Effectiveness of Pharmacotherapy for Severe Personality Disorders: Meta-Analyses of Randomized Controlled Trials

ArticleinThe Journal of Clinical Psychiatry 71(1):14-25 · September 2009with51 Reads
DOI: 10.4088/JCP.08r04526gre · Source: PubMed
Abstract
There has been little systematic attempt to validate current pharmacologic treatment algorithms and guidelines for severe personality disorder. We evaluated studies on the effectiveness of psychoactive drugs on specific symptom domains for borderline and/or schizotypal personality disorder. The literature was searched for placebo-controlled randomized clinical trials (PC-RCTs) on the effectiveness of psychopharmacologic drugs in personality disorder patients. The PubMed, PsychINFO, PiCarta, Cochrane, and Web of Science databases were searched using the search terms borderline personality, schizotypal personality, personality disorder, cluster A, cluster B, treatment, drug, pharmacotherapy, antipsychotic, antidepressant, mood stabilizer, effect, outcome, review, and meta-analysis for studies published between 1980 and December 2007, and references were identified from bibliographies from articles and books. Placebo-controlled randomized clinical trials on the efficacy of antipsychotics, antidepressants, and mood stabilizers regarding cognitive-perceptual symptoms, impulsive-behavioral dyscontrol, and affective dysregulation (with subdomains depressed mood, anxiety, anger, and mood lability) were selected in patients with well defined borderline and/or schizotypal personality disorder. Studies whose primary emphasis was on the treatment of Axis I disorders were excluded. Meta-analyses were conducted using 21 retrieved studies. Antipsychotics have a moderate effect on cognitive-perceptual symptoms (5 PC-RCTs; standardized mean difference [SMD]=0.56) and a moderate to large effect on anger (4 PC-RCTs; SMD=0.69). Antidepressants have no significant effect on impulsive-behavioral dyscontrol and depressed mood. They have a small but significant effect on anxiety (5 PC-RCTs; SMD=0.30) and anger (4 PC-RCTs; SMD=0.34). Mood stabilizers have a very large effect on impulsive-behavioral dyscontrol (6 PC-RCTs; SMD=1.51) and anger (7 PC-RCTs; SMD=1.33), a large effect on anxiety (3 PC-RCTs; SMD=0.80), but a moderate effect on depressed mood (5 PC-RCTs; SMD=0.55). Mood lability as an outcome measure was seldomly assessed. Mood stabilizers have a more pronounced effect on global functioning (3 PC-RCTs; SMD=0.79) than have antipsychotics (5 PC-RCTs; SMD=0.37). The effect of antidepressants on global functioning is negligible. Drug therapy tailored to well-defined symptom domains can have a beneficial effect on patients with severe personality disorder. The findings from this study raise questions on current pharmacologic algorithms.
    • "In a review study, Yoshimatu and Palmer [8] concluded that depression in BPD is more chronic form of depression, which shows poor response to the treatment until BPD symptomatology improves. Studies did not show improvement in depression in BPD with treatments such as pharmacotherapy and ECT [9, 10] . This treatment resistant depressive experience is characterized by a high degree of emotional sensitivity that can lead to more frequent or intense and chronic negative affective experiences [11, 12] . "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Individuals with Borderline Personality Disorder (BPD) may experience a qualitatively distinct depression which includes "mental pain." Mental pain includes chronic, aversive emotions, negative self-concept, and a sense of pervasive helplessness. The present study investigated whether mental pain is elevated in BPD compared to Depressive Disorders (DD) without BPD. Methods: The Orbach and Mikulincer Mental Pain Scale (OMMP) was administered to BPD (N = 57), DD (N = 22), and healthy controls (N = 31). The OMMP assesses total mental pain, comprised of nine subtypes: irreversibility, loss of control, narcissistic wounds, emotional flooding, freezing, self-estrangement, confusion, social distancing, and emptiness. Co-occurring psychiatric diagnoses, depression severity, and other potentially confounding clinical and demographic variables were also assessed. Results: The total Mental Pain score did not differentiate BPD from DD. Moreover, most of the subscales of the OMMP were not significantly different in BPD compared to DD. However, the elevation of mental pain subscale "narcissistic wounds," characterized by feeling rejected and having low self-worth, was a specific predictor of BPD status and the severity of BPD symptoms. Conclusion: On OMMP total score, mental pain was similarly elevated in BPD and DD. However, the narcissistic wounds sub-type of mental pain was a sensitive and specific diagnostic indicator of BPD and, therefore, may be an important aspect of BPD in need of increased focus in assessment and theoretical models.
    Full-text · Article · Dec 2016
    • "However, subjects with ADHD and PD did improve in their core ADHD symptoms, especially emotional dysregulation , but also oppositional defiant symptoms. Second, several medication studies report that psychotropic medications may impact emotional symptoms connected with borderline personality (Ingenhoven and Duivenvoorden, 2011; Lieb et al., 2010; Mercer et al., 2009; Vita et al., 2011) and severe PD (Ingenhoven et al., 2010). Conversely, none of these studies documented improvement in the areas of self-perception and interpersonal functioning assessed by the WISPI-IV. "
    [Show abstract] [Hide abstract] ABSTRACT: Personality disorders (PDs) are commonly found in adults with attention-deficit/hyperactivity disorder (ADHD) and are associated with increased ADHD symptoms and psychosocial impairment. To assess the impact of PDs or personality traits on retention rates in ADHD trials and whether treating ADHD affects the expression of PD, data were analyzed from 2 methylphenidate trials. Assessment of PDs and personality traits included using the Wisconsin Personality Disorders Inventory IV and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Personality Disorders. Attention-deficit/hyperactivity disorder symptoms were evaluated using the Wender-Reimherr Adult Attention Deficit Disorder Scale. Major findings were that subjects with cluster A, cluster B, passive-aggressive, or more than 1 PD showed more attrition. Subjects dropping out also had more schizoid and narcissistic traits. Attention-deficit/hyperactivity disorder symptoms (p < 0.001) and all personality traits (range, p = 0.03 to p = 0.001) improved, but there was almost no correlation between changes on these 2 measures. Conversely, of 11 Wisconsin Personality Disorders Inventory IV items that improved most, 8 resembled ADHD or oppositional defiant disorder symptoms. Copyright
    Article · May 2016
    • "First of all, they may support the opinion expressed by some authors (Saddichha and Schuetz, 2014) that non-planning impulsivity needs to be taken into account when planning for treatment, as it leads to poor problem solving and low resilience, and to a lack of sense of future. As regards drug treatment, we found only one randomized controlled trial dealing with impulsivity in bipolar disorders, which showed an improvement of nonplanning impulsivity with lithium (Hollander et al., 2005), although there is some evidence for efficacy of other mood stabilizers , antipsychotics and antidepressants on impulsive behavior (Ingenhoven et al., 2010; Singh and Zarate, 2006). Our finding may explain why there are contradictory data regarding better adherence with lithium as compared to other mood stabilizers in bipolar patients (Sajatovic et al., 2007). "
    [Show abstract] [Hide abstract] ABSTRACT: Adherence to medication is a major issue in bipolar disorder. Non-planning impulsivity, defined as a lack of future orientation, has been demonstrated to be the main impulsivity domain altered during euthymia in bipolar disorder patients. It was associated with comorbidities. To investigate relationship between adherence to medication and non-planning impulsivity, we included 260 euthymic bipolar patients. Adherence to medication was evaluated by Medication Adherence Rating Scale and non-planning impulsivity by Barrat Impulsiveness Scale. Univariate analyses and linear regression were used. We conducted also a path analysis to examine whether non-planning impulsivity had direct or indirect effect on adherence, mediated by comorbidities. Adherence to medication was correlated with non-planning impulsivity, even after controlling for potential confounding factors in linear regression analysis (Beta standardized coefficient=0.156; p=0.015). Path analysis demonstrated only a direct effect of non-planning impulsivity on adherence to medication, and none indirect effect via substance use disorders and anxiety disorders. Our study is limited by its cross-sectional design and adherence to medication was assessed only by self-questionnaire. Higher non-planning impulsivity is associated with low medication adherence, without an indirect effect via comorbidities. Copyright © 2015 Elsevier B.V. All rights reserved.
    Full-text · Article · May 2015
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