Download PDF
Fortschr Neurol Psychiatr 2005; 73(5): 259-267
DOI: 10.1055/s-2004-830107
Originalarbeit
© Georg Thieme Verlag Stuttgart · New York

Pharmakotherapie bei Persönlichkeitsstörungen

Pharmacotherapy in Personality DisordersD.  Wedekind1 , B.  Bandelow1 , E.  Rüther1
  • 1Klinik für Psychiatrie & Psychotherapie der Georg-August-Universität Göttingen (Direktor: Prof. E. Rüther)
Further Information

Publication History

Publication Date:
15 November 2004 (online)

    Permissions and Reprints

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.

Literatur

  • 1 Soloff P H. Pharmacotherapy of borderline disorders.  Compr Psychiatry. 1981;  22 535-543
    CrossrefPubMedGoogle Scholar
  • 2 American Psychiatric Association .Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington DC: American Psychiatric Association 1994
    Google Scholar
  • 3 Zimmermann M, Mattia J I. Axis I diagnostic comorbidity and borderline personality disorder.  Compr Psychiatry. 1999;  40 245-252
    CrossrefPubMedGoogle Scholar
  • 4 Hori A. Pharmacotherapy for personality disorders.  Psychiatry Clin Neurosci. 1997;  52 13-19
    PubMedGoogle Scholar
  • 5 Androlunis P A, Gluech B C, Stroebel C F. et al . Borderline personality disorder subcategories.  J Nerv Ment Disord. 1982;  170 670-679
    PubMedGoogle Scholar
  • 6 Stein G. Drug treatment of personality disorders.  Br J Psychiatry. 1992;  161 167-184
    PubMedGoogle Scholar
  • 7 Cloninger C R, Svarik D M, Przybeck T R. A psychobiological model of temperament and character.  Arch Gen Psychiatry. 1993;  50 975-990
    PubMedGoogle Scholar
  • 8 Soloff P H. Special feature: Psychobiologic perspectives on treatment of personality disorders.  J Person Disord. 1997;  11 (4) 336-344
    PubMedGoogle Scholar
  • 9 Schmahl C, Bohus M. Symptomorientierte Pharmakotherapie bei Borderline-Persönlichkeitsstörung.  Fortschr Neurol Psychiat. 2001;  69 310-321
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Hirschfeld R M. Pharmacotherapy of borderline personality disorder.  J Clin Psychiatry. 1997;  58 (Suppl. 14) 48-52
    PubMedGoogle Scholar
  • 11 Soloff P H, George A, Nathan R S, Schul P M, Ulrich R F, Perel J M. Progress in pharmacotherapy of borderline disorders: A double-blind study of amitriptyline, haloperidol, and placebo.  Arch Gen Psychiatry. 1986;  43 691-697
    PubMedGoogle Scholar
  • 12 Soloff P H, George A, Nathan S. Amitriptyline versus haloperidol in borderlines: Final outcomes and predictors of response.  J Clin Psychopharmacol. 1989;  9 238-246
    CrossrefPubMedGoogle Scholar
  • 13 Soloff P H, Cornelius J, George A, Nathan S, Perel J M, Ulrich R F. Efficacy of phenelzine and haloperidol in borderline personality disorder.  Arch Gen Psychiatry. 1993;  50 (5) 377-385
    CrossrefPubMedGoogle Scholar
  • 14 Cowdry R W, Gardner D L. Pharmacotherapy of borderline personality disorder: Alprazolam, carbamazepine, trifluoperazin and tranylcypromine.  Arch Gen Psychiatry. 1988;  45 111-119
    PubMedGoogle Scholar
  • 15 Goldberg S C, Schulz S C, Schulz P M, Resnick R J, Hamer R M, Friedel R O. Borderline and schizotypal personality disorders treated with low-dose thiothixene vs placebo.  Arch Gen Psychiatry. 1986;  43 680-686
    CrossrefPubMedGoogle Scholar
  • 16 Montgomery S A, Montgomery D. Pharmacological prevention of suicidal behaviour.  J Affect Disord. 1982;  4 291-298
    CrossrefPubMedGoogle Scholar
  • 17 Frankenburg F R, Zanarini M C. Clozapine treatment of borderline patients: A preliminary study.  Compr Psychiatry. 1993;  34 402-405
    CrossrefPubMedGoogle Scholar
  • 18 Benedetti F, Sforzini L, Colombo C. et al . Low-dose clozapine in acute and continuation treatment of severe borderline personality disorder.  J Clin Psychiatry. 1998;  59 103-107
    CrossrefPubMedGoogle Scholar
  • 19 Chengappa K N, Baker R W, Sirri C. The succesful use of clozapine in ameliorating severe self mutilation in a patient with borderline personality disorder.  J Pers Disord. 1995;  9 76-82
    PubMedGoogle Scholar
  • 20 Szigethy E M, Schulz S C. Risperidone in comorbid borderline personality disorder and dysthymia.  J Clin Psychopharmcol. 1997;  17 326-327
    CrossrefPubMedGoogle Scholar
  • 21 Rocca P, Marchiario L, Cocuzza E, Bogetto F. Treatment of borderline personality disorder with risperidone.  J Clin Psychiatry. 2002;  63 (3) 241-244
    CrossrefPubMedGoogle Scholar
  • 22 Koenigsberg H W, Reynolds D, Goodman M, New A S, Mitropoulou V, Trestman R L, Silverman J, Siever L J. Risperidone in the treatment of schizotypal personality disorder.  J Clin Psychiatry. 2003;  64 (6) 628-634
    Google Scholar
  • 23 Schulz S C, Camlin K L, Berry S A, Jesberger J A. Olanzapin safety and efficacy in patients with borderline personality disorder and comorbid dysthymia.  Biol Psychiatry. 1999;  46 1429-1435
    CrossrefPubMedGoogle Scholar
  • 24 Zullino D F, Quinche P, Haflinger T, Stigler M. Olanzapin improves social dysfunction in cluster B personality disorder.  Hum Psychopharmacol. 2002;  17 (5) 247-251
    PubMedGoogle Scholar
  • 25 Hilger E, Barnas C, Kasper S. Quetiapin in the treatment of borderline personality disorder.  World J Biol Psychiatry. 2003;  4 (1) 42-44
    PubMedGoogle Scholar
  • 26 Walker C, Thomas J, Allen T S. Treating impulsivity, irritability, and aggression of antisocial personality disorder with quetiapine.  Int J Offender Ther Comp Criminol. 2003;  47 (5) 556-567
    CrossrefPubMedGoogle Scholar
  • 27 Liebowitz M R, Quitkin F M, Stewart J W. et al . Antidepressant specificy in atypical depression.  Arch Gen Psychiatry. 1988;  45 129-137
    CrossrefPubMedGoogle Scholar
  • 28 Parsons B, Quitkin F M, McGrath P J. et al . Phenelzine, imipramine and placebo in borderline patients meeting criteria for atypical depression.  Psychopharmacol Bull. 1989;  25 524-534
    PubMedGoogle Scholar
  • 29 Baer L, Jenike M A, Ricciardy J N. et al . Standardized assessment of personality disorders in obsessive compulsive disorder.  Arch Gen Psychiatry. 1990;  47 826-830
    CrossrefPubMedGoogle Scholar
  • 30 Insel T R, Zohar J. Psychopharmacologic approaches to obsessive compulsive disorder. In: Meltzer HY (Hrsg.). Psychopharmacology: The third generation in progress. New York: Raven Press 1987: 1205-1210
    Google Scholar
  • 31 Akiskal H S, Rosenthal T L, Haykal R F. et al . Clinical and sleep EEG findings seperating “subaffective dysthymias” from “character spectrum disorders”.  Arch Gen Psychiatry. 1980;  37 777-793
    PubMedGoogle Scholar
  • 32 Shawcross C R, Tyrer P. The influence of personality on response to monoamine oxidase inhibitors and tricyclic antidepressants.  J Psychiat Res. 1985;  19 557-562
    PubMedGoogle Scholar
  • 33 Black D W, Bell S, Hulbert J. et al . The importance of Axis-II in patients with major depression.  J Affect Disord. 1988;  14 115-122
    CrossrefPubMedGoogle Scholar
  • 34 Vliet I van, Boer J A den, Westenberg H GM. Psychopharmacological treatment of social phobia-a double blind placebo controlled study with fluvoxamine.  Psychopharmacology. 1994;  115 128-134
    PubMedGoogle Scholar
  • 35 Fahlen T, Nillson H L, Borgm K. et al . Social phobia: The clinical efficacy and tolerability of the monoamine oxydase-A and serotonin uptake inhibitor brofaromine. A double-blind placebo-controlled study.  Acta Psychiatr Scand. 1995;  92 351-358
    PubMedGoogle Scholar
  • 36 Versiani M, Nardi A E, Mundim F D. et al . Pharmacotherapy of social phobia - a controlled study with moclobemide and phenelzine.  Br J Psychiatry. 1992;  161 353-360
    PubMedGoogle Scholar
  • 37 Markowitz P J, Calabrese J R, Schulz S C. et al . Fluoxetine treatment of borderline and schizotypal personality disorder.  Am J Psychiatry. 1991;  148 1064-1067
    PubMedGoogle Scholar
  • 38 Salzman S, Wolfson A N, Schatzberg A. et al . Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder.  J Clin Psychopharmacol. 1995;  15 23-29
    CrossrefPubMedGoogle Scholar
  • 39 Cocarro E F, Astill J F, Herbert J L, Schut A G. Fluoxetine treatment of impulsive aggression in DSM III-R personality disorder patients.  J Clin Pharmacol. 1990;  105 373-375
    PubMedGoogle Scholar
  • 40 Cornelius J R, Soloff P H, Perel J M, Ulrich R. Fluoxetine trial in borderline personality disorder.  Psychopharmacol Bull. 1990;  26 149-152
    PubMedGoogle Scholar
  • 41 Mulder R T, Joyce P R, Luty S E. The relationship of personality disorders to treatment outcome in depressed outpatients.  J Clin Psychiatry. 2003;  64 (3) 259-264
    CrossrefPubMedGoogle Scholar
  • 42 Kavoussi R J, Liu J, Cocarro E F. An open trial of sertraline in personality-disordered patients with impulsive aggression.  J Clin Psychiatry. 1994;  55 137-141
    PubMedGoogle Scholar
  • 43 Markowitz P J. Pharmacotherapy of impulsivity, aggression and related disorders. In: Stein D, Hollander E (Hrsg.). Impulsive aggression and disorders of Impulse control. Sussex, England: J Wiley 1995: 263-287
    Google Scholar
  • 44 Katzelnick D J, Kobak K A, Greist J H. et al . Sertraline for social phobia: Placebo-controlled crossover study.  Am J Psychiatry. 1995;  152 1368-1371
    PubMedGoogle Scholar
  • 45 Vliet I van, Boer J A den, Westenber H GM. Psychopharmacological treatment of social phobia: Clinical and biochemical effects of brofaromine, a selective MAO-A inhibitor.  Eur J Neuropychopharmacol. 1992;  2 21-29
    PubMedGoogle Scholar
  • 46 Rinne T, Brink W van den, Wouters L, Dyck R van. SSRI treatment of borderline personality disorder: a randomized, placebo-controlled trial for female patients with borderline personality disorder.  Am J Psychiatry. 2002;  159 (12) 2048-2054
    CrossrefPubMedGoogle Scholar
  • 47 Reist C, Nakamura K, Sagart E, Sokolski K N, Fujimto K A. Impulsive aggressive behaviour: open-label treatment with citalopram.  J Clin Psychiatry. 2003;  64 (1) 81-85
    CrossrefPubMedGoogle Scholar
  • 48 Markowitz P J, Wagner S C. Venlafaxin in the treatment of borderline personality disorder.  Psychopharmacol Bull. 1995;  31 773-777
    PubMedGoogle Scholar
  • 49 Gardner D L, Cowdry R W. Positive effects of carbamazepine on behavioural dyscontrol in borderline personality disorder.  Am J Psychiatry. 1986;  143 519-522
    PubMedGoogle Scholar
  • 50 De La Fuente J M, Lotstra F. A trial of carbamazepin in borderline personality disorder.  Eur Neuropsychopharmacol. 1994;  4 479-486
    CrossrefPubMedGoogle Scholar
  • 51 Stein D J, Simeon D, Frenkel M. et al . An open trial of valproate in borderline personality disorder.  J Clin Psychiatry. 1995;  56 506
    PubMedGoogle Scholar
  • 52 Wilcox J A. Divalproex sodium as a treatment for borderline personality disorder.  Ann Clin Psychiatry. 1995;  7 33-37
    PubMedGoogle Scholar
  • 53 Cocarro E F, Kavoussi R J. Fluoxetine and impulsive aggressive behaviour in personality-disordered subject.  Arch Gen Psychiatry. 1997;  54 1081-1088
    PubMedGoogle Scholar
  • 54 Hollander E, Tracy K A, Swann A C, Coccaro E F, McElroy S L, Wozna P, Sommerville K W, Nemeroff C B. Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders.  Neuropsychopharmacology. 2003;  28 (6) 1186-1197
    PubMedGoogle Scholar
  • 55 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 (5) 442-446
    CrossrefPubMedGoogle Scholar
  • 56 Pinto O C, Akiskal H S. Lamotrigine as a promising approach to borderline personality: an open case series without concurrent DSM IV major mood disorder.  J Affect Disord. 1998;  52 (3) 333-343
    PubMedGoogle Scholar
  • 57 Rizvi S T. Lamotrigine and borderline personality disorder.  J Child Adolescent Psychopharmacol. 2002;  12 (4) 365-366
    PubMedGoogle Scholar
  • 58 Sheard M H. Effect of lithium on human aggression.  Nature. 1971;  230 113-114
    PubMedGoogle Scholar
  • 59 Rifkin A, Quitkin F, Carrillo C. et al . Lithium carbonate in emotionally unstable character disorders.  Arch Gen Psychiatry. 1972;  27 519-523
    PubMedGoogle Scholar
  • 60 Tupin J P, Smith D B, Clanon T L. et al . The long-term use of lithium in aggressive prisoners.  Compreh Psychiatry. 1973;  14 311-317
    PubMedGoogle Scholar
  • 61 Sheard M H, Marini J L, Bridges C I. et al . The effect of lithium on unipolar aggressive behaviour in man.  Am J Psychiatry. 1976;  133 1409-1413
    PubMedGoogle Scholar
  • 62 Links P. Lithium therapy for borderline patients.  J Pers Disord. 1990;  4 173-181
    PubMedGoogle Scholar
  • 63 Lion J R. Benzodiazepines in the treatment of aggressive patients.  J Clin Psychiatry. 1979;  40 70-71
    PubMedGoogle Scholar
  • 64 Eichelmann B. Toward a rational pharmacotherapy for aggressive and violent behaviour.  Hosp Comm Psychiatry. 1988;  39 31-39
    PubMedGoogle Scholar
  • 65 Faltus F J. The use of alprazolam in the treatment of three patients with borderline personality disorder.  Am J Psychiatry. 1984;  141 802-803
    PubMedGoogle Scholar
  • 66 Freinhar J P, Alvarez W A. Clonazepam: A novel therapeutic ajunct.  Int J Psychiatry Med. 1986;  15 (4) 321-328
    PubMedGoogle Scholar
  • 67 Bick P A, Hannah A L. Intramuscular lorazepam to restrain violent patients.  Lancet. 1986;  I 206
    PubMedGoogle Scholar
  • 68 Gardner D L, Cowdry R W. Alprazolam-induced dyscontrol in borderline personality disorder.  Am J Psychiatry. 1985;  142 98-100
    PubMedGoogle Scholar
  • 69 Reich J, Noyes R, Troughton E D. Alprazolam treatment of avoidant personality traits in social phobic patients.  J Clin Psychiatry. 1988;  50 91-95
    PubMedGoogle Scholar
  • 70 Roth A S, Ostroff R B, Hoffman R E. Naltrexone as a treatment for repetitive self- injurious behaviour: an open label trial.  J Clin Psychiatry. 1996;  57 233-293
    PubMedGoogle Scholar
  • 71 Sonne S, Rubey R, Brady K. et al . Naltrexone treatment of self-injurious thoughts and behaviours.  J Nerv Ment Dis. 1996;  184 192-195
    CrossrefPubMedGoogle Scholar
  • 72 Mc Gee M D. Cessation of self-mutilation in a patient with borderline personality disorder treated with naltrexone.  J Clin Psychiatry. 1997;  58 (1) 32-33
    PubMedGoogle Scholar
  • 73 Bohus M J, Landwehrmeyer B G, Stiglmeyr C E, Limberger M F, Bohme R, Schmahl C G. Naltrexon in the treatment of dissociative symptoms in patient with borderline personality disorder: an open-label trial.  J Clin Psychiatry. 1999;  60 (9) 598-603
    Google Scholar
  • 74 Sofoff P H. Algorithms for pharmacological treatment of personality dimensions: Symptom-specific treatments for cognitive-perceptual, affective, and impulsive-behavioural dysregulation.  Bull Menning Clin. 1998;  62 (2) 195-214
    PubMedGoogle Scholar
  • 75 American Psychiatric Association . Practical guidelines for the treatment of borderline personality disorder.  Am J Psychiatry. 2001;  158 (Suppl. 10) 1-44
    CrossrefPubMedGoogle Scholar
  • 76 Zanarini M C. Update on pharmacotherapy of borderline personality disorder.  Curr Psychiatry Rep. 2004;  6 (1) 66-70
    PubMedGoogle Scholar
  • 77 Newton-Howes G, Tyrer P. Pharmacotherapy for personality disorders.  Expert Opin Pharmacother. 2003;  4 (10) 1643-1649
    CrossrefPubMedGoogle Scholar

Dr. med. Dirk Wedekind

Klinik für Psychiatrie und Psychotherapie der Georg-August-Universität

Von Siebold-Straße 5

37075 Göttingen

Email: dwedeki1@gwdg.de

      >