Evidenz für den Einsatz von Antikonvulsiva bei Persönlichkeitsstörungen

Zusammenfassung

Anliegen: Der Einsatz von Psychopharmaka bei Persönlichkeitsstörungen (PKS) ist klinisch weit verbreitet. Diese Arbeit gibt eine systematische Übersicht über randomisierte kontrollierte Studien (RCTs) zum Einsatz von Antikonvulsiva bei PKS. Methode: Basierend auf einer Medline-Recherche wurden die zwischen 1970 und 2008 publizierten RCTs zum genannten Thema systematisch erfasst und ausgewertet. Ergebnisse: In den 12 erfassten RCTs ergab sich für den symptombezogenen Einsatz bei PKS die stärkste Evidenz für Valproat und Topiramat. Die Datenlage für den Einsatz anderer Antikonvulsiva bei Persönlichkeitsstörungen ist spärlich. Schlussfolgerungen: In klinischen Studien haben sich Valproinsäure und Topiramat, möglicherweise auch Lamotrigin, Carbamazepin und Oxcarbazepin zur symptomatischen Behandlung von affektiver Dysregulation und impulsiver Aggressivität bei PKS bewährt. Dennoch sind weitere RCTs dringend erforderlich, da sich die klinische Anwendungspraxis bisher nicht ausreichend auf eine wissenschaftliche Evidenz für die Wirksamkeit und Sicherheit von Antikonvulsiva bei PKS stützen kann.

Abstract

Objective: There is a common practice of polypharmacy and an increased use of mood stabilizers in personality disorders (PD). This paper reviews all randomized controlled trials (RCTs) of anticonvulsants to evaluate the evidence base supporting their use in treatment of PD. Methods: German and English language literature cited in Medline and published between 1970 and 2008 was searched using the following terms: Borderline/personality disorder, anticonvulsant, mood stabilizer, carbamazepine, felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenytoine, pregabalin, tiagabine, topiramate, and valproate. Results: Twelve RCTs were identified which included anticonvulsants in treatment of personality disorders. The anticonvulsants valproate and topiramate appeared to have the most empirical support for having a favorable effect on symptoms of borderline personality disorder. Evidence for the use of other anticonvulsants in patients with PD is sparse. Conclusions: Valproate and topiramate, probably also lamotrigine, carbamazepine, and oxcarbazepine as well, were useful in treating symptoms of affective dysregulation and impulsive aggression in PD. However, further RCTs of anticonvulsants are greatly needed as clinical use of these agents has risen without sufficient evidence supporting their efficacy and safety in personality disorders.

Persönlichkeitsstörung - Antikonvulsiva - mood stabilizer - Psychopharmakotherapie

personality disorder - anticonvulsants - mood stabilizer - psychopharmacotherapy

Literatur

• 1 Swartz M, Blazer D, George L. et al . Estimating the prevalence of borderline personality disorder in the community.  J Personal Disord. 1990;  4 257-272
• 2 Grant B F, Chou S P, Goldstein R B. et al . Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.  J Clin Psychiatry. 2008;  69 533-545
• 3 Bender D S, Dolan R T, Skodol A E. et al . Treatment utilization by patients with personality disorders.  Am J Psychiatry. 2001;  158 295-302
• 4 Zanarini M C, Frankenburg F R, Hennen J. et al . Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years.  J Clin Psychiatry. 2004;  65 28-36
• 5 American Psychiatric Association . Practice guideline for the treatment of patients with borderline personality disorder.  Am J Psychiatry. 2001;  158 1-52
• 6 Abraham P F, Calabrese J R. Evidenced-based pharmacologic treatment of borderline personality disorder: A shift from SSRIs to anticonvulsants and atypical antipsychotics?.  J Affect Disord. 2008;  111 21-30
• 7 Gardner D L, Cowdry R W. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder.  Am J Psychiatry. 1986;  143 519-522
• 8 Cowdry R W, Gardner D L. Pharmacotherapy of borderline personality disorder. Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine.  Arch Gen Psychiatry. 1988;  45 111-119
• 9 De la Fuente J M, Lotstra F. A trial of carbamazepine in borderline personality disorder.  Eur Neuropsychopharmacol. 1994;  4 479-486
• 10 De la Fuente J M, Bobes J, Vizuete C. et al . Effects of carbamazepine on dexamethasone suppression and sleep electroencephalography in borderline personality disorder.  Neuropsychobiology. 2002;  45 113-119
• 11 Bellino S, Paradiso E, Bogetto F. Oxcarbazepine in the treatment of borderline personality disorder: A pilot study.  J Clin Psychiatry. 2005;  66 1111-1115
• 12 Peris L, Szerman N, Ruíz M. Efficacy and safety of gabapentin in Borderline Personality Disorder: a six-month, open-label study.  Vertex. 2007;  18 418-422 (Abstract in Englisch)
• 13 Tritt K, Nickel C, Lahmann C. et al . Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo-controlled study.  J Psychopharmacol. 2005;  19 287-291
• 14 Nickel M K, Nickel C, Mitterlehner F O. et al . Topiramate treatment of aggression in female borderline personality disorder patients: a double-blind, placebo-controlled study.  J Clin Psychiatry. 2004;  65 1515-1519
• 15 Nickel M. Topiramate reduced aggression in female patients with borderline personality disorder.  Eur Arch Psychiatry Clin Neurosci. 2007;  257 432-433
• 16 Nickel M K, Nickel C, Kaplan P. et al . Treatment of aggression with topiramate in male borderline patients: a double-blind, placebo-controlled study.  Biol Psychiatry. 2005;  57 495-499
• 17 Nickel M K, Loew T H. Treatment of aggression with topiramate in male borderline patients, part II: 18-month follow-up.  Eur Psychiatry. 2008;  23 115-117
• 18 Loew T H, Nickel M K, Mühlbacher M. et al . Topiramate treatment for women with borderline personality disorder: a double-blind, placebo-controlled study.  J Clin Psychopharmacol. 2006;  26 61-66
• 19 Hollander E, Allen A, Lopez R P. et al . A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder.  J Clin Psychiatry. 2001;  62 199-203
• 20 Frankenburg F R, Zanarini M C. Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: a double-blind placebo-controlled pilot study.  J Clin Psychiatry. 2002;  63 442-446
• 21 Hollander E, Tracy K A, Swann A C. et al . Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders.  Neuropsychopharmacology. 2003;  28 1186-1197
• 22 Hollander E, Swann A C, Coccaro E F. et al . Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder.  Am J Psychiatry. 2005;  162 621-624
• 23 Schmahl C, Bohus M. Symptomorientierte Pharmakotherapie bei Borderline-Persönlichkeitsstörungen.  Fortschr Neurol Psychiat. 2001;  69 310-321
• 24 Gardner D L, Cowdry R W. Development of melancholia during carbamazepine treatment in borderline personality disorder.  J Clin Psychopharmacol. 1986;  6 236-239
• 25 Loew T H, Nickel M K. Topiramate Treatment of Women With Borderline Personality Disorder, Part II: An Open 18-Month Follow-Up.  J Clin Psychopharmacol. 2008;  28 355-357
• 26 Godt K. Personality disorders in 545 patients with eating disorders.  Eur Eat Disord Rev. 2008;  16 94-99
• 27 Rosenvinge J H, Martinussen M, Ostensen E. The comorbidity of eating disorders and personality disorders: a meta-analytic review of studies published between 1983 and 1998.  Eat Weight Disord. 2000;  5 52-61
• 28 Herzog T, Stiewe M, Sandholz A. et al . Borderline-Syndrom und Essstörungen. Literaturübersicht und Interview-Studien an 172 konsekutiven InanspruchnahmepatientInnen der Freiburger Essstörungsambulanz.  Psychother Psychosom Med Psychol. 1995;  45 97-108
• 29 Mattes J A. Levetiracetam in patients with impulsive aggression: a double-blind, placebo-controlled trial.  J Clin Psychiatry. 2008;  69 310-315
• 30 Mattes J A. Oxcarbazepine in patients with impulsive aggression: a double-blind, placebo-controlled trial.  J Clin Psychopharmacol. 2005;  25 575-579
• 31 Leiberich P K, Nickel M K, Tritt K. et al . Lamotrigine treatment of aggression in female borderline patients, Part II: an 18-month follow-up.  J Psychopharmacol. 2008;  22 805-808