Pharmacotherapy of Personality Disorders

Abstract

Objective: Prevalence of personality disorders have been reported as 10-13% in general population, 30-50% in psychiatric patients, and 15% in psychiatric outpatients. The most common personality disorders are respectively borderline, antisocial, schizotypal, and avoidant. There has been no specific pharmacological approach for the treatment of personality disorders that have different clinical features with various co-morbid psychiatric disorders. The aim of this report is to review the efficacy of psychotropic medications used for the treatment of personality disorders. Methods: By using “borderline, antisocial, schizotypal, narcissistic, obsessive compulsive, avoidant personality, and pharmacotherapy” as keywords at the Pubmed database we primarily searched for the double blind, placebo controlled, randomized trials and also included some of the open label trials. Results: Most of the research on this topic was on pharmacotherapy of borderline personality disorder. Polypharmacy, that has been used widely in treatment of these cases, has been reported ineffective in most of the patients. The antidepressants have been replaced by mood stabilizers. The antidepressants and mood stabilizers have been reported to decrease mood symptoms like anger, depression, dysphoria, and to enhance adherence to psychotherapy. The most effective mood stabilizer was divalproex. The antipsychotics have been recommended to be used at psychotic and behavioral symptomatology. At the treatment of antisocial personality disorder CBT is recommended and there was no evidence based pharmacotherapy. In the treatment of schizotypal personality disorder, the antipsychotics have been reported effective. Pergolide and guanfacine have been reported to be useful in the treatment of cognitive disorders. The first line treatment options of avoidant personality disorder are venlafaxine and SSRIs. Conclusions: Most of the studies in literature have been focused at borderline personality disorder that has been difficult to treat. According to the guidelines, psychotherapy is the first line treatment for personality disorders. Pharmacotherapy has been reported to increase the efficiency of psychotherapy in BPD which presents with various symptoms of mood, cognition, and behavior. The studies in the literature report that Polypharmacy is not useful for these patients contrary to the popular belief. The research about other personality disorders is limited. More clear understanding of etiopathogenesis of personality disorders; would be helpful in development of more effective pharmacological agents in their treatment.

Keywords

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Kişilik Bozukluklarında İlaç Tedavisi

Öz

Giriş: Kişilik bozukluğunun genel toplumda yaygınlığı %10-13, psikiyatrik tanı alan hastalarda %30-50, psikiyatri kliniğine başvuranlarda ise %15 olarak bildirilmektedir. En sık görülen kişilik bozuklukları sırasıyla; borderline kişilik bozukluğu (BKB), antisosyal kişilik bozukluğu (ASKB), şizotipal kişilik bozukluğu (SKB)ve kaçıngan kişilik bozukluğu (KKB) olarak tanımlanmaktadır. Klinikte farklı belirtiler ve çeşitli ruhsal bozukluklarla karşımıza çıkan kişilik bozukluklarının özgül bir farmakoterapisi bulunmamaktadır. Bu yazında kişilik bozukluğu tedavisinde kullanılan psikotrop ilaçların ekinliğinin gözden geçirilmesi amaçlanmıştır. Yöntem: Pubmed arama motorunda borderline, antisosyal, şizotipik, narsisistik, şizoid, obsesif kompulsif, kaçıngan kişilik bozukluğu ve farmakoterapi anahtar kelimeleri kullanılarak 1980 ve 2011 yılları arasında ingilizce dilde yayınlanmış olan öncelikle çift–kör, randomize, plasebo kontrollü çalışmalar araştırılmıştır, konuyla ilişkili açık uçlu çalışmaların bir kısmına yer verilmiştir. Bulgular: Yapılan tarama sonucunda bu konuda yapılan araştrımaların çoğunun borderline kişilik bozukluğu (BKB) tedavisiyle ilişkili olduğu görülmüştür. BKB’de yaygın olarak kullanılan çoklu ilaç kullanımının tedavide etkin olmadığı belirtilmektedir. Antidepresan tedavinin yerini mizaç düzenleyiciler almaktadır. Antidepresan ve mizaç dengeleyecilerin öfke, depresyon, disfori gibi ‘mizaç’ belirtilerini azalttığı ve psikoterapi uygulamalarını kolaylaştırdığı belirtilmektedir. Mizaç düzenleyicilerden özellikle divalproik asitin daha etkili olduğu bildirilmektedir. Antipsikotik tedavilerin psikotik belirtilerin ve davranış bozukluklarının ortaya çıktığı durumlarda kullanılması önerilmektedir. Antisosyal kişilik bozukluğunun temel tedavisi Bilişsel Davranışçı Terapi (BDT) olarak tanımlanmaktadır ve farmakoterapisine yönelik kanıta dayalı veriler oldukça sınırlıdır. Şizotipal kişilik bozukluğu tedavisinde ise antipsikotik ilaçların yararlı olduğu bildirilmekte ve bu hastalarda sıklıkla izlenen bilişsel bozuklukların tedavisinde pergolid ve guanfasinin gibi ilaçların yararlı olabildiği belirtilmektedir. Kaçıngan kişilik bozukluğu tedavisinde ise ilk seçenek olarak venlafaksin ve serotonin geri alım inhibitörlerinin yaralı olduğu bildirilmektedir. Sonuç: Literatürde araştırmaların büyük çoğunluğu klinik uygulamada da sıklıkla zorluk yaşandığı bilinen borderline kişilik bozukluğunun tedavisine odaklanmıştır. Tedavi klavuzlarında kişilik bozukluklarının psikoterapiyle tedavisi önerilmektedir. Özellikle farklı psikiyatrik belirtilerle karşımıza çıkabilen BKB’ye özgü olan mizaç, davranış, bilişsel bozuklukların tedavisinde farmakoterapinin psikoterapiden yararlanımı arttırdığı belirtilmektedir. Çoklu psikotrop kullanımının bu hasta grubunda sanıldığının aksine yararının olmadığı saptanmıştır. Diğer kişilik bozukluklarıyla yapılan araştırmalar ise sınırlı sayıdadır. Kişilik bozukluklarının etiyopatogenizinin daha iyi anlaşılması bu konuda daha etkin farmakoterapi seçeneklerinin gelişmesini sağlayacaktır.

Anahtar Kelimeler

• borderline kişilik bozukluğu, farmakoterapi, kişilik bozuklukları

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