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Differential Effectiveness of Antipsychotics in Borderline Personality Disorder: Meta-Analyses of Placebo-Controlled, Randomized Clinical Trials on Symptomatic Outcome Domains

Ingenhoven, Theo J.M. MD, PhD*; Duivenvoorden, Hugo J. PhD

Journal of Clinical Psychopharmacology: August 2011 - Volume 31 - Issue 4 - p 489-496
doi: 10.1097/JCP.0b013e3182217a69
Review Articles

Objective: In clinical practice, antipsychotic drugs are widely used in borderline personality disorder (BPD). To evaluate current pharmacological treatment algorithms and guidelines for BPD, the authors reviewed and meta-analyzed studies on the effectiveness of antipsychotics on specific symptom domains in BPD.

Methods: The literature was searched for placebo-controlled, randomized clinical trials (PC-RCTs) on the effectiveness of antipsychotics regarding cognitive perceptual symptoms, impulsive behavioral dyscontrol, and affective dysregulation (with subdomains depressed mood, anxiety, anger, and mood lability) in BPD. Studies whose primary emphasis was on the treatment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition schizotypal personality disorder or Axis I disorders were excluded.

Results: Meta-analyses were conducted using 11 retrieved studies including 1152 borderline patients. Antipsychotics have a significant effect on cognitive perceptual symptoms (9 PC-RCTs; standardized mean difference [SMD], 0.23) and mood lability (5 PC-RCTs; SMD, 0.20) as well as on global functioning (8 PC-RCTs; SMD, 0.25), but these effects have to be qualified as small. Antipsychotics have a more pronounced effect on anger (9 PC-RCTs; SMD, 0.39). Antipsychotics did not have a significant effect on impulsive behavioral dyscontrol, depressed mood, and anxiety in BPD.

Conclusion: Drug therapy tailored to well-defined symptom domains can have beneficial effects in BPD. At short term, antipsychotics can have significant effects on cognitive-perceptual symptoms, anger, and mood lability, but the wide and long-term use of antipsychotics in these patients remains controversial. The findings from this study raise questions on current pharmacological algorithms and clinical guidelines.

From the *Center for Psychotherapy, Pro Persona, Centers for Mental Health Care, Lunteren; and †Department of Psychology and Psychotherapy, Netherlands Institute for Health Sciences, Erasmus MC, Rotterdam, The Netherlands.

Received October 3, 2010; accepted after revision February 28, 2011.

Reprints: Theo J.M. Ingenhoven, MD, PhD, Center for Psychotherapy, Pro Persona, Centers for Mental Health Care, Klomperweg 175, Postal code 6741PH, Lunteren, The Netherlands (e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.