Pharmacological Treatments for Personality Disorder

We have previously reviewed the nature-nurture debate that arises when considering the relative importance of biology and the environment in determining human behavior. So, it should come as no surprise that the use of medication for the treatment of personality disorders 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 personality 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 environment thereby creating deeply-rooted, maladaptive patterns of relating to others. Thus, it only made sense that treatment should focus on changing those patterns and related behaviors, via curative environmental methods such as psychotherapy, and that medications have no place in such treatment.

But more recently, many clinicians have begun to recognize that human behavior and emotion (including the maladaptive behavioral-emotional patterns of personality disorder) are at least partially determined by our genetic make-up. 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 is helpful and should be considered when medication: 1) enables someone to participate in therapy in a meaningful and effective manner, particularly if they might not be able to do so without medication, 2) reduces someone's discomfort sufficiently so that they can make necessary changes, 3) promotes a positive experience of recovery; and 4) enables someone to attend therapy in order 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.

Another middle-of-the-road opinion is that while 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, the environment is important only because certain environmental events have the potential to cause lasting changes to brain chemistry, particularly 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 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 cognition, emotion, and impulse control: the very problems that are typical of personality disorders.

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 that provide hope to recovering people while providing clinicians a promising tool that may advance recovery efforts.