The role of pharmacotherapy in the treatment of patients with borderline personality disorder

Most patients with borderline personality disorder (BPD), especially early in their treatment, will need pharmacotherapy along with supportive or exploratory psychotherapy. A benzodiazepine anxiolytic will suffice for some. Many require more definitive treatment with an antidepressant or a neuroleptic in low dosage. Those with bipolar II comorbidity may benefit from lithium or, if the irritability component is pronounced, from carbamazepine. In practice, a variety of personality factors and comorbid conditions, over-represented in populations of BPD patients, often complicate the clinical picture. Depending upon the mix of these factors, drugs may have to be avoided, nonstandard combinations of drugs may be necessary, or a safer but less effective drug may have to be substituted for a generally more effective drug whose abuse in a suicidal patient might have more dangerous consequences. Examples of complicating factors, namely premenstrual syndrome (PMS), bulimia, agoraphobia, major affective (including bipolar II manic-depressive) disorder, hypersomnia, and so forth are discussed.