Pharmakotherapie bei Persönlichkeitsstörungen

Zusammenfassung

Menschen mit einer Persönlichkeitsstörung stellen einen wesentlichen Anteil an der klinisch psychiatrischen Population dar, und in weitaus größerem Anteil als Komorbidität zu einer Achse-I-Störung. Persönlichkeitsstörungen gelten weithin als schwer behandelbar und problematisch im therapeutischen Setting, und eine mögliche Pharmakotherapie erfolgt oft ohne klare empirische Grundlage. Psychopharmaka können die Ausprägung von Persönlichkeitsdimensionen modifizieren. Hierbei handelt es sich um bestimmte störungsrelevante Temperamentsvariablen. Die moderne Psychopharmakotherapie von Persönlichkeitsstörungen beruht auf neurobiologischen Grundlagen. Diese sind weitgehend tierexperimentell bestätigt und sind auf bestimmte rezeptorspezifische Funktionen beim Menschen übertragbar. Die Behandlung ist somit symptomorientiert, nicht störungsspezifisch. Es wird betont, dass lediglich einzelne Merkmale und nicht die Gesamtpersönlichkeit beeinflusst werden. Nur ein Teil der theoretisch aufgrund ihrer Wirkweise als effektiv anzunehmenden Substanzen ist wissenschaftlich bei unterschiedlichen Persönlichkeitsstörungen überprüft worden. Eine Übersicht über die Studienlage wird dargelegt und Empfehlungen zu Kombinationen und Dosierungen gegeben. Eine Psychotherapie ist nach wie vor Grundlage der Behandlung von Persönlichkeitsstörungen. Eine Pharmakotherapie bei bestimmten Persönlichkeitsstörungen sollte aber nicht erst bei Misserfolg der Psychotherapie bedacht werden. Vielmehr sollten sich Psychotherapie und Psychopharmakotherapie wechselseitig ergänzen. Es besteht eine Rationale sowohl für die Kurzzeit- als auch für die Langzeitbehandlung. Eine Langzeitbehandlung sollte trotz der dürftigen Studienlage vor allem bedacht werden, wenn langandauernde und schwere Störungen der Affektivität das klinische Bild prägen. Zahlen über Behandlungserfolge variieren in den verschiedenen Untersuchungen, sind bei schweren Störungsbildern aber sicherlich geringer als bei Achse-I-Störungen einzuschätzen. Die Verordnung einer geeigneten Substanz sollte aus dem empirisch begründeten Behandlungsalgorithmus abgeleitet werden.

Abstract

Subjects with personality disorders represent a relevant subset of the clinical psychiatric population and, to an even bigger extent, a comorbid condition to an axis-I diagnosis. Personality disorders appear to be difficult to treat and problematic in the therapeutic setting, and a pharmacologic treatment often does not follow recommendations from empirical studies. Psychopharmacologic drugs are able to modify the expression of certain personality dimensions, which are mainly disorder-related variables of temperament. Modern pharmacotherapy of personality disorders has a neurobiological basis. This is underlined by evidence from animal studies and can be associated with certain receptor-specific functions in humans. Treatment is consequently symptom-related and not specific for any disorder. It must be stressed that certain features but not the entire personality can be modified by drug treatment. Data from drug studies are still relatively scarce. An overview of studies on personality disorders is presented including information on dosages and augmenting strategies.

Psychotherapy still is the basic treatment for personality disorders. However, psychopharmacological interventions should not only be considered when psychotherapy has failed. Treatments should be complementary from the start. There is a rationale for short- and long-term treatment. The latter is indicated, despite of the scarcity of data, when longer lasting and severe affective symptoms emerge. Response rates vary among the trials and appear to be lower than in non-comorbid axis-I disorders. A treatment algorithm is presented.

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