Borderline” kişilik bozukluğu: Duygudurum dengeleyicilerinin tedavideki yeri

Bu yazıda, bipolar bozuklukla ortak olarak, “borderline” kişilik bozukluğunun (BKB) psikofarmakolojik tedavisinde kullanılan duygudurum dengeleyicilerin etkinliğini gözden geçirmek amaçlanmıştır. Bu çerçevede, BKB ile bipolar bozukluğun örtüşen fenomenolojisi ve ayırıcı klinik tanının özellikleri de literatür eşliğinde gözden geçirilecektir. Her iki bozukluk da tanı açısından ortak özellikler gösterebilir ve fenomenolojik açıdan örtüşebilirler, birlikte var olma sıklıkları da oldukça yüksektir. Her iki bozukluğun birbirinden ayrıştırılması için duygudurum kaymalarının niteliği, impulsivitenin tipleri ve bozuklukların uzunlamasına gidişine dikkat edilmelidir. BKB tedavisinde lityum, karbamazepin, okskarbazepin, sodyum valproat ve lamotrijin gibi duygudurum dengeleyicilerin etkinliğine dair çeşitli araştırmalar mevcuttur. BKB’nin bipolar bozukluklardan ayrıştırılması kolay değildir. Çok dikkatli bir değerlendirme gereklidir. Bu ayrıştırmanın yapılabilmesi tedavi açısından da yararlı olabilir. BKB tedavisinde valproat ve lamotrijinin etkinliği ile ilgili çok sayıda araştırma sonucu mevcuttur. Diğer duygudurum dengeleyiciler ile ilgili bulgular ise yetersizdir. BKB tedavisinde herhangi bir ilacın kullanımı resmi otoriteler tarafından onaylanmamıştır. BKB tedavisinde psikoterapötik yaklaşımlar önemli yerlerini korumaktadırlar. Bununla birlikte, duygudurum dengeleyicilerin kullanımında semptom temelli yaklaşım önerilmiştir.

Borderline personality disorder: the place of mood stabilizers in the treatment

This article aims to review the effectiveness of mood stabilizers used in the psychopharmacologic treatment of both bipolar disorder and borderline personality disorder. In this context, the overlapping phenomenology of borderline personality disorder and bipolar disorder and the differential diagnosis of clinical features will be also reviewed with the literature. Both disorders can show common features in terms of diagnosis and overlap in phenomenological perspective. Coexistence of both disorders is quite frequent. The nature of mood shifts, types of impulsivity and the longitudinal course of the disorders should be considered to differenciate them. There are findings on the effectiveness of mood stabilizers such as lithium, carbamazepine, oxcarbazepine, sodium valproate or lamotrigine in the treatment of the borderline personality disorder. The differentiation of borderline personality disorder from bipolar disorder is not easy. A very careful evaluation is required. This differentiation may also be useful in terms of treatment. A greater number of research results are available on the effectiveness of valproate and lamotrigine in the treatment of borderline personality disorder. Findings related to other mood stabilizers are insufficient. In the treatment of borderline personality disorder, there is not any drug approved by the official authorities. Psychotherapeutic approaches still retain their important place in the treatment. However, symptom- based approach is proposed in the use of mood stabilizers.

PDF

___

1. Gunderson JG. Borderline Personality Disorder: A Clinical Guide. Washington, D.C: American Psychiatric Press, 2001.
2. Kernberg OF. Borderline Conditions and Pathological Narcissism. New York: Jason Aronson, 1975.
3. Siever LJ, Davis KL. A psychobiological perspective on the personality disorders. Am J Psychiatry 1991; 148:1647-1658.
4. Skodol AE, Siever LJ, Livesley WJ, Gunderson JG, Pfohl B, Widiger TA. The borderline diagnosis II: biology, genetics and clinical course. Biol Psychiatry 2002; 51:951-963.
5. Lerner HD, Sugarman A, Gaughran J. Borderline and schizophrenic patients. A comparative study of defensive structure. J Nerv Ment Dis 1981; 169:705-711.
6. Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. Am J Psychiatry 2004; 161:2108-2114.
7. Akiskal HS, Chen SE, Davis GC, et al. Borderline: an adjective in search of a noun. J Clin Psychiatry 1985; 46:41-48.
8. Deltito J, Martin L, Riefkohl J, Kissilenko A, Corless C Morse P. Do patients with borderline personality disorder belong to the bipolar spectrum? J Affect Disord 2001; 67:221-228.
9. Akiskal HS. Temperament and mood disorders. Harv Ment Health Lett 2000: 16;5-6.
10. Smith DJ, Muir WJ, Blackwood DH. Is borderline personality disorder part of the bipolar spectrum? Har Rev Psychiatry 2004; 12:133-139.
11. Perugi G, Akiskal HS, Lattanzi L, Cecconi D, Mastrocinque C, Patronelli A, Vignoli S, Bemi E. The high prevelance of ‘soft’ bipolar (II) features in atypical depression. Compr Psychiatry 1998; 39:63-71.
12. Paris J. Borderline personality disorder. CMAJ 2005; 172:1579- 1583.
13. Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev 2006; (1):CD005653.
14. Gunderson JG, Weinberg I, Daversa MT, Kueppenbender KD, Zanarini MC, Shea MT, Skodol AE, Sanislow CA, Yen S, Morey LC, Grilo CM, McGlashan TH, Stout RL, Dyck I. Descriptive and longitudinal observations on the relationship of borderline personality disorder and bipolar disorder. Am J Psychiatry 2006; 163:1173-1178.
15. Linehan M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press, 1993.
16. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference- focused psychotherapy. Arch Gen Psychiatry 2006; 63:649-658.
17. Fountoulakis KN. The contemporary face of bipolar illness: complex diagnostic and therapeutic challenges. CNS Spectr 2008; 13:763-774, 777-779.
18. Paris J, Gunderson J, Weinberg I. The interface between borderline personality disorder and bipolar spectrum disorders. Compr Psychiatry 2007; 48:145-154.
19. Links PS, Heslegrave RJ, Mitton JE, Van Reekum R, Patrick J. Borderline psychopathology and recurrences of clinical disorders. J Nerv Ment Dis 1995; 183:582-586.
20. Perugi G, Toni C, Travierso MC, Akiskal HS. The role of cyclothymia in atypical depression: toward a data-based reconceptualization of the borderline-bipolar II connection. J Affect Disord 2003; 73:87-98.
21. Erkiran M, Sönmez G, Evren C, Aytaçlar S, Oral T. Manik dönemin faktör analizine dayanan alt tipleri ve mizaçla ilişkisi. Turk Psikiyatri Derg 2008; 19:157-166.
22. Serretti A, Zanardi R, Rossini D, Cusin C, Lilli R, Smeraldi E. Influence of tryptophan hydroxylase and serotonin transporter genes on fluvoxamine antidepressant activity. Mol Psychiatry 2001; 6:586-592.
23. Sanislow CA, Grilo CM, McGlashan TH. Factor analysis of the DSM-III-R borderline personality disorder criteria in psychiatric inpatients. Am J Psychiatry 2000; 157:1629-1633.
24. Sanislow CA, Grilo CM, Morey LC, Bender DS, Skodol AE, Gunderson JG, Shea MT, Stout RL, Zanarini MC, McGlashan TH. Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study. Am J Psychiatry 2002; 159:284-290.
25. Stepp SD, Pilkonis PA. Age-related differences in individual DSM criteria for borderline personality disorder. J Pers Disord 2008; 22:427-432.
26. Goodman M, Patil U, Triebwasser J, Diamond E, Hiller A, Hoffman P, Goldberg S, Koenigsberg H, Siever L, New A. Parental viewpoint of trajectories to borderline personality disorder in female offspring. J Pers Disord 2010; 24:204-216.
27. Koenigsberg HW, Harvey PD, Mitropoulou V, Schmeidler J, New AS, Goodman M, Silverman JM, Serby M, Schopick F, Siever LJ. Characterizing affective instability in borderline personality disorder. Am J Psychiatry 2002; 159:784-788.
28. Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, Siever LJ. Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res 2001; 35:307-312.
29. Mackinnon DF, Pies R. Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord 2006; 8:1-14.
30. Swann AC, Steinberg JL, Lijffijt M, Moeller FG. Impulsivity: differential relationship to depression and mania in bipolar disorder. J Affect Disord 2008; 106:241-248.
31. Flory JD, Harvey PD, Mitropoulou V, New AS, Silverman JM, Siever LJ, Manuck SB. Dispositional impulsivity in normal and abnormal samples. J Psychiatr Res 2006; 40:438-447.
32. Wilson ST, Stanley B, Oquendo MA, Goldberg P, Zalsman G, Mann JJ. Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. J Clin Psychiatry 2007; 68:1533-1539.
33. Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Moeller FG. Impulsivity: a link between bipolar disorder and substance abuse. Bipolar Disord 2004; 6:204-212.
34. Goldberg JF, Perlis RH, Bowden CL, Thase ME, Miklowitz DJ, Marangell LB, Calabrese JR, Nierenberg AA, Sachs GS. Manic symptoms during depressive episodes in 1,380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry 2009; 166:173-181.
35. Dumais A, Lesage AD, Alda M, Rouleau G, Dumont M, Chawky N, Roy M, Mann JJ, Benkelfat C, Turecki G. Risk factors for suicide completion in major depression: a case-control study of impulsive and aggressive behaviors in men. Am J Psychiatry 2005; 162:2116-2124.
36. Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv 2002; 53:738-742.
37. Thase ME, Denko T. Pharmacotherapy of mood disorders. Annu Rev Clin Psychol 2008; 4:53-91.
38. Zanarini MC, Frankenburg FR, Reich DB, Hennen J, Silk KR. Adult experiences of abuse reported by borderline patients and Axis II comparison subjects over six years of prospective follow- up. J Nerv Ment Dis 2005; 193:412-416.
39. Zanarini MC, Frankenburg FR, Reich DB, Silk KR, Hudson JI, McSweeney LB. The subsyndromal phenomenology of borderline personality disorder: a 10-year follow-up study. Am J Psychiatry 2007; 164:929-935.
40. Zanarini MC, Frankenburg FR, Hennen J, Silk KR. 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.
41. Clarkin JF, Yeomans FE, Kernberg OF. Psychotherapy for Borderline Patients. New York: John Wiley and Sons, 1999.
42. Livesley WJ. A practical approach to the treatment of patients with borderline personality disorder. Psychiatr Clin North Am 2000; 23:211-232.
43. American Psychiatric Association. Practice Guidelines for the Treatment of Patients With Borderline Personality Disorder. Washington, DC: American Psychiatric Association, 2001.
44. Mercer D, Douglass AB, Links PS. Meta-analyses of mood stabilizers, antidepressants and antipsychotics in the treatment of borderline personality disorder: effectiveness for depression and anger symptoms. J Pers Disord 2009; 23:156-174.
45. Stein DJ. Drug treatment of the personality disorders. Br J Psychiatry 1992; 161:167-184.
46. Gardner DL, Cowdry RW. Positive effects of carbamazepine on behavioural dyscontrol in borderline personality disorder. Am J Psychiatry 1986; 143:519-522.
47. Cowdry RW, Gardner DL. Pharmacotherapy of borderline personality disorder: Alprazolam, carbamazepine, trifluoperazine, and tranylcipromine. Arch Gen Psychiatry 1988; 45:111-119.
48. Kravitz HM, Fawcett J. Carbamazepine in the treatment of affective disorders. Med Sci Res 1987; 15:1-8.
49. Blumer D, Heibronn M, Himmelhoch J. Indications for carbamazepine in mental illness: atypical psychiatric disorder or temporal lobe syndrome? Compr Psychiatry 1988; 29:108-122.
50. Denicoff KD, Meglathery SB, Post RM, Tandeciarz SI. Efficacy of carbamazepine compared with other agents: a clinical practice survey. J Clin Psychiatry 1994; 55:70-76.
51. Bellino S, Paradiso E, Bogetto F. Oxcarbazepine in the treatment of borderline personality disorder: a pilot study. J Clin Psychiatry 2005; 66:1111-1115.
52. Polc P. Enhancement of GABAergic inhibition: a mechanism of action of benzodiazepines, phenobarbital, valproate and L-cycloserine in the cat spinal cord. Electroencephalogr Clin Neurophysiol Suppl 1982; 36:188-198.
53. Wilcox JA. Divalproex sodium in the treatment of aggressive behaviour. Ann Clin Psychiatry 1994; 6:17-20.
54. Wilcox JA. Divalproex sodium as a treatment for borderline personality disorder. Ann Clin Psychiatry 1995; 7:33-37.
55. Hollander E, Allen A, Lopez RP, Bienstock CA, Grossman R, Siever LJ, Merkatz L, Stein DJ. A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001; 62:199-203.
56. Hollander E, Swann AC, Coccaro EF, Jiang P, Smith TB. Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder. Am J Psychiatry 2005; 162:621-624.
57. Frankenburg FR, Zanarini MC. 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.
58. Pinto OC, Akiskal HS. Lamotrigine as a promising approach to borderline personality: an open case series without concurrent DSM-IV major mood disorder. J Affect Disord 1998; 51:333-343.
59. Green B. Lamotrigine in mood disorders. Curr Med Res Opin 2003; 19:272-277.
60. Preston GA, Marchant BK, Reimherr FW, Strong RE, Hedges DW. Borderline personality disorder in patients with bipolar disorder and response to lamotrigine. J Affect Disord 2004; 79:297-303.
61. Tritt K, Nickel C, Lahmann C, Leiberich PK, Rother WK, Loew TH, Nickel MK. Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo- controlled study. J Psychopharmacol 2005; 19:287-291.