The Psychopharmacology of Personality Disorders

BRAIN TRUST: CONVERSATIONS IN PSYCHOPHARMACOLOGY

-Series Editor Joseph F. Goldberg, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with Michael Gitlin, MD, to discuss psychopharmacologic options for personality disorders.¹

They highlighted the dimensional nature of personality disorders,² contrasting them with the categorical DSM model.

“The relationship between treating personality disorders and the use of medicines is not as natural as it would be for classic symptom-based disorders, such as mood disorders, anxiety disorder, and psychotic disorders. Because, when we describe symptom-based disorders, we have symptoms, we have time frames, and it fits the medical model. The DSM is categorical, meaning there are allegedly boundaries around all of the disorders. The problem is all of psychopathology, but most of all personality pathology, is dimensional, not categorical,” said Gitlin.

Gitlin emphasized the importance of treating specific symptom complexes like impulsive aggression and affective liability rather than the entire disorder. He suggested using anticonvulsants, low-dose antipsychotics, and serotonergic drugs for different symptom profiles.

“Instead of saying, do I know how to treat borderline personality disorder with medicine, what we should do is take a step back say, what are the symptom complexes that dominate the features of that personality disorder? And then say, do I know how to treat that?” said Gitlin.

They also discussed the role of therapeutic alliance and placebo effects in enhancing treatment outcomes. A collaborative approach, where the patient is an active participant in the treatment plan, can enhance adherence and treatment outcomes.

Overall, the conversation underscores the need for personalized, goal-oriented approaches in managing personality disorders.

Dr Goldberg is a clinical professor of psychiatry at The Icahn School of Medicine at Mount Sinai in New York, NY and the immediate-past president of the American Society of Clinical Psychopharmacology.

Dr Gitlin is the distinguished professor of clinical psychiatry at the UCLA School of Medicine. He is currently the director of the Adult Division in the Department of Psychiatry, Medical Director of the Neuropsychiatric Behavioral Health Services and director of the Mood Disorders Clinic at the UCLA Neuropsychiatric Hospital.

References

1. Gitlin MJ. Pharmacotherapy of personality disorders: conceptual framework and clinical strategies. J Clin Psychopharmacol. 1993;13(5):343-353.

2. Monaghan C, Bizumic B. Dimensional models of personality disorders: challenges and opportunities. Front Psychiatry. 2023;14:1098452.