoms of schizophrenia, presumably reflect similar dopamine activation and can be treated with the same drugs.

Drawing on the algorithm proposed by the APA treatment guideline, Dr. Soloff suggested that for affective dysregulation, as reflected by anger or temper outbursts, rejection sensitivity, or depressed or labile mood, selective serotonin reuptake inhibitors (SSRIs) or related agents are the drugs of choice.

If neither of two successive SSRIs is effective, the next step might be a low-dose antipsychotic if anger is a significant component, or clonazepam if anxiety predominates. A switch to a monoamine oxidase (MAO) inhibitor could follow

Switching to or adding a mood stabilizer should be the next step. The research is strongest for lithium, although some studies support valproate or carbamazepine in this context, he said.

For coguitive-perceptual symptoms, which typically take the form of dissociation, illusions, paranoid ideation, or hallucinations and can lead to aggressive behavior, low-dose antipsychotics, such as 2.5-10 mg of olanzapine and 1-4 mg/day of risperidone, are the first choice, with an increased dose if they fail.