Pharmacological Management of Borderline Personality Disorder and Common Comorbidities
Pharmacological Management of Borderline Personality Disorder and Common Comorbidities
Pharmacological Management of Borderline Personality Disorder and Common Comorbidities
https://doi.org/10.1007/s40263-023-01015-6
CURRENT OPINION
Abstract
Comorbidity between borderline personality disorder (BPD) and other mental disorders is common. Although no specific
pharmacological treatments have been approved for the treatment of BPD, many drugs, including antidepressants such as
selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, second-generation antipsychotics, and even benzodiaz-
epines, are routinely prescribed off label. Nonetheless, recommendations for off-label drugs in these patients are highly varied,
with a notable lack of agreement among clinical guidelines. The most common reason for pharmacological treatment and
polypharmacy in these patients is comorbidity with other psychiatric disorders. In this context, we reviewed major clinical
guidelines and the available data on pharmacotherapy in patients with BPD to develop practical recommendations to facilitate
decision-making in routine clinical practice, thus helping clinicians to select the optimal therapeutic approach in patients with
BPD who have comorbid disorders. This review confirmed that no clear recommendations for the pharmacological treatment
are available in clinical guidelines. Therefore, based on the available evidence, we have developed a series of recommenda-
tions for pharmacotherapy in patients with BPD who present the four most common comorbidities (affective, anxiety, eating,
and drug use disorders). Here, we discuss the recommended treatment approach for each of these comorbid disorders. The
prescription of medications should be considered only as an adjunct to BPD-specific psychotherapy. Polypharmacy and the
use of unsafe drugs (i.e., with a risk of overdose) should be avoided. Our review highlights the need for more research to
provide more definitive guidance and to develop treatment algorithms.
Key Points
1 Introduction
Comorbidity with other mental disorders is common in
Borderline personality disorder (BPD) is a serious mental individuals with borderline personality disorder (BPD).
illness with an estimated community prevalence of 2.7% Pharmacotherapy is substantially more common than
[1–3]. In individuals seeking treatment at outpatient men- recommended in clinical guidelines.
tal health clinics, the prevalence is approximately 10%, Several approaches are proposed to guide the pharmaco-
with rates as high as 20% in psychiatric inpatients [2, 3]. logical management of patients with BPD with the most
BPD is a heterogeneous disorder that may include emo- common comorbidities (affective, anxiety, eating, and
tion dysregulation (intense, rapidly changing emotions), drug use disorders).
The prescription of medications should only be con-
* Juan C. Pascual sidered as an adjunct to BPD-specific psychotherapy.
jpascual@santpau.cat Polypharmacy and unsafe drugs should be avoided.
1
Universitat Autònoma de Barcelona (UAB), Barcelona, Several different treatment algorithms and therapeutic
Spain
recommendations are provided for use in routine clinical
2
Department of Psychiatry, Hospital de la Santa Creu i Sant practice to treat patients with BPD and comorbidities.
Pau, Av. Sant Antoni Mª Claret 167, 08025 Barcelona, Spain
3
Institut d’Investigació Biomèdica-Sant Pau (IIB-NTPAU),
Centro de Investigación Biomédica en Red de Salud Mental,
CIBERSAM, Barcelona, Spain
Vol.:(0123456789)
490 J. C. Pascual et al.
impulsivity (with dysfunctional behaviors such as self- No psychotropic drugs have been officially approved for
harm, drug abuse, or binge eating), and unstable iden- the specific treatment of BPD. Although some studies have
tity and interpersonal relationships. Not surprisingly, this been performed, most of these are small, with relatively
clinical heterogeneity is often associated with many other short treatment periods and a wide range of different meas-
mental disorders and somatic conditions [1]. ures. In addition, most RCTs excluded patients with comor-
Other mental disorders are common in patients with bidities. In short, the evidence to support pharmacotherapy
BPD, as evidenced by the high comorbidity rates reported in this setting is weak [8, 12].
in numerous cross-sectional and longitudinal studies In routine clinical practice, many drugs are commonly
[2–5]. The findings of an epidemiological study in the prescribed “by default” in patients with BPD, as evidenced
USA suggested that BPD is rarely diagnosed alone, with by data from the USA and some European countries, where
high lifetime prevalence rates in these patients for anxi- ≥ 80% of patients with BPD are on pharmacotherapy, and
ety disorders (84.8%), mood disorders (82.7%), substance 50% are taking three or more drugs [12–18]. Although some
use disorders (SUD; 78.2%), and eating disorders (ED; clinical guidelines recommend pharmacotherapy to treat cer-
33.7%) [4, 5]. Similarly, several other mental disorders tain BPD symptoms, such as impulsivity, emotional distur-
also present high rates of comorbidity with BPD, includ- bances, or cognitive-perceptual symptoms, recent expert rec-
ing posttraumatic stress disorder (PTSD), attention deficit ommendations do not support the use of pharmacotherapy
hyperactivity disorder (ADHD), and bipolar disorder [5]. as a first-line treatment or for specific domains [2, 9, 19].
However, it is important to consider that the symptoms of The main factor associated with pharmacological treat-
BPD frequently overlap with several disorders that share ment or polypharmacy is comorbidity with other mental
the same features. For example, while impulsivity with health disorders, most notably—and congruently—affective,
drug abuse or binge eating is a key marker of BPD, it is anxiety, and eating disorders [14, 15, 20]. Nonetheless, phar-
also a common symptom in other disorders [2]. macotherapy in BPD patients is widespread, even in patients
In patients with BPD, co-occurring psychiatric disor- with no comorbidities. For example, one study involving a
ders are often chronic, and may be associated with severely sample of 457 individuals with BPD found that close to 80%
impaired social and occupational functioning that requires of comorbidity-free patients with BPD were also receiving
social support; moreover, they are often difficult to treat pharmacological treatment (62.9% received antidepressants,
[2, 6]. Since the first randomized control trial (RCT) of 59.7% benzodiazepines, 22.6% mood stabilizers, and 27.4%
psychotherapy for patients with BPD was performed in antipsychotics) with 42% on polypharmacy [15].
1993 [7], more than ten different manualized psychothera- Antidepressants, particularly selective serotonin reup-
pies for BPD have been evaluated [8]. Of those psycho- take inhibitors (SSRI) such as citalopram and fluoxetine,
logical interventions, five—dialectical behavioral therapy are the most commonly prescribed drugs for BPD, despite
(DBT), mentalization-based treatment (MBT), schema the lack of evidence to support their use [18, 20]. Gunder-
focused therapy (SFT), transference-focused psychother- son et al. [21], found that the prescription of antidepres-
apy (TFP), and systems training for emotional predictabil- sants in patients with BPD was most commonly associated
ity and problem solving (STEPPS)—have been established with comorbidity for affective disorders (odds ratio 2.77).
as evidence-based treatments (EBT) for BPD. To date, the Although the use of benzodiazepines is not recommended
two approaches that have received the most attention, as due to their highly addictive nature and their potential for
evidenced by the number of clinical trials performed, are behavioral disinhibition, prescription rates nevertheless
DBT and MBT [8]. To better manage the complex comor- remain high, particularly in patients with affective and anx-
bidities associated with BPD, several evidence-based ious disorders who do not present SUD [15, 18, 20].
psychotherapeutic approaches have been adapted for use The prescription of mood stabilizers, such as topiramate
in this challenging patient profile, especially those with and valproate, in patients with BPD is associated with the
comorbid SUDs, EDs, and PTSD [8]. presence of anxiety and eating disorders; by contrast, antip-
Unfortunately, not all individuals have access to these sychotics (mostly atypical ones such as quetiapine and olan-
intensive, highly specialized treatments, which are difficult zapine) are not associated with any axis I comorbidity [18,
to implement in most health care facilities due to insufficient 20].
resources [8–11]. In this context, it is not surprising that The pharmacological treatment of BPD has been evalu-
many clinicians routinely prescribe drugs for the treatment ated in clinical guidelines and in several reviews [2, 12,
of patients with BPD, despite the weak evidence supporting 19]. However, no consensus on therapeutic indications
the value of pharmacotherapy to improve core BPD symp- has been reached. Importantly, none of those publications
toms, interpersonal impairment, and functional difficulties have addresses the specific question of the pharmacological
[12]. treatment of comorbidities in BPD. This is relevant given
that comorbidity with other mental disorders is common in
Pharmacotherapy for BPD and Common Comorbidities 491
patients with BPD, which partially explains why many indi- also symptom duration is a key factor to consider [23].
viduals with BPD receive pharmacotherapy. Moreover, the In any case, it is essential to prioritize BPD-appropriate
specific drug that should be prescribed for a given comorbid- psychotherapy, rather than polypharmacy alone.
ity is not clear, in large part due to the weak evidence base. As Fig. 1 and Table 2 show, the recommended first-line
In this context, the aim of the present review was to better treatment for a patient with BPD with a mild–moderate
clarify this question. In addition, we aimed to develop prac- MDD episode is BPD-specific psychotherapy. Some clini-
tical recommendations for the pharmacological treatment cal guidelines on the treatment of MDD episodes (regardless
of patients with the most common comorbidities. Below, of the presence or not of BPD) also recommend psycho-
we discuss each comorbid disorder separately, taking into therapeutic interventions for mild-to-moderate depression
account the course of these disorders in individuals with as a first-line treatment; however, the routine use of anti-
BPD over time. depressants should be avoided due to the poor risk–benefit
ratio [26]. If the MDD episode is severe or fails to respond
to psychotherapy, pharmacotherapy can be considered. The
2 Comorbid Mood Disorders mood disorder should be first treated with antidepressants
following the recommendations of clinical guidelines for
Mood disorders are one of the most common disorders in MDD [26–28].
individuals with BPD. Up to 80% of patients with BPD A wide range of antidepressants, including SSRIs, selec-
present one or more episodes of major depressive disor- tive norepinephrine reuptake inhibitors (NRIs), selective ser-
der (MDD) in their lifetime and 10–30% of patients with otonin and norepinephrine reuptake inhibitors (SNRIs), and
MDD have co-occurring BPD [2, 3, 21, 22]. BPD is strongly others, are available to treat depressive episodes [26]. SSRIs
associated with many mood disorders, especially MDD such as fluoxetine, sertraline, citalopram, or escitalopram
and dysthymia, with an odds ratio (OR) for any mood dis- seem to be the first and most common option prescribed by
order of 14.93 [4]. Even in BPD patients without MDD, clinicians for BPD [18, 20]. Antidepressants with an unsafe
depressive symptoms and transient “micro-depressions” profile, such as tricyclic antidepressants (TCAs) or mono-
are common and difficult to clinically differentiate from amine oxidase inhibitors (MAOIs), are not recommended
MDD [23]. Skodol et al. [24] found that having BPD was due to the risk of overdose, lower tolerability profiles, and
the most robust predictor of persistent MDD; that study also potential adverse reactions [2, 8].
found that when both of these disorders co-occur, the MDD Although mood stabilizers (e.g., lithium, valproate) are
episodes last longer and the interepisodic interval may be commonly prescribed in combination with antipsychotics
shorter. Improvement in MDD is often predicted by a prior in patients with MDD as adjunctive strategies [26, 28],
decrease in BPD symptoms; by contrast, the reverse is not there is a notable lack of studies investigating the effec-
necessarily true: improvements in MDD are not always fol- tiveness of this approach in patients with comorbid BPD
lowed by a reduction in BPD symptoms [21]. Longitudinal and MDD. Nevertheless, valproate in combination with
studies suggest that treatment for BPD may yield positive antidepressants could be efficacious for treatment-resist-
results in both disorders and that remission of BPD is a pre- ant MDD and has also shown some beneficial effects in
dictor of MDD remission [25]. patients with BPD [12, 27]. Lamotrigine was also found
In patients with comorbid BPD and MDD, the available to have beneficial effects in treatment-resistant MDD
clinical evidence for pharmacological treatment is insuf- [26–30]. Two small preliminary studies have suggested
ficient to establish any reliable recommendations. Despite that this drug may have an effect on impulsivity, anger,
these limitations, we have developed a practical treatment and behavioral dyscontrol in BPD [12]. However, the large
algorithm and recommendations, based on our review of (n = 276) randomized clinical trial carried out by Craw-
the evidence and our clinical experience (Fig. 1). In clini- ford et al. [31] in patients with BPD found no evidence
cal practice, the first step is to try to differentiate between to support the use of lamotrigine (400 mg/day) for the
“micro-depressions” in BPD, which are a common compo- treatment of BPD symptoms. Similarly, the findings of a
nent of BPD psychopathology, and MDD, which is a clini- recent Cochrane systematic review did not support the use
cally distinct entity. Table 1 presents several practical hall- of lamotrigine for people with personality disorders [12].
marks that may indicate the presence of micro-depressions Finally, several meta-analyses have found that atypical
in BPD. In these patients, depressive symptoms are usually antipsychotics such as aripiprazole, quetiapine, olanzap-
transient and stress related, rarely last for more than a few ine, and risperidone may be efficacious as an adjunctive
days, and are usually precipitated by stress and interper- treatment for individuals with MDD [26]. Some studies
sonal factors. However, given the transitory nature of these also suggest that these atypical antipsychotics may be use-
micro-depressions, the presence of depressive symptoms ful in the treatment of patients with BPD [12]. Therefore,
in a cross-sectional assessment could suggest MDD, but
492 J. C. Pascual et al.
Fig. 1 Algorithm for the management of patients with borderline sive disorder; SFT, schema-focused therapy; SSRI, selective seroto-
personality disorder and comorbid major depressive disorder. AD, nin reuptake inhibitor; STEPPS, systems training for emotional pre-
antidepressants; APS, antipsychotics; BPD, borderline personality dictability and problem solving; TCA, tricyclic antidepressants; TFP,
disorder; DBT, dialectical behavioral therapy; EBT, evidence-based transference-focused psychotherapy
treatment; MBT, mentalization-based treatment; MDD, major depres-
these second-generation antipsychotics could also be use- be considered an adjunct to psychological therapy [2]. In
ful as adjunctive strategies for individuals with BPD and addition, the effects of prescription drugs need to be moni-
severe or resistant MDD. tored closely; if they are not effective and/or induce exces-
Clearly, pharmacological treatment in patients with sive side effects, their use should be discontinued. If the
comorbid BPD and MDD is important. However, we must response to pharmacological treatment is poor, the ineffec-
also keep in mind that in BPD, drug therapy should only tive treatment should be discontinued. Additionally, every
Pharmacotherapy for BPD and Common Comorbidities 493
Table 1 Factors for selecting antidepressants and characteristics of borderline personality disorder micro-depressions to help differentiate from
major depressive disorder.
Table 2 Summary recommendations for antidepressants. risks, most notably those associated with polypharmacy
(more than half of patients with BPD take three or more
First line Mechanism Dose range, mg
psychotropic medications) [18]. Although the main reason
Citalopram SSRI 20–40 for pharmacological treatment or polypharmacy in BPD is
Escitalopram SSRI 10–20 comorbidity with psychiatric disorders, it is important to
Fluoxetine SSRI 20–60 underscore the fact that most patients are medicated, even
Paroxetine SSRI 20–40 those with no comorbidities [15, 18]. A second risk is related
Sertraline SSRI 50–200 to patient preferences for pharmacotherapy rather than psy-
Second line chotherapy. Several meta-analyses have shown that the opti-
Venlafaxine SNRI 75–225 mal first-line treatment for this condition is BPD-specific
Desvenlafaxine SNRI 50–100 psychological therapy, and these findings are reflected in
Duloxetine SNRI 60–120 the recommendations of most clinical guidelines [2, 8, 9].
Third line (adjunctive therapy) Unfortunately, specialized psychotherapy for BPD is often
Aripiprazole Partial agonist D2,5-HT2 5–15 not available, which explains why pharmacotherapy is some-
Olanzapine Antagonist D2,5-HT2 2.5–30 times used—inappropriately—as an alternative [9].
Quetiapine Antagonist D2,5-HT2 100–300 In short, in patients with BPD and comorbid MDD, anti-
Valproate GABA 500–1000 (dose depressant treatment should only be offered as an adjunct to
adjusted to plasma psychological therapy. Interestingly, both BPD and MDD
levels) may respond to BPD-specific psychotherapy, which under-
5-HT, 5-hydroxytryptamine (serotonin); D2, dopaminergic D2 scores the importance of prioritizing this treatment approach
receptor; GABA gamma-aminobutyric acid; SNRI, serotonin and over polypharmacy [2, 23, 32].
noradrenaline reuptake inhibitor; SSRI, selective serotonin reuptake
inhibito
with BPD, with a tendency to decrease significantly after departments, where benzodiazepines are prescribed to rap-
10 years (although recurrence rates are high) [5]. idly alleviate anger [15, 35].
Anxiety disorders can be treated with psychotherapy,
pharmacotherapy, or a combination of both [33]. The treat-
ment plan should be chosen only after careful consideration 4 Comorbid Eating Disorders
of individual factors such as patient preferences, previous
treatment attempts, and illness severity [33]. In patients with Eating disorders also present high rates of comorbidity with
comorbid BPD and anxiety, the best approach may be to start BPD. In a meta-analysis that examined the prevalence of
psychotherapy, which all the main evidence-based treatment personality disorders among individuals with EDs, BPD was
guidelines agree should be the first-line treatment for BPD present in 28% of patients with bulimia nervosa (BN), 25%
[2, 10]. The psychological intervention with the highest level of those with anorexia nervosa (AN) binge-eating/purging
of evidence for the treatment of anxiety disorders is CBT subtype (AN–BP), and 10.8% of patients with AN restrictive
[33]. Nonetheless, MBT or DBT, with specific modules such subtype (AN–R) [36]. Similarly, the prevalence of EDs (of
as emotional regulation, mindfulness, and distress tolerance, any type) among individuals with BPD is elevated, ranging
could be also a useful psychological intervention for the from 14% to 53%; the most common ED in these patients is
treatment of anxiety symptoms in BPD [11, 34]. eating disorder not otherwise specified (EDNOS) [5]. For-
When psychotherapy is unavailable or not as effective tunately, the available data suggest that comorbidity rates
as expected, or if the patient expresses a preference for between BPD and ED decrease significantly over time, with
pharmacotherapy, drug therapy should be considered. one study showing that most individuals with BPD who met
However, the patient must be fully informed about both criteria for ED experienced remission over time [5].
the risks and benefits of the available pharmacological Anorexia nervosa is a serious condition associated with
alternatives. SSRIs and SNRIs are recommended as first- high rates of morbidity and mortality. In patients with severe
line drug therapy for anxiety disorders, mainly because AN comorbid with BPD, the general recommendations in
drugs these are associated with fewer adverse effects than clinical guidelines for AN should be followed in terms of
other therapeutic options such as TCAs or MAOIs [35, treatment setting, day hospital treatment, psychotherapy, or
36]. Due to their efficacy and lack of major side effects, nutritional management independently of BPD comorbid-
the SSRIs (escitalopram, citalopram, fluoxetine, sertraline, ity [39]. As all the clinical guidelines point out, there is a
fluvoxamine, and paroxetine) and one SNRI (venlafaxine) notable lack of evidence to support pharmacotherapy for
have received the highest grade of recommendation [36]. AN, and most guidelines strongly recommend caution when
For patients with comorbid BPD and anxiety disorder, prescribing drugs in this patient population due to the risk
treatment with SSRIs or SNRIs should only be recom- of medical complications. Nonetheless, some guidelines
mended when combined with BPD-specific psychotherapy. suggest that short-term treatment with SSRIs or low-dose
If the patient fails to respond to standard treatments, sev- antipsychotics (especially olanzapine) may be justified in
eral alternative strategies (e.g., atypical antipsychotics or certain cases, such as in patients with a critically low body
anticonvulsants) can be considered, but never as first-line mass index [39, 40].
treatment and always keeping in mind the need to avoid For individuals with BPD and less severe, non-life-threat-
polypharmacy and its attendant risks [9, 11, 35]. Despite ening EDs (AN, BN, or EDNOS), the disorder should be
the common use of low-dose atypical antipsychotics (e.g., managed concurrently with BPD-specific treatment, prefera-
quetiapine or olanzapine) and anticonvulsants (e.g., pre- bly coordinated by the BPD therapist [2]. Nevertheless, Car-
gabaline or gabapentine) as adjunctive treatments, these mona I Farrés et al. [41] suggested that comorbidity between
are not recommended in current guidelines as a first-line BPD and EDs predicted early dropout from DBT skills
strategy (except for pregabalin for GAD) [36]. training. In this regard, effective adaptations of DBT have
All clinical guidelines advise against the use of benzo- been developed for individuals with comorbid BPD and ED,
diazepines due to their addictive potential as well as their which could improve treatment retention in these patients [2,
capacity to increase suicidal tendencies and disinhibition 41]. For individuals who have difficulty accessing first-line
(2). In real-world clinical practice, however, benzodiaz- psychotherapy or who do not respond to therapy, second-
epines are commonly prescribed for the treatment of BPD line psychotherapy may be helpful. Although the current
[11, 15, 33]. The prescription of benzodiazepines in this evidence base is weak, psychotropic medications, which
patient population is likely attributable to several differ- may affect appetite and body weight, could be prescribed as
ent factors, including comorbidity with anxiety disorders, an adjunct to psychotherapy [39, 40]. This pharmacological
patient demand for sedatives, the tendency of many psy- treatment includes antidepressants (SSRIs; e.g., fluoxetine),
chiatrists to treat specific symptoms in these patients, and antipsychotics (e.g., quetiapine), psychostimulants (e.g., lis-
the clinical management of exacerbations in emergency dexamfetamine), and anticonvulsants (e.g., topiramate) [37].
Pharmacotherapy for BPD and Common Comorbidities 495
5 Comorbid Substance Use Disorders medications are routinely prescribed off label for this con-
dition despite the lack of agreement among clinical guide-
BPD is generally characterized by greater impulsivity and lines. Comorbidity between BPD and other psychiatric
a preference for short-term rewards. This inability to focus disorders is considered to be the main factor associated
on the long term predisposes patients to develop SUD [5]. with both pharmacological treatment and polypharmacy
The overall lifetime prevalence of SUD in patients with in these patients.
BPD is approximately 78% [2–4]. However, longitudinal Our review of the evidence leads us to make the fol-
studies show that despite the high prevalence of SUD in lowing conclusions and clinical recommendations for
this patient population, prevalence rates tend to decrease the management of patients with BPD and a comorbid
over time [5]. disorder: (1) psychotherapy should be the first-line treat-
The first-line treatment for patients with comorbid BPD ment for all individuals with BPD, regardless of whether
and SUD is psychological therapy, although it is important a comorbidity is present or not; (2) while some drugs can
to note that the presence of comorbid SUD increases the risk be helpful, their main role is as an adjunct to BPD-specific
of early dropout from psychotherapy for BPD [2, 41, 42]. psychotherapy; (3) off-label drug prescription and polyp-
Specific treatment manuals designed to lower the risk of harmacy is common in BPD despite the lack of robust evi-
treatment dropout and improve efficacy have been developed dence; (4) patients who receive BPD-specific psychother-
for patients with comorbid BPD and SUD [40]. In these apy usually require fewer medications, which can help to
patients, there are several potentially effective treatment reduce polypharmacy; (5) BPD-specific treatment should
options, including a version of DBT adapted specifically be prioritized over the treatment of comorbidities, except
for BPD patients with comorbid SUD (DBT–SUD), dynamic for severe episodes of MDD, severe substance use, or life-
deconstructive psychotherapy, and schema therapy for addic- threatening AN; (6) pharmacotherapy may be useful in
tion (Dual Focus Schema Therapy; DFST) [42–45]. severe cases, or when psychotherapy is ineffective, but it is
In cases of severe substance use, the treatment of the SUD important to avoid polypharmacy and sedatives. Likewise,
should be prioritized over BPD, especially when psycho- the patient should be informed about the possible adverse
therapy is not effective or when the patient expresses a pref- side effects of these drugs and about alternative medica-
erence to receive treatment for the SUD, which may include tions. Doing so allows the patient to take an active role in
hospitalization and/or pharmacological treatment. However, decision-making, which is important given the uncertainty
patients should be informed about the limited evidence for surrounding the optimal treatment approach (2).
the efficacy of pharmacological treatment, as well as the Finally, we need the identification of new pharmaco-
risks and benefits of the various pharmacological alterna- logical targets in the treatment of BPD and new drug can-
tives. Studies have shown that patients with alcohol use dis- didates to treat BPD and comorbidities with potential ben-
order (AUD) and BPD comorbidity benefit from pharma- eficial effects, such as psychedelic-assisted psychotherapy
cotherapy to the same extent as patients with a dependence approaches [47, 48]. New clinical trials and naturalistic
disorder without this comorbidity [46]. Consequently, treat- studies are needed to clarify the role of pharmacother-
ments for AUD, which include disulfiram, naltrexone, and apy in the treatment of BPD, particularly in patients with
acamprosate for relapse prevention, should always be offered comorbid conditions. Despite the relatively weak evidence
to these patients [42, 46]. Other off-label medications, such base, we believe that clinicians will find the recommenda-
as anticonvulsants (e.g., pregabaline, gabapentine, or topira- tions and algorithms proposed here for the pharmacologi-
mate) or atypical antipsychotics (e.g., quetiapine or olanzap- cal treatment of individuals with BPD and comorbidities to
ine), may be considered [46]. Prescription of these drugs be of value for the clinical management of these patients.
should be done cautiously, keeping in mind the need to avoid
Acknowledgements We would like to thank Bradley Londres (biomed-
polypharmacy and to limit the use of sedatives. ical editor and translator at Londres Biomedical Editing) for profes-
sional English language editing of the final version of the manuscript.
6 Conclusions Declarations
Funding This study was supported by the Centro de Investigación Bio-
Comorbidity with other mental disorders is common in médica en Red de Salud Mental (CIBERSAM) and by a grant from
individuals with BPD. The prevalence of these comorbid Instituto de Salud Carlos III (PI21/00505) and co-financed by the
disorders tends to decrease gradually over time in parallel European Regional Development Fund (ERDF). Open Access Fund-
with the clinical improvement of the typical symptoms ing provided by Universitat Autonoma de Barcelona.
that characterize BPD. No drugs have yet been approved
specifically for the treatment of BPD. Nonetheless, various Conflict of interest Juan C. Pascual, Laia Arias, and Joaquim Soler
declare they have no conflicts of interest.
496 J. C. Pascual et al.
Ethics approval This study adhered to the principles outlined in the Cochrane Database Syst Rev. 2020;5(5):CD012955. https://doi.
Declaration of Helsinki. org/10.1002/14651858.CD012955.pub2.
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Availability of data and material Not applicable. macological interventions for people with borderline personality
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ing and writing this manuscript and approved the final version for sub- comparison subjects over 16 years of prospective follow-up. J Clin
mission and agree to be accountable for the work. Psychopharmacol. 2015;35(1):63–7. https://doi.org/10.1097/JCP.
0000000000000232.
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people with personality disorder: the influence of patient factors
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original author(s) and the source, provide a link to the Creative Com-
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