A preliminary study of lamotrigine in the treatment of affective instability in borderline personality disorder

Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA 02478, USA.
International clinical psychopharmacology (Impact Factor: 2.46). 07/2009; 24(5):270-5. DOI: 10.1097/YIC.0b013e32832d6c2f
Source: PubMed


The objective of this study was to evaluate the effectiveness of lamotrigine in reducing affective instability in borderline personality disorder (BPD). We conducted a 12-week, double-blind, placebo-controlled study of 28 patients who met Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for BPD. Patients could not meet Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for bipolar disorder. Patients could be taking one antidepressant during the study. Patients were randomly assigned to treatment with flexible-dose lamotrigine or placebo in a 1 : 1 manner. The primary outcome measures were: (i) the Affective Lability Scale total score; and (ii) the Affective Instability Item of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). The study randomized 15 patients to receive lamotrigine and 13 patients to receive placebo. Patients in the lamotrigine group had significantly greater reductions in the total Affective Lability Scale scores (P<0.05) and significantly greater reductions in scores on the affective instability item of the ZAN-BPD (P<0.05). A secondary finding was that patients in the lamotrigine group had significantly greater reductions in scores on the ZAN-BPD impulsivity item (P = 0.001). Results from the study suggest that lamotrigine is an effective treatment for affective instability and for the general impulsivity characteristic of BPD.

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    • "However, adverse cognitive sequelae may interfere with psychotherapy for some BPD patients, and potential weight loss may become troubling for patients with comorbid eating disorders. Lamotrigine treatment improves impulsivity, affective symptoms,111 and aggression,41,112 but it requires lengthy titration to avoid life-threatening rash and toxicity. Valproate appears to be particularly efficacious in BPD patients with prominent impulsive aggression, rather than affective instability.113 "
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    ABSTRACT: The best available evidence for psychopharmacologic treatment of borderline personality disorder (BPD) is outlined here. BPD is defined by disturbances in identity and interpersonal functioning, and patients report potential medication treatment targets such as impulsivity, aggression, transient psychotic and dissociative symptoms, and refractory affective instability Few randomized controlled trials of psychopharmacological treatments for BPD have been published recently, although multiple reviews have converged on the effectiveness of specific anticonvulsants, atypical antipsychotic agents, and omega-3 fatty acid supplementation. Stronger evidence exists for medication providing significant improvements in impulsive aggression than in affective or other interpersonal symptoms. Future research strategies will focus on the potential role of neuropeptide agents and medications with greater specificity for 2A serotonin receptors, as well as optimizing concomitant implementation of evidence-based psychotherapy and psychopharmacology, in order to improve BPD patients' overall functioning.
    Full-text · Article · Jun 2013
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    • "BPD patients than in other personality disorders (Gunderson et al., 2006). Finally, treatment studies indicate that mood stabilizers may ameliorate the symptoms of both disorders (Hollander et al., 2003; Reich et al., 2009). A recent epidemiologic study clearly showed that, among DSM-IV Axis I disorders, BPD displayed its highest association with BD, even when controlled for additional comorbidity (Grant et al., 2008). "
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    ABSTRACT: BACKGROUND: The nature of the relationship between bipolar disorder (BD) and borderline personality disorder (BPD) is controversial. The aim of this study was to characterize the clinical profile of patients with BD and comorbid BPD in a world-wide sample selected during a major depressive episode (MDE). METHODS: From a general sample of 5635 in and out-patients with an MDE, who were enrolled in the multicenter, multinational, transcultural BRIDGE study, we identified 2658 subjects who met bipolarity specifier criteria. Bipolar specifier patients with (BPD+) and without (BPD-) comorbid BPD were compared on diagnostic, socio-demographic, familial and clinical characteristics. RESULTS: 386 patients (14.5%) met criteria for BPD. A diagnosis of BD according to DSM-IV criteria was significantly more frequent in the BPD- than in BPD+, while similar rates in the two groups occurred using DSM-IV-Modified criteria. A subset of the BD criteria with an atypical connotation, such as irritability, mood instability and reactivity to drugs were significantly associated withthe presence of BPD. BPD+ patients were significantly younger than BPD- bipolar patients for age, age at onset of first psychiatric symptoms and age at first diagnosis of depression. They also reported significantly more comorbid Alcohol and Substance abuse, Anxiety disorders, Eating Disorder and Attention Deficit Hyperactivity Disorder. In comparison with BPD-, BPD+ patients showed significantly more psychotic symptoms, history of suicide attempts, mixed states, mood reactivity, atypical features, seasonality of mood episodes, antidepressants induced mood lability and irritability, and resistance to antidepressant treatments. LIMITATIONS: Centers were selected for their strong mood disorder clinical programs, recall bias is possible with a cross-sectional design, and participating psychiatrists received limited training. CONCLUSIONS: We confirm in a large sample of BD patients with MDE the high prevalence of patients who meet DSM-IV criteria for BPD. Further prospective researches should clarify whether the mood reactivity and instability captured by BPD DSM-IV criteria are distinguishable from the subjective mood of an instable, dysphoric, irritable manic/hypomanic/mixed state or simply represent a phenotypic variant of BD, related to developmental factors.
    Full-text · Article · Aug 2012 · Journal of Affective Disorders
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    ABSTRACT: The drug treatment of affective symptoms in borderline personality disorder (BPD) has been the subject of four recent meta-analyses of randomized controlled studies (RCTs). This paper reviews the current evidence-based recommendations for the psychopharmacological treatment of the affective symptoms in BPD: affective instability, anger, depression, and anxiety. There was not enough data on affective instability as an outcome measure to make a good conclusion. Most of the evidence point to a large reduction of anger with mood stabilizers and antipsychotics. Mood stabilizers are also moderately effective against depressed mood and anxiety. Contrary to prior guidelines, selective serotonin reuptake inhibitors (SSRIs) were shown to be minimally effective against depression in BPD. Omega 3 fatty acids helped reduce depression. These results suggest that clinicians should raise their threshold for prescribing medication for affective instability, anxiety, and depression, but not for anger. Clinicians must also weigh the benefits of medication over their side effects in the neurologic and metabolic domains. The meta-analyses were limited by the heterogeneity in methodology, by the small number of RCTs for each drug and small sample sizes, and by the exclusion of patients with comorbidities that are common in this population.
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