Personality Disorders

The clinician managing personality disorders navigates the complex pharmacotherapy landscape where no medications are FDA-approved for any PD, yet symptom-targeted prescribing is common and sometimes necessary. Evidence-based guidelines (NICE, APA, Cochrane reviews) generally advise AGAINST polypharmacy for BPD and recommend pharmacotherapy only for specific symptom domains or comorbid conditions. The NP's primary role is coordinating evidence-based psychotherapy (DBT for BPD) while judiciously prescribing for specific targets. Symptom domain approach: (1) Affective dysregulation (mood instability, intense anger, emotional lability) -- mood stabilizers (lamotrigine has most evidence in BPD; valproic acid; lithium less studied), SSRIs; (2) Impulsive-behavioral dyscontrol (self-harm, substance use, binge eating, reckless behavior) -- mood stabilizers, SSRIs, naltrexone (for endorphin-mediated self-harm); (3) Cognitive-perceptual disturbances (transient paranoia, dissociation, ideas of reference) -- low-dose atypical antipsychotics; (4) Comorbid conditions (MDD, GAD, PTSD, ADHD, eating disorders, SUD) -- standard evidence-based treatment for each. The clinician must resist pressure to add medications for each presenting symptom, recognizing that polypharmacy without evidence base is a significant problem in PD treatment. Regular medication review with tapering of ineffective agents is essential.