An update on pharmacotherapy for personality disorders

Personality disorders are common and present in many medical settings. Prevalence ranges between 4% and 15%, both in men and in women [1 Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet. 2015;385:717–726. [CrossRef], [PubMed], [Web of Science ®] ]. The highest prevalence has been reported in people followed by with health-care services and in people in contact with the criminal justice system. Patients with personality disorders have higher morbidity and mortality than others, partly because they present an increased incidence of suicide and homicide, partly for poor research for care and lifestyle factors that amplify the risk for cardiovascular and respiratory diseases. Many patients suffer from multiple personality disorders or traits that span several types of disturbances; besides significant comorbidity exists with alcohol and chemical abuse, and with anger traits [2 Angstman KB, Rasmussen NH. Personality disorders: review and clinical application in daily practice. Am Fam Physician. 2011;84(11):1253–1260. [PubMed], [Web of Science ®] ]. Problems in coping with interpersonal relationships that are at the heart of the majority of personality disorders can also affect therapeutic relationships. Experts generally agree that personality disorders have roots in childhood and adolescence, but many clinicians avoid the diagnosis at early ages for the fear of stigmatizing patients. The 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes the dimensional nature of personality disorders across the lifespan and has removed age-related caveats for this diagnosis in young people. There is evidence that patients with personality disorders are prescribed psychotropic medications with greater frequency than any other diagnostic group. Nevertheless, since in the USA there are no FDA-approved medication for the treatment of these disorders, pharmacotherapy usually results off-label and pharmacological strategies remain lacking [3 Ripoll LH, Triebwasser J, Siever LJ. Evidence-based pharmacotherapy for personality disorders. Int J Neuropsychopharmacol. 2011;14:1257–1288. [CrossRef], [PubMed], [Web of Science ®] ]. Evidence-based practice recommends a combined approach including both psychotherapy and pharmacotherapy. It seems very difficult to translate present research into precise clinical recommendations for the treatment of personality disorders. This is due to different study limitations: considered populations of patients are heterogeneous, because of many assessment criteria used; there are small sample sizes and short follow-up; there is generally poor control of coexisting comorbidity with other mental illnesses [4 Bateman AW, Gunderson J, Mulder R. Treatment of personality disorder. Lancet. 2015;385:735–743. [CrossRef], [PubMed], [Web of Science ®] ]. The use of psychotropic agents in the treatment of personality disorders derives from the observation that behavioral traits associated with personality disorders may be related to neurochemical alterations of the central nervous system. Notwithstanding it is reasonably supposed that these behavioral traits could respond to drugs, this psychobiological model remains largely underestimated. At present, drug choices only address specific aspects of personality disorder’s pathological effects, such as affective instability and cognitive disturbances. Another important goal is the process of collaboration with patients. Many patients show demanding, aggressive, dependent, or manipulative behaviors, and for such a reason, physicians often feel frustrated, irritated, or helpless [2 Angstman KB, Rasmussen NH. Personality disorders: review and clinical application in daily practice. Am Fam Physician. 2011;84(11):1253–1260. [PubMed], [Web of Science ®] ]. A core strategy for experts is an intervention based on active listening and construction of a collaboratively developed crisis and safety plan. It is important, for example, to not confuse the chronic loneliness and emptiness of some personality disorders with depressive symptoms, and to accurately take into account that most often the crises could pass very quickly. To establish an open collaborative relationship with the patient may be more important than the actual medication chosen.