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Pharmacotherapy of Personality Disorders with Impulsivity

  • Authors: Charles L. Bowden, MD
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Target Audience and Goal Statement

This activity is intended for psychiatrists, primary care physicians, psychologists, neurologists, pharmacists, and other mental health professionals.

The goal of this activity is to provide current treatment protocols and clinical strategies for the treatment and management of psychiatric disorders and to update the clinician and the researcher on the latest developments in psychiatry and mental health.

Upon completion of this activity, participants will be able to:

  1. Delineate the clinical characteristics of a mood disorder.
  2. Distinguish the various aspects and treatments of aggression.
  3. Discuss the approaches to the treatment of substance abuse in children and adolescents.


  • Charles L Bowden, MD

    Professor, University of Texas Health Science Center, San Antonio

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Pharmacotherapy of Personality Disorders with Impulsivity

Authors: Charles L. Bowden, MDFaculty and Disclosures



In many ways, personality disorders have been the stepchildren of the DSM-IV. In part, this is due to the view that mild symptomatology is not associated with illness of serious consequence. In addition, because the DSM-IV emphasizes full syndromes based on cross-sectional assessment of personality disorders, which often do not fit into neat syndromal boxes, personality disorders become difficult diagnoses. At the same time, personality disorders are not alone in their diagnostic challenge; studies demonstrate that there is no predictable relationship between the phenomenology of depression and its severity, duration, or course.[1] Furthermore, personality disorders may be influenced by etiologic factors, both biologic and stressful, an understanding of which may better guide treatment decisions.[2]

Despite these disadvantages, progress has been made in psychopharmacologic management of personality disorders. The most effective strategies have been symptom-based, and, at least initially, time-limited. A symposium at the 153rd annual meeting of the American Psychiatric Association in Chicago, Illinois, organized by John Oldham, MD, of Columbia University in New York, NY, brought together a group of leading investigators.


Mood Stabilizers

Several lines of evidence support a beneficial role for mood stabilizers in the treatment of impulsivity.[3] Phenotypically, this makes sense because several DSM-IV syndromes not viewed as bipolar disorders feature symptoms that are relatively specific to the core dimensions of behavior disturbed in bipolar states. For example, most of the symptomatic criteria for borderline personality disorder describe impulsivity, affective instability, quick mood shifts, and irritable, hostile behaviors, both self- and other-directed.

Additionally, many of the complex behavioral disturbances observed in bipolar patients fundamentally involve impulsivity. Examples include job changes, frequent divorces and remarriages, hypersexuality, and high rates of bankruptcy. Psychological tests that measure temperament indicate that novelty-seeking scores are higher in recovered bipolar patients than in patients recovered from major depressive disorder. Novelty-seeking is characterized by impulsivity, quick temper, disorderliness, and extraversion. Furthermore, the scores were essentially similar among bipolar patients who were depressed and who were manic.

Impulsivity is often, although certainly not always, linked to aggressive, hostile behaviors. Conversely, not all aggressive acts are impulsive, some being premeditated. Many clinical trials of mood stabilizers in impulsive states have measured impulsivity and aggression concurrently.

Lithium has been shown to be more effective than placebo[4] in impulsive, overly aggressive youth, but only equal to placebo in another study, which reported methylphenidate as superior to lithium.[5] Carbamazepine has been reported as modestly effective in impulsive, aggressive patients. McElroy and associates[6] have also reported efficacy of mood stabilizers, particularly divalproex, in patients with intermittent explosive disorder.

Suicidal behavior in bipolar disorder often features an impulsive component. Lithium has been associated with significantly fewer suicides and suicidal attempts than was carbamazepine. In a 1-year, double-blind, randomized, placebo-controlled study comparing divalproex and lithium, Bowden and colleagues[7] found low rates of suicidal symptomatology and no suicides in all 3 groups. However, rates of hospitalization for depression were higher in placebo-treated patients than in patients treated with divalproex or lithium.

There is indirect evidence that impulsivity in bipolar disorder may be linked to affective instability, shorter periods of treatment before drop-out, and increased frequency of episodes. A recently completed study[8] of rapidly cycling patients treated prophylactically with either lamotrigine (Lamictal) or placebo has yielded interesting information on efficacy. While lamotrigine was mildly to moderately effective for the combined group of patients with bipolar I and II disorder, sharp differences emerged when bipolar I and II patients were analyzed separately. Lamotrigine was highly superior to placebo among bipolar II patients, but less so for bipolar I patients. The primary factor driving this difference was the higher relapse and drop-out rate for bipolar II patients receiving placebo than for bipolar I patients. These results suggest that affective instability may be more characteristic of bipolar II, cyclothymic and temperamental variants of bipolar disorder, as suggested by Akiskal, Koukopoulos and others.


Medication Management of Impulsive Substance Abuse

Herb Kleber, MD,[9] reviewed the serious problem of impulsive seeking of abusable substances, which varies with the category of the substance. More pharmacologic treatments provide at least partial benefit in reducing drug-seeking behavior for heroin dependence than for other addictions. These include agonists such as methadone, partial agonists such as buprenorphine and antagonists such as naltrexone. No medications directly affecting impulsive abuse in alcohol dependence, marijuana use or cocaine abuse currently exist. The narcotic antagonist naltrexone reduces likelihood of a lapse becoming a relapse, but does not directly affect impulse seeking.


Pharmacotherapy of Impulsive Personality Disorders

A study[10] of patients with borderline personality disorder found that initial severity of impulsivity predicted long-term illness course. Typical and atypical antipsychotics have been reported as effective in acute management of impulsive aggression. Their role in long-term use is less studied and is limited by tolerability. Mood stabilizers have demonstrated low to moderate rates of effectiveness, with a recent study of divalproex being among the more positive reports.[11] SSRIs have also been reported effective in reducing aggressive behaviors in persons with borderline personality disorder. However, patients did not report subjective improvement in 1 study, and rates of patient drop-out have been high in trials of drugs of all types to date.


Long-term Patterns of Medication Use in Borderline Personality Disorder

Dr. Oldham[12] reviewed data from the National Institutes of Mental Health-sponsored Collaborative Longitudinal Personality Disorder Study. Patients with borderline personality disorder were significantly more likely to have received mood stabilizers than were patients with major depression. By contrast, antidepressant use did not differ between the groups.


Cognitive Therapy Techniques to Enhance Adherence to Medication Treatments

Adherence to treatment regimens is often unsatisfactory in psychiatric disorders and may be worse among patients with conditions that feature prominent impulsivity. However, little study of psychotherapeutic strategies to improve treatment adherence has occurred. Judith Beck[13] reviewed the approach with cognitive therapy relevant to medication compliance, emphasizing identifying thoughts and beliefs related to noncompliant behavior. These commonly include inadequate information about the psychiatric disorder, distorted ideas about medication, and practical difficulties such as complex dosage regimens.


Implications for Clinical Practice

  • Symptom-targeted strategies appear to provide the best likelihood of success when using medications to improve the care of patients with personality disorders.  
  • Impulsivity appears to be the most consistent fundamentally disturbed behavior linking the spectrum of bipolar conditions, including those that present more as personality disorders or aberrations of temperament.  
  • Mood stabilizers have been used extensively to treat impulsive and aggressive disorders. Although most studies have limitations in design, moderate efficacy in at least half of patients studied has been reported. Results differ across drugs. More positive data have been published for valproate, although most are from open-label trials.  
  • The role of impulsive drug seeking is a major component of persistent drug abuse. Currently, therapies are at best of modest utility. More systematic studies of drugs and of psychological strategies are needed to address cues that trigger impulsive drug seeking.  
  • Naturalistic long-term studies indicate high rates of prescriptions of mood stabilizers for patients with borderline personality disorders.  
  • Cognitive therapies to enhance adherence to medication treatments are promising, but surprisingly poorly studied in systematic trials.  


  1. Van Praag HM. A transatlantic view of the diagnosis of depressions according to the DSM III: II. did the DSM III solve the problem of depression diagnosis? Compr Psychiatry. 1992;23:330-338.
  2. Van Praag HM. Over the mainstream: diagnostic requirements for biological psychiatric research. Psychiatry Res. 1997;72:201-212.
  3. Bowden CL. The use of mood stabilizers in the treatment of impulsivity. Program and abstracts from the 153rd Annual American Psychiatric Association Meeting; May 13-18, 2000; Chicago, Illinois. Abstract 106A.
  4. Siassi I. Lithium treatment of impulsive behavior in children. J Clin Psychiatry. 1982;43:482-484.
  5. Carlson GA, Rapport MD, Kelly KL, Pataki CS. The effects of methylphenidate and lithium on attention and activity level. J Am Acad Child Adolesc Psychiatry. 1992;3:262-270.
  6. McElroy SL, Soutullo CA, Beckman DA, Taylor P, Keck PE. DSM-IV intermittent explosive disorder: a report of 27 cases. J Clin Psychiatry. 1998;59:203-210.
  7. Bowden CL, Calabrese JR, McElroy SL, et al, for the Divalproex Maintenance Study Group. A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Arch Gen Psychiatry. 2000;57:481-489.
  8. Hamer RM, Simpson PM. The efficacy of lamotrigine in rapid cycling and non-rapid cycling patients with bipolar disorder. Biol Psychiatry. 1999;4:1711-1712.
  9. Kleber HD. Medication management of impulsive substance abuse. Program and abstracts from the 153rd Annual American Psychiatric Association Meeting; May 13-18, 2000; Chicago, Illinois. Abstract 106B.
  10. Links PS. Pharmacotherapy of patients with impulsive personality disorders. Program and abstracts from the 153rd Annual American Psychiatric Association Meeting; May 13-18, 2000; Chicago, Illinois. Abstract 106C.
  11. Kavoussi RJ, Coccaro EF. Divalproex sodium for impulsive aggressive behavior in patients with personality disorder. J Clin Psychiatry. 1998;59:676-680.
  12. Oldham J, Bowden CL, Kleber HD, Links PS, Beck JS. Pharmacotherapy of impulsive personality disorders. Program and abstracts from the 153rd Annual American Psychiatric Association Meeting; May 13-18, 2000; Chicago, Illinois. Abstracts 106A-E.
  13. Beck JS. Cognitive therapy techniques to enhance medication compliance. Program and abstracts from the 153rd Annual American Psychiatric Association Meeting; May 13-18, 2000; Chicago, Illinois. Abstract 106E.

Suggested Reading

  • Hollander E. Managing aggressive behavior in patients with obsessive-compulsive disorder and borderline personality disorder. J Clin Psychiatry. 1999;60(suppl 15):38-44.  
  • Oldham JM. Longitudinal patterns of medication utilization in BPD. Program and abstracts from the 153rd Annual American Psychiatric Association Meeting; May 13-18, 2000; Chicago, Illinois. Abstract 106D.
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