Borderline Personality Disorder Medications

Psychotherapy (talk therapy) is the centerpiece of treatment for borderline personality disorder (BPD), but medications may be prescribed to relieve symptoms like mood swings, depression, impulsivity, and aggression. Depending on the types and severity of symptoms, treatment may involve antidepressants, antipsychotics, mood stabilizers, or anxiolytics (anti-anxiety drugs).

It is important to note that no drug regimen has proven effective in treating all people with BPD, and there are currently no medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of BPD. As such, any pharmaceutical drug treatment must be individualized and closely monitored by a trained mental healthcare provider.

This article looks at the four classes of drugs commonly used in people with BPD as well as novel BPD medications currently under investigation.

Antidepressants

Studies across different countries have shown that antidepressants are the most commonly prescribed drug class for people with BPD, with close to 80% of BPD patients taking them.

Antidepressants—namely selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs)—have been most studied.

While SSRIs work primarily by increasing serotonin levels (important for mood management), MAOIs work by blocking several other neurotransmitters.

MAOIs

MAOIs were the first drugs on the market for treating depression. They are also used to treat other psychiatric disorders, including panic disorder and social phobia.

As their name implies, MAOIs inhibit the monoamine oxidase enzyme from breaking down neurotransmitters in the brain, namely norepinephrine, serotonin, and dopamine. This blockage increases levels of these neurotransmitters and allows them to work on cells affected by depression.

There are different MAOIs. Two that have been studied in BPD are:

• Nardil (phenelzine): It improves depression and impulsive aggression in BPD. The primary side effect of this medication may be uncomfortable activation.
• Parnate (tranylcypromine): Limited data exist, but some studies have shown that this medication improves affective symptoms and interpersonal sensitivity in BPD.

SSRIs

SSRIs work by increasing available serotonin levels in the brain. This neurotransmitter is thought to have a positive impact on mood, sleep, and emotion regulation, among other functions.

Side effects of SSRIs are typically temporary and mild, and include decreased sexual interest, insomnia, fatigue, headaches, upset stomach, nausea, or diarrhea.

Types of SSRIs include:

• Prozac (fluoxetine): This medication has been shown to lead to mild improvements in affective symptoms, anger, and impulsive aggression. Effects may be more pronounced in men and people with high levels of impulsive aggression.
• Luvox (fluvoxamine): This medication has been shown to lead to mild improvement in affective instability, not impulsivity, in some studies.
• Paxil (paroxetine): Limited data show this medication leads to possible decrease in suicidality without significant effects on depression.

Mood Stabilizers and Anticonvulsants

Mood stabilizers and anticonvulsants are used to help with BPD symptoms like anger, mood swings, and impulsivity. Mood stabilizers are traditionally used to treat affective disorders like bipolar disorder. About 36% of BPD patients take mood stabilizers.

Mood stabilizers and anticonvulsants that are prescribed to people with BPD include:

• Tegretol (carbamazepine): This medication can improve impulsivity, but can also worsen melancholic depression.
• Depakote (divalproex sodium): This improves interpersonal sensitivity, irritability, and aggression (primarily in people with high impulsive aggression).
• Lamictal (lamotrigine target): This improves anger, affective instability, and impulsivity, but carries a risk of a potentially life-threatening rash.
• Eskalith (lithium carbonate): Limited data show improvement in affective instability and possibly overall functioning with the use of this medication.
• Topamax (topiramate): This improves anger, anxiety, interpersonal dysfunction, and self-reported quality of life, but its side effect of weight loss can be problematic for those who also have an eating disorder.

Antipsychotics

Antipsychotics can be used to help manage anger issues that are common in BPD patients. While atypical antipsychotics can be used to treat impulsive aggression and improve affective instability, psychosis, and interpersonal dysfunction in BPD, the long-term risks vs. benefits of this drug class for people with BPD are not clear.

Typical antipsychotics used for the treatment of BPD include:

• Prolixin Decanoate (fluphenazine decanoate) and Fluanxol Depot (flupenthixol depot): Both have limited data on effectiveness, but are used to treat suicidality and self-injurious behavior.
• Haldol (haloperidol): This medication improves paranoia and anger, and potentially treats anxiety and affective symptoms. It may increase sedation and depression, however.
• Loxitane (loxapine): Limited data support its effectiveness, but it is used to help with depression and anger.
• Navane (thiothixene): Limited data support its effectiveness, but it is used to improve cognitive-perceptual symptoms and psychoticism.

Atypical antipsychotics used for BPD include:

• Abilify (aripiprazole): This medication improves affective symptoms, aggression, paranoia, and overall functioning.
• Zyprexa (olanzapine): This improves mood swings, impulsivity, aggression, interpersonal sensitivity, and severity of the disorder in general. It carries a high risk of weight gain and metabolic effects.

Anxiolytics

People with BPD can experience intense anxiety lasting from a few hours to several days. As such, they may be prescribed anti-anxiety medications called anxiolytics.

Anti-anxiety medications work by increasing GABA (a natural calming agent that reduces brain activity), and as such, they may be useful in times of extreme agitation and distress. However, no randomized controlled clinical trials have examined their usefulness, and very little research exists to support their use in the treatment of BPD.  

General side effects of anti-anxiety medications include feelings of sleepiness, fatigue, and mental fogginess or grogginess. Anti-anxiety medications can also accumulate in a person’s system over time. Long-term use is associated with sleep issues, memory issues, emotional dysregulation, and dependence.

Anxiolytics commonly prescribed for BPD include:

• Ativan (lorazepam): Like the other medications on this list, this benzodiazepine produces a calming effect by enhancing the effects of GABA.
• Klonopin (clonazepam): This medication is approved for the treatment of panic disorder.
• Xanax (alprazolam): This is used to treat both anxiety and panic disorders.
• Valium (diazepam): This is typically used to treat anxiety, seizures, and alcohol withdrawal.

Stopping these medications abruptly can result in withdrawal symptoms, including irritability, nausea, tremor, dizziness, blood pressure changes, rapid heart rate, and seizures.

Novel Treatments Under Investigation

Researchers are looking into several new treatments for BPD, including: 

• Omega-3 fatty acids: These may have some benefit in impulsivity and aggression. They are considered safe even in BPD and substance use disorder.
• Opioid antagonists: Opioid antagonists have shown some preliminary success in reducing self-harm behaviors characteristic of BPD.
• Vasopressin antagonists: For these medications, researchers are working off of the findings that vasopressin concentration in the cerebrospinal fluid is positively correlated with uninhibited aggression, that intranasal vasopressin production increases the perception of threats in response to neutral stimuli, and that increased vasopressin concentration may partially explain predisposition toward enhanced irritability and aggression in people with BPD.
• Histone deacetylase inhibitors: These drugs work by altering the epigenetic modification of histones (basic proteins associated with DNA). In other words, they can help undo the biological changes that occur from early life stress (a well-known risk factor for BPD). Researchers say the deacetylase inhibitory properties of sodium valproate (i.e., its ability to reverse epigenetic modifications and gene expression) may partially explain its efficacy in BPD treatment.

A Word From Verywell 

Medications can potentially decrease symptoms and improve quality of life for people with BPD, but finding what works takes time. Know that the right drug regimen can make a major difference.

Recent studies have shown that remission rates for BPD are high. It’s important to remember, however, that medical therapy is an adjunct to psychotherapy, which remains the mainstay of treatment for BPD.

These medications also come with side effects. You should discuss all the risks and benefits of using a particular drug with your healthcare provider before starting to take it.