Personality disorders: Treatment overview
Treatment of co-occurring disorders
Clinicians who diagnose a co-occurring personality disorder and other psychiatric disorder should consider providing psychotherapy and pharmacotherapy. Several careful reviews of the literature indicate that personality pathology, despite popular belief, does not worsen the outcome of major depressive disorder (Mulder, 2002; Kool et al., 2005).
This finding is is very important for primary care providers to keep in mind. The strongest support that personality pathology predicts poor outcome comes from the weakest studies, which did not carefully define personality, who was treated, how the treatment was conducted or how outcome was defined.
Pharmacotherapy with a co-occurring psychiatric diagnosis
It is important to identify the comorbid psychiatric diagnosis and treat robustly with the appropriate medication. If there is a comorbid personality disorder, the main pharmacotherapy adjustment is to consider the toxicity of large amounts of medication because patients with BPD have a potential for overdose.
Comorbid bipolar disorder and BPD
The use of lithium for comorbid bipolar disorder and BPD is somewhat controversial. Several good studies demonstrate that lithium for patients with bipolar disorder without comorbid personality disorder can reduce suicidal behaviours and completed suicides (Baldessarini et al., 2006; Cipriani et al., 2005). However, there is no research about suicide and lithium in patients with BPD and comorbid bipolar disorder. This is important because lithium has a narrow therapeutic range for lethal overdose.
Comorbidity of bipolar disorder and BPD has been estimated to be between nine per cent (Zanarini et al., 2004) and 28 per cent (Gunderson et al., 2006). Clarifying this comorbidity is important because modifications in pharmacotherapy (e.g., using atypical antipsychotics instead of lithium) will be required in patients with comorbid bipolar disorder and BPD.
Pharmacotherapy for target symptoms
When using medication, it is preferable to target identifiable comorbid psychiatric diagnoses other than the personality disorder and use the appropriate medication. However, when clearcut comorbid diagnoses are not present, it is reasonable to consider medications for target symptoms (e.g., brief psychotic reactions or emotional lability).
The literature suggests that mood stabilizers (Cowdry, 1992) and atypical neuroleptics can target symptoms. Atypical neuroleptics have sometimes been seen as ego or brain "glue," making these patients less sensitive to characteristic meltdowns.
Borderline personality disorder: recognition and management (NICE guideline CG78, 2009)
Antisocial personality disorder: prevention and management (NICE guideline CG77], 2008)
Clinical Practice Guideline for the Management of Borderline Personality Disorder (National Health and Medical Research Council, 2012)
Treatment guidelines for personality disorders (Project Air, 2015)