What medication is usually prescribed for borderline personality disorder?

There are no medications specifically approved by the U.S. Food and Drug Administration (FDA) to treat borderline personality disorder (BPD). ^[4] However, prescription medications are often used to manage the symptoms that occur with BPD, such as anxiety, sleep problems, depression, aggression, mood swings, impulsivity, or psychotic symptoms. ^[4] This includes medications such as antidepressants, antipsychotics, mood stabilizers, and anxiolytics (anxiety medications).

Antidepressants

Antidepressant medications can be used to treat anxiety and depression symptoms in patients with BPD. ^[19]Serotonin reuptake inhibitors (SSRIs) and Monoamine Oxidase Inhibitors (MAOIs) are two common antidepressants studied to treat BPD symptoms.

Serotonin reuptake inhibitors (SSRIs) 

SSRIs increase the level of serotonin in the brain and are used to treat BPD symptoms such as depression ^[5]; sudden, extreme mood changes, both highs, and lows (mood instability);  anxiety, inappropriate and excessive anger or rage, impulsiveness; rejection sensitivity, and suicidal thoughts and behaviors. ^[5]

Common side effects include dry mouth (xerostomia), sexual problems, sleep problems, changes in weight, anxiety, dizziness, headache, and gastrointestinal issues. ^[5]

SSRIs can cause serious side effects such as electrical problems with the heart (QT interval), leading to a dangerous and fatal condition called Torsades de Pointes, an extremely rapid heart rhythm (tachycardia). 

SSRIs can also impair the body’s ability to clot (hypercoagulation) and increase the risk of suicidal thoughts and actions in children and adults 25 and younger. ^[5] 

Three SSRIs that have been shown as effective in treating some symptoms of BPD include:

• Fluoxetine (Prozac): Patients taking fluoxetine have shown minor improvement in anger, sensitivity to rejection, depressed mood, anxiety, impulsive behaviors, and affective symptoms. ^[8]
• Fluvoxamine (Luvox): BPD patients taking fluvoxamine show minor improvements in affective instability (rapid and intense mood swings) but not impulsivity. ^[15]
• Paroxetine (Paxil): Paroxetine may decrease suicidal behaviors but isn’t as effective in treating depression. ^[15]

Monoamine oxidase inhibitors (MAOIs)

MAOIs block an enzyme called monoamine oxidase, which plays a role in mood.^[18] MAOIs are not considered the first choice in treating mental health disorders, but  are often prescribed after other antidepressants fail. This is due to them having an increased risk for dangerous, possibly fatal interactions with certain medications or foods. ^[18]

Two MAOIs used to treat BPD symptoms include phenelzine (Nardil) and tranylcypromine (Parnate) which may improve symptoms such as depression and impulsive aggression. ^[15]

Antipsychotics (neuroleptics)

Antipsychotics, as a whole, have been associated with worsening the overall severity of borderline personality disorder. ^[15] Antipsychotic medications are frequently used for borderline personality disorder. They may effectively reduce impulsiveness, aggression, anxiety, and psychotic symptoms. ^[13]

First generation antipsychotics

First generation antipsychotics may improve some BPD symptoms, such as anger and impulsive aggressiveness. They pose risks of extrapyramidal symptoms (drug-induced movement disorder) ^[9], tardive dyskinesia (involuntary movements of tongue, lips, face, or body), and the deterioration of day to day functioning. ^[15] 

• Haloperidol (Haldol): Haloperidol improves BPD symptoms of paranoia and anger, and may improve anxiety and affective symptoms. However, it may also worsen BPD symptoms overall, asbecause it can increase the risk of sedation, depression, and other side effects. ^[15] 
• Loxapine (Loxitane): Whilst research findings are mostly inconclusive, some studies have found thatloxapine may improve BPD symptoms of depression and anger. ^[15]
• Thiothixene (Navane): Whilst research findings are mostly inconclusive, some studies have found that thiothixene may improveany psychotic symptoms associated with BPD, such as paranoia, aggression, impulsivity and antisocial behavior.
• Flupenthixol decanoate (Prolixin Decanoate) and flupenthixol depot (Fluanxol Depot): These antipsychotics can improve symptoms of suicidal thoughts and behaviors. ^[15]

Atypical antipsychotics

Atypical (second generation) antipsychotics tend to have fewer side effects and tend to be more effective at decreasing impulse aggression than first generation antipsychotics. 

Psychotic symptoms are thought to be triggered by an overproduction of dopamine, Antipsychotics have been shown to reduce dopamine transmission, which can reduce these symptoms. ^[10]

Atypical antipsychotics used to treat BPD symptoms include:

• Olanzapine (Zyprexa) Olanzapine has been shown to improve symptomssuch as anger, aggression, paranoia, [15,21] self-harming and suicidal ^[21]
• Aripiprazole (Abilify) has been shown to reduceimpulsive behavior, psychosis (loss of touch with reality), emotional instability, and interpersonal dysfunction. ^[15]
• Risperidone (Risperdal) has been shown to reduce experiences of psychosis and the incidence of extrapyramidal adverse effects (drug-induced movement disorder). ^[2]
• Quetiapine (Seroquel) hasconflicting results in the treatment of BPD, but may improve aggression, hostility, anxiety, and depression in people with BPD. ^[21]
• Paliperidone (Invega Trinza® and Invega Hafyera®) Although data is limited, a 12-week pilot study showed paliperidone significantly improved impulsivity, anger, and dissociative symptoms and overall symptom improvement. ^[21]

Mood Stabilizers and Anticonvulsants

Mood stabilizers and anticonvulsants can be used to treat BPD symptoms such as mood instability, aggression, impulsivity, and overall day to day functioning. ^[15]

Mood stabilizers and anticonvulsants prescribed to treat BPD symptoms include:

• Carbamazepine (Tegretol): This drug may improve impulsivity but may worsen melancholic depression ^[15], which involves severe episodes of persistent sadness, slowing of physical or mental activities, and hopelessness). ^[14]
• Divalproex sodium (Depakote): This medication improves interpersonal sensitivity, irritability, and aggression, mainly in people with high impulsive aggression. ^[15]
• Lamotrigine target (Lamictal): Lamotrigine has been shown to improve anger, mood instability, and impulsivity, but there is a small risk it can cause a potentially life-threatening rash and toxicity.^[15]
• Lithium carbonate (Eskalith): This has been shown to improvemood instability and may improve overall functioning, but data is limited. ^[15]
• Topiramate (Topamax): This has been shown to improve anger, anxiety, and problems maintaining relationships. Some peoplewith BPD have reported that it improves their quality of life, but it is associated with weight loss, which may be a problem for people with eating disorders.^[15]

Not all mood stabilizers are safe for pregnant women or of childbearing age due to the risk of congenital disabilities. ^[20] You should consult your doctor or health care provider if you plan on becoming pregnant or are currently pregnant or breastfeeding.

Anxiolytics

Anxiolytics are medications used to treat anxiety and other mental health conditions such as panic disorders and insomnia. ^[17] anxiolytic drugs stimulate GABA receptors, which creates calming effects. ^[1]

The brain can grow accustomed to anxiety medications, which reduce their effectiveness and may require higher doses or medication changes. ^[1]Anxiety medications may be misused or abused, which can have life-threatening consequences. ^[17] 

Benzodiazepines are commonly used to treat anxiety, insomnia, seizures, spastic disorders, and agitation and may be used to treat anxiety in BPD patients. ^[3] 

However, the use of anxiolytics and sedatives to treat BPD should be closely monitored, since they can cause disinhibition, which can be a problem for people with BPD since they can be impulsive. ^[20] 

Common benzodiazepines include: 

• Lorazepam (Ativan): Lorazepam is a sedative that creates a calming effect. It can be helpful if used for a short time for crisis management. ^[20]
• Clonazepam (Klonopin): Clonazepam is used to treat panic disorder. Clonazepam may improve impulsivity and anxiety, but there is limited data available on its effectiveness. ^[8]
• Alprazolam (Xanax): Alprazolam is commonly used to treat anxiety and panic disorders. Alprazolam, like clonazepam, may improve impulsivity and anxiety, but there is limited data available on its effectiveness, and some data shows it might lower inhibition and control. Since BPD can cause impulsivity, this could be problematic, especially if suicidal thoughts and self-harming behaviors are present.^[8]
• Diazepam (Valium): Diazepam has the same calming effect lorazepam and other benzodiazepines have. It can be helpful if used for a short period and to help manage symptoms when crisis management is necessary, such as for a short period while a patient is an inpatient. ^[20]

Using benzodiazepines requires well-coordinated and planned treatment approaches, such as using time-limited prescriptions. ^[20]

Common side effects of benzodiazepines include ^[3]: 

• Headache
• Nausea or vomiting
• Diarrhea
• Problems breathing or shortness of breath
• Respiratory arrest (not breathing)
• Loss of consciousness
• Tremors (involuntary shaking or movements)^[4]

Benzodiazepines can cause more severe side effects, such as angle-closure glaucoma, caused by intraocular eye pressure, which compresses the optical nerve at the back of the eye. ^[3] Benzodiazepines should be used sparingly in pregnant and breastfeeding women, due to some potential risks to the baby. ^[3]

Other medications

• Channel blockers can regulate the overactivity of the neurotransmitter glutamate. ^[3] One study showed memantine added to another typical drug treatment improved BPD symptoms. ^[7]
• Opioid antagonists have been shown to reduce some self-harm behaviors. ^[7]
• Neuropeptides such as oxytocin, opioids, and vasopressin may help with BPD symptoms. ^[15] The neuropeptide oxytocin has been shown to lessen threat sensitivity in patients with BPD and studies suggest that it may improve interpersonal dysfunction. ^[16]
• Omega-3 fatty acids have shown to improve symptoms of BPD, especially for impulsivity and mood dysregulation. Omega-3 fatty acids may be used in combination with another therapy. ^[11] 
• ORY-2001 (Vafidemstat) is being evaluated in clinical studies for treating central nervous system (CNS) diseases such as Alzheimer’s Disease (AD) and Borderline Personality Disorder. ^[12]

Preliminary studies have shown a significant reduction in neuroinflammation after six months and 12 months of treatment. ORY-2001 may reduce cognitive deterioration and normalize genes related to cognitive function, neuroplasticity, and memory. ^[12] The first assessment on humans has proven it is safe and well tolerated.^[12]

Other BPD treatments

Several types of psychotherapy have been shown as effective in the treatment and management of BPD. 

The most effective approaches include:

• Dialectical behavior therapy (DBT) DBT was developed using CBT, for the treatment of BPD. Many therapists view DBT as the ‘gold standard’ therapeutic approach for BPD management. According to DBT, people with BPD can learn techniques that focus on interpersonal effectiveness, distress tolerance, mindfulness, and emotion regulation. ^[6]
• Mentalization-Based Treatment (MBT) focuses on strengthening the BPD patient’s capacity to mentally process information and understand their own and others’ mental states, such as thoughts, feelings, beliefs, and behaviors, to help them make sense of them. ^[6]