BPD Medication: Types, Side Effects And Challenges

Borderline personality disorder (BPD) is a mental health condition categorized as a “cluster B” personality disorder, a grouping characterized by thinking or behavior that can seem dramatic or erratic.

Individuals affected by BPD tend to struggle to manage their emotions, which can lead to impulsive behavior, negative self image, unstable interpersonal relationships and extreme sensitivity to rejection.

Stressful situations can often be the catalyst to emotional regulation issues, and BPD typically occurs with many other health conditions, says David Brendel, M.D., Ph.D., a board-certified psychiatrist in Boston who has experience treating borderline personality disorder.

There are no medications currently approved by the FDA to treat borderline personality disorder. However, medication may be prescribed to help address specific symptoms a person with BPD is experiencing or to treat comorbid conditions. As mentioned, many individuals affected by BPD also have other mental health conditions, including mood disorders, anxiety disorders, substance abuse disorders, eating disorders, attention deficit hyperactivity disorder (ADHD), bipolar disorder and somatoform disorders (physical symptoms often caused by psychological or emotional factors).

Here’s a look at some of the types of medications that may be prescribed for BPD.

Antidepressants

According to a 2020 study in Current Psychiatry Reports, the antidepressant medication category of selective serotonin reuptake inhibitors (SSRIs) are among the most commonly prescribed for individuals with BPD3^[3]Stoffers-Winterling J, Storebø OJ, Lieb K. Pharmacotherapy for Borderline Personality Disorder: an Update of Published, Unpublished and Ongoing Studies. Curr Psychiatry Rep. 2020;22(8):37. . This class of medication is believed to work in part by increasing the brain’s levels of serotonin, a neurotransmitter associated with mood and emotions.

While SSRIs tend to have fewer side effects compared to other types of antidepressants, they are still possible and can include feeling agitated, shaky, anxious or sick; experiencing dizziness or blurred vision; and having a lower sex drive.

Antipsychotics

Another category of medications that providers may prescribe to individuals with BPD is antipsychotics. There are two types of antipsychotic drugs: conventional antipsychotics, which mainly work by blocking the dopamine-2 receptor, and second-generation (or atypical) antipsychotics, which work by more selectively blocking dopamine receptors. By blocking dopamine receptors, which are responsible for sending messages in the brain, it’s believed these drugs can reduce the flow of messages, thus alleviating symptoms such as affective dysregulation, paranoid ideation and impulsiveness.

Most antipsychotics prescribed in the U.S. are in the latter category of atypical antipsychotics. Medications in this category include clozapine (Clozaril, FazaClo ODT or Versacloz); olanzapine (Zyprexa); and quetiapine (Seroquel).

“The main possible side effects [of antipsychotics] are sedation and what’s called metabolic syndrome, which can cause weight gain, increased blood sugars and potentially diabetes, and changes in cholesterol and triglyceride levels,” says Dr. Brendel.

Mood Stabilizers

Mood stabilizers are another type of commonly prescribed medication for individuals with borderline personality disorder. This can include medications like lithium (Eskalith, Lithobid) and lamotrigine (Lamictal). These medications work by helping level out mood and reduce associated symptoms like agitation, sleep disturbances and delusions.

Side effects of mood stabilizers can include nausea, weight gain, fatigue, slowed thinking, tremor, vomiting and diarrhea, slurred speech and confusion. A rare but serious side effect is Stevens-Johnson syndrome, which Dr. Brendel describes as “a severe rash and systemic disorder.”

While medication is often prescribed to people with BPD, it’s not the main form of treatment supported by evidence. “The primary evidence-based treatment is psychotherapy, not medication,” says John M. Oldham, M.D., a distinguished emeritus professor in the Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine, who has worked extensively on personality disorders.

There are several types of therapy demonstrated to have efficacy in the treatment of borderline personality disorder^[4]Borderline Personality Disorder. Stat Pearls. Accessed 06/05/2023. :

• Dialectical behavior therapy (DBT): DBT is a type of therapy originally created to treat individuals with borderline personality disorder as well as other conditions categorized by emotional dysregulation. Its goal is to help individuals understand what triggers them to act in impulsive or destructive ways and establish new coping skills in the categories of mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation.
• Mentalization-based therapy (MBT): MBT is another therapy shown to help individuals with borderline personality disorder, as this form of therapy aims to help people understand both their own thoughts and feelings as well as those of other people. It focuses on people’s current experiences, rather than their past.
• Transference-focused psychotherapy (TFP): Transference-focused psychotherapy leverages the therapist-patient relationship to treat BPD, aiming to help the individual undergoing treatment gain insight into their interpersonal issues. The therapist and patient may meet as often as five times a week, focusing on how the patient’s past impacts their present.
• Cognitive behavioral therapy (CBT): CBT focuses on changing an individual’s thinking patterns
• Eye Movement Desensitization and Reprocessing (EMDR): While not originally designed for BPD, EMDR—a type of therapy that asks an individual to briefly focus on a trauma while also experiencing bilateral stimulation (typically eye movements)—has shown some promise when it comes to treating symptoms of the condition.

As far as other treatments that might be useful for individuals living with BPD, Dr. Brendel says those are “usually targeted toward symptoms or diagnosis comorbidities.” So, for example, if a patient also has ADHD, sleep disturbances or alcohol use disorder, then medications might be prescribed to address those issues.

A number of factors can make the diagnosis and treatment of borderline personality disorder challenging.

For one, “[BPD is] very difficult to diagnose because it does appear so differently,” explains Abby Ingber, executive director of the National Education Alliance for Borderline Personality Disorder. “It presents completely differently in different situations, and two people with borderline personality disorder could only have one symptom that’s the same,” says Ingber.

While there are nine symptoms (or behaviors) that can connotate a BPD diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), only five of the behaviors have to be met for a diagnosis to be made.

Additionally, many people living with BPD have other conditions as well. “Many patients with BPD don’t just have BPD alone; they often have co-occurring conditions such as anxiety disorders or depression,” says Dr. Oldham. Those co-occurring conditions must be treated alongside BPD, but doctors must be careful to not prescribe too many different medications or medications that may negatively impact other symptoms.

Another challenge is the prevalence of self-harm and suicidality among individuals with borderline personality disorder. “You want to use the medications that are least likely to have a lethal effect if taken in an overdose, and monitor medication use carefully with the patient because of that potential for self injury and potential risk,” says Dr. Oldham.

And in the treatment of BPD overall, there’s the issue of accessibility when it comes to some of the types of evidence-based therapy, according to Ingber. Not every therapist is trained in methods such as DBT and MBT, which can make finding help in one’s area even more difficult.

It can also be a challenge to find experienced physicians who are also understanding, says Dr. Oldham. ” [People living with BPD] are people who are not willfully being manipulative or difficult, but rather they are suffering greatly, and the form of that suffering can be to kind of blame other people,” says Dr. Oldham. “But that’s illness-driven behavior, and that’s what the treatment is needed for.”