New Antipsychotics in Treatment of Mood Instability and Cognitive Perceptual Symptoms in Borderline Personality Disorder

In the last years, results of meta-analyses and conclusive findings of systematic reviews have induced a noticeable shift of experts' opinions and clinical practice from antidepressants to mood stabilizers and second generation antipsychotics as first-line treatment of borderline personality disorder (BPD). Available data on the efficacy of second generation antipsychotics in BPD are increasing and indicate a promising option in the management of this severe personality disturbance. This review aims to report and discuss data from case reports, open label studies, and randomized controlled trials (RCTs) concerning efficacy and tolerability of second generation antipsychotics in the treatment of BPD patients. The indication of clozapine in BPD management is limited, particularly due to adverse reactions. Concerning risperidone and its metabolite paliperidone, clinical data are sparse and derive from few case reports and open investigations on small samples. Quetiapine was tested in several open label studies and showed its main clinical effect in reducing impulsivity and anger. The only RCT of ziprasidone did not find signicant differences versus placebo. At present, promising data of efficacy from RCTs are available for olanzapine and, with a lower number of trials, for aripiprazole. The majority of trials indicated that olanzapine and aripiprazole are efficacious both in treating cognitive-perceptual symptoms (a more strictly defined antipsychotic effect) and in decreasing mood instability and impulsive dyscontrol (a mood stabilizing effect). Further investigations in large samples are needed to deal with current limitations in methods and confirm present findings and initial recommendations for clinical practice.