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Personality disorder medication guide

Medication

The use of medication to 'treat' people given a diagnosis of personality disorder is, to say the very least, controversial. This language suggests that it is possible, and desirable, to treat personality itself. National guidelines state that medication should not routinely be used for the treatment of people given a diagnosis of borderline personality disorder or antisocial personality disorder.

NICE Guidelines on medication and personality disorder

Guidelines from the National Institute of Clinical Excellence (NICE) state that drug treatments should not be used to treat borderline personality disorder, antisocial personality disorder or  behaviour or ‘symptoms’ associated with these diagnoses (e.g. self harm, marked emotional instability, risk taking behaviour, anger, aggression and transient psychotic behaviour).  Guidelines have not been developed for the treatment of people given a diagnosis of other personality disorders.

In addition the guidelines state that antipsychotic drugs (also known as major tranquilisers) should not be used for the medium or long term treatment of borderline personality disorder.

According to NICE guidelines the only time medication should be considered is;

  • when an individual has additional mental health problems that should be treated according to guidelines for those diagnoses (e.g. an eating disorder, alcohol dependence, depression)
  • as a short term measure (for no more than one week) during a crisis

If your treatment, or that of someone you care about, does not seem in keeping with these guidelines you can find out what to do on the Treatment and Your Rights section of this website.

To read the NICE guidelines in full go to the Resources section of this website.

Issues to think about

  • Opinion is divided about the use of medication in mental health. Some people find it helpful to take medication whereas others object to it.
  • The use of medication to ‘treat’ mental health issues is based on understanding peoples’ distress as a physical problem in the brain such as a chemical imbalance, rather than a response to our living situation or experiences.
  • Medication, like any other drugs, alters the chemistry of our brain and makes us feel differently. Some people find this helpful or necessary and others find it distressing or unhelpful.
  • Drugs cannot target the particular feelings, thoughts or perceptions we might be struggling with but will have a much broader impact.
  • Some people argue that when the medication stops and the effects of the drug wear off then they are left with the same problems and difficulties that led them to take it in the first place. This may be because they have not dealt with the underlying causes or issues but simply dulled their own response to it.
  • Medication does not cure mental health issues but offers some relief from ‘symptoms’.
  • Many people experience unwanted effects from medication, often called side effects. For some people these are intolerable but others are less affected or decide the benefits outweigh the unwanted effects.

There are many different points of view about the use of medication and people will find different things helpful at different times. Some people find it useful to consider these issues because mental health services and GPs often work with a particular understanding of mental health which makes the use of medication seem inevitable. However, unless you are under a section of the Mental Health Act or a court order, you have a choice about whether or not to take medication (for more information see Treatment and Your Rights section of this website).

For more information about different views on the use of medication see the Links section of this website.

Unwanted side effects

All drugs cause unwanted effects, often called side effects. Each individual will be affected differently so will need to weigh up for yourself whether the benefits of a medication outweigh the side effects. To help you make an informed decision it is important that you have access to information. Every time you are prescribed a new medication you should be given a leaflet about it and have the chance to talk to your Doctor or psychiatrist about side effects. If you don’t feel you have been given enough information ask to speak to your Doctor or a pharmacist or find more information in the Links section of this website.

Many of the common side effects often improve as your body adjusts to the medication. If you find this is not the case you can talk to your Doctor about changing the dosage, the type of medication you are on or trying alternatives to drugs.

Information about periods and pregnancy

Some medications may affect your periods, and sometimes stop your periods altogether. It is still possible to get pregnant in this situation. Even if your periods stop, continue to use contraception.

Some medications affect how well the contraceptive pill works, so if you usually take the pill to prevent getting pregnant and are prescribed another medication, talk to your Doctor about this.

Many drugs can affect a foetus in the womb, or be passed on through breast milk so if you are planning to get pregnant, are already pregnant or breast feeding speak to your Doctor about your medication.

Many psychiatric drugs have a withdrawal effect which mimics the original symptoms the drug was prescribed to treat. For example some antidepressants may make people feel depressed as you stop taking them. Similarly when people stop taking some anti psychotic drugs the medication has a rebound effect and an individual may experience psychotic symptoms. This often leads both clinicians and people having treatment to mistakenly think that they need to restart or continue the medication.

Antidepressant medications

People given a diagnosis of personality disorder often experience feelings linked to depression such as a feeling of chronic emptiness, hopelessness, lack of energy etc. It is quite common for people to be given a diagnosis of depression as well as personality disorder. According to NICE guidelines, it is only in these circumstances or when someone is in crisis that medication should be prescribed. There is some evidence to show that anti depressants may be helpful in treating depression where this sits alongside a diagnosis of personality disorder. However research does not indicate it is helpful in the routine treatment of feelings of depression often experienced by people given a diagnosis of BPD.

Antidepressant medications may take several weeks before they have any noticeable effect on mood. To see whether a treatment is helpful to you would need to persevere for several weeks to give them an opportunity to work.

There are a number of different types of antidepressants which work in different ways. People often find that they respond to some types of antidepressant much better than others so it is common for people to try a few different types before finding which, if any, work best for them. However antidepressants do not work for everybody and individuals may choose not to continue taking these drugs.

  • Tricyclic Antidepressants (TCA)

e.g. amitryptyline (Tryptizol®); clomipramine (Anafranil®); dothiepin (Prothiaden®); lofepramine (Gamanil®); and many others.

This group of older antidepressants are thought to tackle depression by increasing energy levels and improving sleep and appetite. They block the reuptake of certain neurotransmitters (chemicals within the brain which act as messengers between cells and areas of the brain), noradrenaline and serotonin. These neurotransmitters are associated with the regulation of moods. Whilst these drugs act on these systems there is no evidence to suggest that people experiencing depression have an imbalance or abnormality in these systems.

There is evidence to suggest that amitriptyline can be helpful in treating depression among people given a diagnosis of borderline personality disorder. However NICE guidelines state that this group of antidepressants ought to be avoided in the treatment of people given a diagnosis of BPD because of considerable unwanted/side effects.

  • Selective Serotonin Reuptake Inhibitors (SSRIs)

e.g. fluoxetine (Prozac®); fluvoxamine (Faverin®); paroxetine (Seroxat®); citalopram (Cipramil®); sertraline (Lustral®)

This more modern group of antidepressants usually cause fewer side effects than tricyclic antidepressants. According to NICE guidelines however, there is no evidence that that they are effective in treating depression for people given a diagnosis of BPD. They are called selective because they do not act on the noradrenaline system (which tryclyclics do) but do affect the serotonin system. They are thought to work mainly by reducing people’s reactions to triggers in their environment, by producing a serenic effect. There are some doubts about their effectiveness in treating very severe depression where an individual may need to go into hospital.

According to NICE Guidelines there is no evidence that these drugs are effective in treating people given a diagnosis of BPD.

  • Monoamine Oxidase Inhibitors (MAOIs)

e.g isocarboxazid (Marplan); phenelzine (Nardil); moclobemide (Mannerix/Aurorix); tranylcypromine (Parnate)

This group of medications tend to be used only in the most severe cases of depression as they have considerable side effects including interactions with a broad range of foods. As their name suggests they act by reducing the activity of monoamine oxidase which breaks down monoamine neurontransmitters. As a result these drugs increase the availability of monoamine neurotransmitters such as norepinephrine, dopamine and serotonin which are thought to be involved in mood regulation.

Evidence suggests that phenelzine (Nardil) may be effective in treating hostility among people given a diagnosis of BPD but there is no evidence that it is helpful with any other symptoms.

Medication Common unwanted/side effects Less common unwanted/side effects
Tricyclic Antidepressants (TCAs) Drowsiness, constipation, dry mouth, blurred vision, weight gain, headache. Twitching, jerks, confusion or disorientation, hallucinations.
SSRIs Drowsiness, nausea and vomiting, insomnia, sexual dysfunction, loss of appetite, dry mouth, headache, tooth grinding, sexual dysfunction. Twitching, jerks, shake,tremor, dyskinesias, confusion or disorientation,mania, psychosis, suicidality.
MAOIs Dizziness/faintness on standing (postural hypotension), drowsiness, feeling alert and unable to sleep, dry mouth, headache, constipation. Twitching, jerks, confusion or disorientation, hallucinations, 'the cheese effect' - dangerous increase in blood pressure if certain foods eaten.

This information refers to some of the most common antidepressant medications but there are many more, for more information on different medications see the links section of this website.

Antipsychotic medications also known as major tranquilisers or neuroleptics

This group of medications are often called antipsychotics but they do not specifically target the symptoms of psychosis and are better understood as tranquilisers. People taking these medications often talk about feeling detached or less bothered by the things that were causing them distress, this has been described a as a feeling of ‘who cares?’ As a result the difficult experiences associated with psychosis may be reduced or not feel as all consuming as they were without medication.

NICE Guidelines state that antipsychotic drugs should not be used in the medium or long term treatment of people given a diagnosis of borderline personality disorder, or the routine treatment of people given a diagnosis of antisocial personality disorder. However it has in the past been common practise to prescribe antipsychotics to people given a diagnosis of PD to reduce difficulties such as dissociative symptoms, self-destructive impulses, aggression, hallucinations, paranoid thoughts and also intense anxiety, anger or irritability.

Many people who have taken antipsychotics say the unwanted side effects make it harder, or even impossible, to do the activities that they know help their overall wellbeing and mental health (e.g. exercising, spending time with other people, learning new things, reading). This is likely to be because one of the side effects can be a loss of interest and motivation.

Antipsychotic drugs, like all psychiatric medication has an impact by altering the effects of neurotransmitters, chemicals within the brain which act as messengers between cells and different areas within the brain. Antipsychotics reduce activity of the neurotransmitter known as dopamine and it is this which creates the feeling of detachment. However drugs cannot influence just one targeted neurotransmitter and so antipsychotics also impact on others such as serotonin and noradrenaline.

Tranquilisers or antipsychotics can be broadly separated into two groups, the main differences between these are the way they are thought to work and the unwanted or side effects they cause. Second generation, or atypical, antipsychotics are now prescribed more frequently than the older first generation drugs which have very unpleasant and significant side effects.

There has not been much research comparing the effects of different antipsychotics and so there is no evidence to say which one, if any, are most effective in treating people given a diagnosis of PD.

  • First generation or typical antipsychotics

e.g. chlorpromazine (Largactil®), flupenthixol (Depixol®), fluphenazine (Moditen®, Modecate®) haloperidol (Serenace®, Haldol®), trifluoperazine (Stelazine®), zuclopenthixol (Clopixol®), trifluoperazine (Stelazine®) and others.

  • Second generation or atypical antipsychotics

e.g. aripiprazole (Abilify®), olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), amisulpiride (Solian®), clozapine (Clozaril®), zotepine (Zoleptil®), ziprasidone

Medication Common unwanted/side effects Less common unwanted/side effects
First generation/typical antipsychotics Extra-pyramidal side effects e.g. a sensation of inner restlessness/ agitation or turmoil, involuntary movement disorders, rigidity, slow movement/stiffness. Reduced sex drive and ability to ejaculate/orgasm. Hormonal changes, drowsiness, constipation, dry mouth, weight gain, blurred vision, lack of motivation/interest, and altered menstrual cycle, weight gain, thirst. Tardive dyskinesia (abnormal movements of mouth and face), muscle spasms( known as dystonia), suicide.
Second generation/atypical antipsychotics Weight gain, Reduced sex drive and ability to ejaculate/orgasm. drowsiness, excessive salivation, constipation, low blood pressure, lack of motivation/interest, hormonal changes, thirst. Extra-pyramidal side effects e.g. a sensation of inner restlessness/ agitation or turmoil, involuntary movement disorders, rigidity, slow movement/stiffness, tardive dyskinesia (abnormal movements of mouth and face), muscle spasms (known as dystonia), suicide.

Mood stabilisers/anti manic drugs

Common Examples:  Lithium (Priadel®, Camcolit®), Carbamazine (Tegretol®),  Oxcarbazepine (Trileptal®), Sodium Valporate (Epilim®), Valporate Semisodium (Depakote®), Gabapentin (Neurontin®)

Others: lamotrigine (Lamictal®), clonazepam (Rivotril®), tiagabine (Gabitril®), topiramate (Topamax®) and vigabatrin (Sabril®)

Medications often known as mood stabilisers are called this because of the effect they are believed to have on people rather than the way they work or the chemical process that they induce within the body. Most mood stabilisers except Lithium are anti convulsants which means they are used to treat epilepsy. It is not known how they work but one theory is that they stabilise the way that cells in the brain (called neurons) are fired and so reduce the likelihood of excessive firing.

Most research on mood stabilisers has focused on the treatment of people given a diagnosis of bipolar disorder (also known as manic depression or bipolar affective disorder). People given a diagnosis of personality disorder often report experiences of intense mood swings and other difficulties such as explosive anger, impulsivity, aggression and feelings of depression, linked to mood. As a result these drugs have been used to treat mood related symptoms in people given a diagnosis of PD. However, a review of research carried out by NICE concluded that there is no evidence to show that any medications are effective as an overall mood stabiliser for people given a diagnosis of borderline personality disorder.

Unwanted side effects:

Some mood stabilisers affect how well the contraceptive pill works, so if you usually take the pill to prevent getting pregnant and are prescribed a mood stabiliser, talk to your doctor about this.

Lithium is a very toxic substance, which must be very closely monitored by regular blood tests to prevent blood levels becoming dangerously high. It can interact with other medications to produce concentrations above the acceptable range. Signs of excessive amounts of lithium in the blood are unsteadiness, confusion and blurred vision.

Medication Common unwanted/side effects Less common unwanted/side effects
Lithium Tremor, nausea, diarrhoea, excessive thirst, frequent urination, weight gain, thyroid problems, discordination or muscle weakness, skin and hair changes. Unsteadiness, confusion, blurred vision – these can be signs of excessive lithium in the blood and immediate medical attention is required.
Carbamazine Drowsiness, double vision, dizziness, nausea, vomiting, sedation, skin rashes. Slight risk of significant reduction in white blood cell count (agranulocytosis). Talk to your Doctor About any infection you develop.
Sodium Carbamazine Increased appetite, weight gain, nausea, stomach irritation, drowsiness. Very rarely the liver can be affected so regular liver tests are performed at the beginning of treatment.
Gabapentin Drowsiness, dizziness, discoordination, visual disturbances, headaches, tremor, nausea, vomiting, slurred speech,throat pains. Pancreatitus, liver problems, skin condition known as Stevens-Johnson syndrome – if you notice any skin problems, tingling or itching let your Doctor know immediately.
Sodium Valporate Nausea, stomach cramps, diarrhoea, tremor, lethargy, weight gain, slurred speech, hair thinning/change in texture. For women - irregular periods, gynaecomastia (breast enlargement), polycystic ovaries, increase in testosterone levels. Blood abnormalities – if you notice any unusual bruising, coughing or a sore throat tell your Doctor straight away. Liver damage, pancreatitis.
Valporate Semisodium Nausea, stomach cramps, diarrhoea, tremor, lethargy, weight gain, slurred speech, hair thinning/change in texture. Blood abnormalities – if you notice any unusual bruising, coughing or a sore throat tell your Doctor straight away. Liver damage, pancreatitis.
Lamotrigine Rashes, fevers. skin condition known as Stevens-Johnson syndrome - if you notice any skin problems, tingling or itching let your Doctor know immediately.

 

Information gathered from:

Full NICE Guidelines for Borderline Personality Disorder

D. Healy (2009) Psychiatric Drugs Explained Elsevier

 




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