Personality disorder medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ayesha Anwar, M.B.B.S[2]

Overview

PD affects all aspects of individual life and causes interference with psychological and behavioral growth. It causes emotional distress and social impairment. It affects the quality of life grimly and has dire consequences on life years. Early recognition is crucial to start appropriate management and prevent complications from this debilitating condition.

Management of PDs lacks evidence-based guidelines, and health authorities across the world have formulated their independent guidelines. American Society of Psychiatry guidelines exists only for BPD, while European guidelines are present for BPD, ASPD, and PD general. It includes acute treatment by hospitalization if there is a risk of self or other people harm and chronic management of the disorder. Indications for inpatient management include; suicidal intent and plan, impulse control loss, imminent danger to self and others, and severe symptoms impairing functioning and unresponsive to outpatient treatment. An initial assessment should be performed. The second step is designing a treatment plan and discussing it with the patient. Family support and patient education play a vital role in effective management. Prior to starting the therapy, it is essential to rule out PTSD, depression, and anxiety and manage them if these conditions co-exist. Substance use disorder needs to be recognized and treated as well.

Medical Therapy

• No medical therapy is approved by Food and Drug administration, FDA for treatment of personality disorders. Pharmacotherapy is utilised to manage symptoms during acute decompensation and trait vulnerabilities.

• Mood dysregulatory symptoms like emotional lability, anger outbursts, depressive crashes, and other affective dysregulation symptoms are managed with (selective serotonin reuptake inhibitors) SSRIs or selective norepinephrine reuptake inhibitors (SNRIs) like venlafaxine. Mood stabilizers like lithium, valproate, carbamazepine, lamotrigine or topiramate are used as second line.

• Impulse behavioural dyscontrol symptoms are self-mutilation, aggression, eroticism, reckless sex, extravagant spending and uncontrolled substance use. They are managed with SSRIs as first line and monoamine oxidase inhibitors (MAOIs) as second line . British guidelines recommend against the use of medications for these symptoms .

• Cognitive perceptual symptoms incorporate paranoia, delusions, hallucination, derealisation, depersonalization and suspiciousness. Low dose neuroleptics or antipsychotic medications are used. They help with psychotic symptoms as well as mood issues.

Administration

The route of administration of medications used in personality disorders is oral in most cases. The doses of drugs (antidepressants and mood stabilisers) in PDs is same as used for clinical depression and bipolar disorder. As compared to this, the doses of antipsychotics like neuroleptics is lower than used for psychotic disorders like schizophrenia.

Antidepressants

Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days

• Preferred regimen (1): Fluoxetine 20 mg PO qd initially, and then increase weekly by 20 mg up to a maximum of 80 mg/day.
• Preferred regimen (1): Escitalopram-10 mg PO qd initially, and then increased to 20 mg after a week.
• Preferred regimen (1): Sertraline-25 mg PO qd initially, and then increased weekly to 50 mg weekly to a maximum of 200 mg/day. Safer in pregnancy.
• Preferred regimen (1): Duloxetine-20-30 mg PO BID initially, and then increased to 60 mg qd after one week.
• Preferred regimen (1): Venlafaxine (extended release)-37.5 to 75 mg PO qd initially, and then increased by ≤75mg/day over 4-7 days, maximum dose is 225 mg/day. (immediate release)- 75mg PO q8-12 hr and can be titrated over 4-7 days.

Mood Stabilizers

• Lamotrigine-25 mg per day for two weeks, 50 mg per day for next two weeks, 100 mg/day for next (5th week) and 200 mg daily from next week (6th week) and onwards.
• Lithium-started at 100- 200 mg per day and titrated over next few months to 600 mg per day. Lower initial doses are used to prevent adverse effects and gradually it is increased to maintain the levels between therapeutic window of 0.8-1.0 mEq/L.
• Valproic acid-500-750 mg per day; started with 250 mg and increased over 1 to 3 days to 500-1000 mg.

Antipsychotics

• Quietiapine-25 mg daily, initially increments in dosage is done daily and after day 4, it is done after days to maximum of 150 mg/day.
• Risperidone-initally 0.5 mg per day and increased to 1mg after a month.
• Aripiprazole-2.5 mg daily