BPD Medication: Types, Side Effects, Considerations - Verywell Health

There are currently no medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of borderline personality disorder (BPD). Any pharmaceutical drug treatment for BPD must be individualized and closely monitored by a trained mental healthcare provider.

However, medications can be prescribed to relieve BPD symptoms like mood swings, depression, impulsivity, and aggression. Depending on the types and severity of BPD symptoms, treatment may involve antidepressants, antipsychotics, mood stabilizers, or anxiolytics (anti-anxiety drugs).

This article looks at the four classes of BDP medications that are commonly prescribed as well as some newer ones that are being explored. 

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Can Medications Help Treat BPD?

While it's not considered the first-line treatment, there are some medications that may help some people with BPD.

Antidepressants

Studies have shown that antidepressants are the most commonly prescribed medications for people with BPD, with close to 80% of BPD patients taking them.

Antidepressants—specifically, selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs)—have been most studied. SSRIs work primarily by increasing serotonin levels (a neurotransmitter that's important for mood management).

MAOIs

MAOIs were the first drugs on the market for treating depression. They are also used to treat other psychiatric disorders, including panic disorder and social phobia.

MAOIs work by blocking the monoamine oxidase enzyme to keep it from breaking down neurotransmitters in the brain (specifically, norepinephrine, serotonin, and dopamine). This action increases levels of these neurotransmitters and lets them work on brain cells affected by depression.

There are different MAOIs. Two that have been studied in BPD are:

• Nardil (phenelzine): This medication improves depression and impulsive aggression in BPD. The primary side effect of Nardil is uncomfortable activation.
• Parnate (tranylcypromine): A few studies have suggested that Parnate improves affective symptoms and interpersonal sensitivity in some people with BPD.

MAOIs are not the first choice of treatment for depression. Compared to SSRIs, MAOIs have more side effects, including dry mouth, drowsiness, insomnia, dizziness, and lightheadedness. These medications are also linked to major drug interactions and can trigger high blood pressure if dietary restrictions are not followed.

SSRIs

SSRIs work by increasing available serotonin levels in the brain. This neurotransmitter is thought to have a positive effect on mood, sleep, and emotion regulation. The side effects of SSRIs are usually only temporary and mild. Common side effects of SSRIs include decreased sexual interest, insomnia, fatigue, headaches, upset stomach, nausea, or diarrhea.

Types of SSRIs that have been studied for BPD include:

• Prozac (fluoxetine): This medication has been shown to lead to mild improvements in affective BPD symptoms, anger, and impulsive aggression. The effects seem to be more noticeable in men and people with high levels of impulsive aggression.
• Luvox (fluvoxamine): This medication has been shown to lead to mild improvement in affective instability, but not impulsivity, in some people with BPD.
• Paxil (paroxetine): Limited research suggests that this medication may lead to decreased suicidality in some people with BPD without significant effects on depression.

Mood Stabilizers and Anticonvulsants

Mood stabilizers and anticonvulsants are used to help with BPD symptoms like anger, mood swings, and impulsivity. Mood stabilizers are traditionally used to treat affective disorders like bipolar disorder. About 36% of BPD patients take mood stabilizers.

Mood stabilizers and anticonvulsants that are prescribed to people with BPD include:

• Tegretol (carbamazepine): This medication can improve impulsivity, but can also make melancholic depression worse.
• Depakote (divalproex sodium): This medication improves interpersonal sensitivity, irritability, and aggression (primarily in people with high impulsive aggression).
• Lamictal (lamotrigine target): This medication may help improve BPD symptoms like anger, affective instability, and impulsivity, but carries a risk of a potentially life-threatening rash.
• Lithobid (lithium carbonate): Limited research has shown improvement in affective instability and possibly overall functioning in some people with BPD.
• Topamax (topiramate): This medication improves anger, anxiety, interpersonal dysfunction, and self-reported quality of life in some people with BPD. However, its side effect of weight loss can be a problem for some people (e.g., those with eating disorders). 

A 2018 review found that a majority of people with BPD were taking antidepressants, followed by anxiolytics (46.6%), anticonvulsants (38.6%), and mood stabilizers (35.9%). Around 71% of people with BPD were found to be taking some form of BPD medication for at least six years.

Antipsychotics

Antipsychotics can be used to help manage anger issues that are common in people living with BPD. While atypical antipsychotics can be used to treat impulsive aggression and improve affective instability, psychosis, and interpersonal dysfunction in BPD, the long-term risks compared to the benefits of using this drug class for people with BPD are not clear.

Typical antipsychotics used for the treatment of BPD include:

• Prolixin Decanoate (fluphenazine decanoate): There is limited data on the effectiveness of these drugs, but they can be used to treat suicidality and self-injurious behavior in some people with BPD.
• Haldol (haloperidol): This medication improves paranoia and anger and potentially treats anxiety and affective symptoms in some people with BPD. However, it can also increase sedation and depression.
• Loxitane (loxapine): Some studies have suggested this medication could be effective for some people with BPD, but it is used to help with depression and anger.
• Thiothixene: Some research supports using this medication to improve cognitive-perceptual symptoms and psychoticism in some people with BPD.

Atypical antipsychotics used for BPD include:

• Abilify (aripiprazole): This medication improves affective symptoms of BPD, aggression, paranoia, and overall functioning in some people with BPD.
• Zyprexa (olanzapine): This drug improves mood swings, impulsivity, aggression, interpersonal sensitivity, and severity of BPD. However, it carries a high risk of weight gain and metabolic effects.

Despite some evidence of improvement in the individual symptoms of BPD, typical antipsychotics are associated with worsening severity of overall BPD symptoms. Their use should be closely monitored by a provider.

Side effects of these medications include slowness, stiffness, tremor, and restlessness. With long-term use, there is a risk of tardive dyskinesia (involuntary movements that can be permanent).

Anxiolytics

People with BPD can have intense anxiety lasting from a few hours to several days. They might be prescribed anti-anxiety medications (anxiolytics) to help ease these symptoms.

Anti-anxiety medications work by increasing GABA—a natural calming agent that reduces brain activity. The medications might be useful in times of extreme agitation and distress, but no randomized controlled clinical trials have looked at their usefulness in the treatment of BPD.  

General side effects of anti-anxiety medications include feelings of sleepiness, fatigue, and mental fogginess or grogginess. Anti-anxiety medications can also build up in a person's system over time. Long-term use is associated with sleep issues, memory issues, emotional dysregulation, and dependence.

Anxiolytics commonly prescribed for BPD include:

• Ativan (lorazepam): This benzodiazepine produces a calming effect by enhancing the effects of GABA.
• Klonopin (clonazepam): This medication is approved for the treatment of panic disorder.
• Xanax (alprazolam): This is used to treat both anxiety and panic disorders.
• Valium (diazepam): This is typically used to treat anxiety, seizures, and alcohol withdrawal.

Stopping these medications suddenly can lead to withdrawal symptoms, including irritability, nausea, tremor, dizziness, blood pressure changes, rapid heart rate, and seizures.

If you are having suicidal thoughts, dial 988 to contact the 988 Suicide & Crisis Lifeline and connect with a trained counselor. If you or a loved one are in immediate danger, call 911. The service is available to everyone 24 hours a day, seven days a week.

People who are deaf or hard of hearing can contact the Lifeline via TTY using your preferred relay service or dial 711 then 988.

Novel Treatments Under Investigation

Researchers are looking into several new treatments for BPD, including: 

• Omega-3 fatty acids. These dietary fatty acids may have some benefits in treating BPD symptoms like impulsivity and aggression. They are considered safe for people with BPD and substance use disorder.
• Opioid antagonists. Opioid antagonists have shown some early success in reducing self-harm behaviors characteristic of BPD, but more research is needed.
• Vasopressin antagonists. Researchers think that vasopressin concentration in the cerebrospinal fluid is positively linked to uninhibited aggression in BPD. Some studies have shown that intranasal vasopressin production increases the perception of threats in response to neutral stimuli. Increased vasopressin concentration could partially explain the predisposition toward enhanced irritability and aggression in people with BPD.
• Histone deacetylase inhibitors. These drugs work by changing the epigenetic modification of histones, which are basic proteins associated with DNA. These medications may help undo the biological changes that occur from early life stress—a well-known risk factor for BPD. Researchers think that the deacetylase inhibitory properties of sodium valproate‚ in other words, its ability to reverse epigenetic modifications and gene expression—may partially explain why it can be helpful in people with BPD.

Are There Any Other BPD Treatments?

The main treatment for BPD is talk therapy (psychotherapy). Some people with BPD benefit from other kinds of therapy:

• Cognitive behavioral therapy (CBT) includes a specific program called Systems Training for Emotional Predictability and Problem Solving (STEPPS). Dialectical behavioral therapy (DBT) is another kind of CBT that helps people replace behaviors that are not helping them with more effective coping skills. 
• Schema-focused therapy helps people with BPD change their worldviews and beliefs that are unhelpful. 
• Dynamic deconstructive psychotherapy is a 12-month treatment program to help people with BPD who have tried other kinds of therapy and have not found them effective. 
• Mentalization-based therapy helps people with BPD learn to make sense of themselves and the world around them, especially as it pertains to their relationships with others. 
• Transference-based psychotherapy helps people with BPD work on forming and maintaining healthy relationships and avoiding BPD splitting. 

What Are the Side Effects of BPD Medication?

While the side effects of BPD medications vary depending on the type, some common side effects of the treatment to be aware of include: 

• Weight changes (gaining or losing)
• Dry mouth
• Feeling sleepy (sedation) or fatigued 
• Trouble sleeping (insomnia) 
• Dizziness
• Dry mouth
• Sexual side effects
• Constipation
• Nausea

Less common but potentially serious side effects of some BPD medications may include:

• Involuntary movement disorder called tardive dyskinesia
• Restlessness or agitation 
• Blood test changes (e.g., higher cholesterol levels)
• Confusion or behavior changes 
• Worsening symptoms of depression and anxiety
• Suicidal thoughts or actions

Precautions and Considerations

If you are pregnant or breastfeeding, you'll need to talk to your provider about BPD medications. Some of them may not be safe to take because they could affect a developing fetus or be passed to a baby through breast milk.

If you have certain medical conditions that affect how your body breaks down drugs, your BPD medication or dose might need to be changed. Your provider will also need to know about any other medications, over-the-counter (OTC) products, or supplements you take to make sure they will not interact with a BPD medication.

Do not change your dose or suddenly stop taking your BPD medication without talking to your provider first.

The cost of your BPD medication will depend on a few factors such as:

• Which medication you're taking
• Whether you get a brand-name or generic version of the drug
• How much you take and how often you need to have your prescription filled
• Where you have your prescription filled
• What kind of insurance coverage you have (if any)
• Whether you qualify for any discount programs or prescription coupons

If you can't afford your BPD medication, talk to your provider. They may have resources that can help you pay for your prescriptions. They may also be able to change where they send your prescription to be filled if you find that it costs less somewhere else—for example, switching to a different pharmacy.

If the cost of your medications is keeping you from taking them, your provider may talk to you about possibly switching to a more affordable treatment.

How to Cope With BPD

Living with BPD has challenges, but having a support team of your loved ones and providers can help you navigate them. 

Work on developing healthy coping skills and reach out for help if you feel like your treatment needs to be changed to better meet your needs and goals. 

Health-promoting habits like getting regular physical activity, nourishing your body, sleeping well, and reducing stress will also help you cope with BPD. 

Summary

Medication is not the first-line treatment for BPD, but it can help some people manage the condition more effectively. 

Your provider might want you to try adding medication to therapy and other strategies that are part of your BPD treatment plan. While they can have benefits, medications also come with side effects and risks to consider. 

If you're not sure if your BPD medication is helping, talk to your provider. Never change your dose or stop taking your BPD medication without asking your provider first. 

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