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Mental Disorders

Medications for Treating Personality Disorder

Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.

We have previously reviewed the nature-nurture debate that arises when considering the relative importance of biology (nature) and human experience (nurture) in determining human behavior. We previously likened this debate to a similar debate:  Which came first, the chicken or the egg?  We attempted to provide evidence that a nature-nurture debate is as futile as chicken-or-egg.  The answer is both nature and nurture combine in some manner to cause behavior.  Because we do not yet know the exact relationship between nature and nurture, it comes as no surprise that the use of psychiatric medications to modify behavior has been somewhat controversial. 

Prior to the most recent research evidence suggesting a strong link between biology and behavior, many clinicians did not believe that medication was useful, nor appropriate for the treatment of personality disorders.  The rationale for these convictions resulted from the way in which personality disorders were understood.  How could medication change people's personalities or alter their manner of relating to others?  From this perspective, personality disorders occurred when normal personality development became derailed by harmful, traumatic, or otherwise stressful events in someone's life.  It was believed that once derailed, deeply-rooted, maladaptive patterns of relating to others were formed.  From this perspective, it only made sense that treatment should focus on changing those behavioral patterns. Medications had no place in such treatment.  

More recently, many clinicians (if not most) have begun to recognize that human behavior and emotion are at least partially determined by our genetic make-up.  This includes the harmful behavioral and emotional patterns inherent in personality disorders.  As such, many clinicians now believe that medication can be very beneficial in the treatment of many psychological disorders, including personality disorder.

A moderate position held by many clinicians is that medication can be helpful in some situations.  Clinicians usually begin to consider medications when:

1) Medication is helpful to limit symptoms of co-occurring disorders (for instance, depression and Borderline Disorder).
2) Medication reduces someone's discomfort sufficiently until they can make lasting changes that will more permanently alleviate their discomfiture.
3) Medication promotes a positive and more rapid experience of recovery, which in turn increases motivation for treatment.
4) Medication enables someone to attend therapy that might otherwise be unable to participate in a meaningful way.
5) Medication limits symptoms sufficiently so that symptoms do not interfere with the ability to learn and acquire essential skills needed for recovery.

Consider the example of someone with an Avoidant Personality Disorder. Their extreme anxiety about social situations and relationships may prohibit them from attending therapy, while medication might enable them to do so.

Medications don't necessarily "cure" personality disorders. They can alleviate some symptoms that may interfere with, slow down, or disrupt treatment.   This may include symptoms of the personality disorder itself, or symptoms associated with other co-occurring disorders. Symptoms that often interfere with the progression of therapy include anxiety, depression, irritability, substance abuse, or mood swings. In fact, The Practice Guidelines for the Treatment of Borderline Personality Disorder of the American Psychiatric Association, published in 2001, as well as the American Psychiatric Association's Guideline Watch, published in 2005, recommends psychotherapy for the treatment of the Borderline Personality Disorder and states that adjunctive pharmacology, targeting specific symptoms, can also be helpful.

However, some clinicians and researchers are dissatisfied with a moderate approach to medications.  Instead, they conclude that personality traits and temperament are biologically determined.  From this perspective, life experiences are only important because certain stressful events have the potential to cause lasting changes to brain chemistry. This is particularly true in the developing brains of children.

In his chapter on somatic treatments in the Handbook for Personality Disorders, Paul Soloff (2005) explains his view that the dichotomy between nature and nurture is artificial and contrived. He asserts that personality traits and temperament are, in fact, biologically determined.  To support his view, he references research that demonstrated an association between a history of childhood sexual abuse and changes to brain chemistry (in the brain's serotonergic system) in women with Borderline Personality Disorder (Rinne, Westenberg, denBoer, et.al., 2000).   Soloff argues for a pharmacological approach in the treatment of personality disorders because medications are capable of modifying neurotransmitter functions associated with many of the symptoms of personality disorders.  Medications that modify neurotransmitter function can improve problems with thinking, emotion, and impulse control.  These are the very problems that are typical of personality disorders.

However, the reverse can also be argued.  If harmful experiences, such as abuse, cause changes to brain chemistry and functioning, healing experiences have the potential to do the same.  New corrective experiences (via psychotherapies) cause new thinking patterns to develop.  These new patterns also modify emotional response patterns.  As all thoughts and emotions are electro-chemical events in the brain, these new cognitive and emotional patterns form new neural pathways overtime.  In other words, changing thoughts and emotions can also modify neurotransmitter functioning.

New research methodologies and technologies have continued to provide us a much better understanding of how the brain works, including the biological and chemical underpinnings of behavior and emotions. Because of these advancements, new treatment options continue to emerge. These advancements provide hope to recovering people, while providing clinicians promising tools that advance recovery efforts.