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Evidence-Based Reviews
A clinical approach to pharmacotherapy for personality disorders
Current Psychiatry. 2021 April;20(4):26-32 | doi:10.12788/cp.0112
Donald W. Black, MD Professor Emeritus Department of Psychiatry University of Iowa Carver College of Medicine Staff Psychiatrist Iowa City Veterans Administration Medical Center Iowa City, Iowa
Disclosure Dr. Black is a consultant to Otsuka. He is an Associate Editor for Current Psychiatry.
Cluster C.“Anxious cluster” disorders are united by anxiousness, fearfulness, and poor self-esteem. Many of these patients also display interpersonal rigidity.15 These disorders include avoidant, dependent, and obsessive-compulsive PD. There are no treatment guidelines or clinical trial data for these disorders.
Why consider pharmacotherapy for personality disorders?
The consensus among experts is that psychotherapy is the treatment of choice for PDs.15 Despite significant gaps in the evidence base, there has been a growing interest in using psychotropic medication to treat PDs. For example, research shows that >90% of patients with borderline PD are prescribed medication, most typically antidepressants, antipsychotics, mood stabilizers, stimulants, or sedative-hypnotics.16,17
Increased interest in pharmacotherapy for PDs could be related to research showing the importance of underlying neurobiology, particularly for antisocial and borderline PD.18,19 This work is complemented by genetic research showing the heritability of PD traits and disorders.20,21 Another factor could be renewed interest in dimensional approaches to the classification of PDs, as exemplified by DSM-5’s alternative model for PDs.1 This approach aligns with some expert recommendations to focus on treating PD symptom dimensions, rather than the syndrome itself.22
Importantly, no psychotropic medication is FDA-approved for the treatment of any PD. For that reason, prescribing medication for a PD is “off-label,” although prescribing a medication for a comorbid disorder for which the drug has an FDA-approved indication is not (eg, prescribing an antidepressant for major depressive disorder [MDD]).
Principles for prescribing
Despite gaps in research data, general principles for using medication to treat PDs have emerged from treatment guidelines for antisocial and borderline PD, clinical trial data, reviews and meta-analyses, and expert opinion. Clinicians should address the following considerations before prescribing medication to a patient with a PD.
