Table 2 Open in new tab Consensus-based...

Indication

Recommendations

Perceptual disturbances

Short-term use of low-dose antipsychotic drugs are considered first choice with no preference for typical or atypical antipsychotics.
Dosages typically one third to a half of those required for antipsychotic treatment.
Choice based on predicted side-effects (weight gain, lethargy, parkinsonism, cardiac side effects).
Avoid use of benzodiazepines and tricyclic antidepressants.

Impulsivity

For acute treatment (hours, days), short-term use of low-dose antipsychotic drugs.
For medium term effects, anti-epileptic drugs should be considered, with topiramate and lamotrigine being first choice and valproic acid being second choice. In case of treatment resistance, low-dose antipsychotic drugs can be considered (third choice).
Avoid use of benzodiazepines and tricyclic antidepressants.

Affective liability

For persistent and invalidating mood swings, an SSRI, lamotrigine or an atypical antipsychotic drug can be considered.
In case of a depressive disorder, an SSRI or SNRI is first choice, but in case treatment resistance, subsequent steps should be based on treatment algorithms for depressive disorder.
In case of a low/depressed mood without a depressive disorder, treatment with an atypical antipsychotic drug or lamotrigine should be considered.
In case of persistent anger/hostility, the anti-epileptics topiramate and lamotrigine are first choice and in case of treatment resistance, valproic acid or atypical antipsychotics are second choice.
In case of persistent anxiety an SSRI or low-dose antipsychotic drug can be considered. With some reservations, benzodiazepines can also be considered.

Dissociation

No evidence for any drug.
Avoid use of benzodiazepine and tricyclic antidepressants.

Table 2

Open in new tab

Consensus-based preferred choices for pharmacological treatment of personality disorders^a.

Indication	Recommendations
Perceptual disturbances	Short-term use of low-dose antipsychotic drugs are considered first choice with no preference for typical or atypical antipsychotics. Dosages typically one third to a half of those required for antipsychotic treatment. Choice based on predicted side-effects (weight gain, lethargy, parkinsonism, cardiac side effects). Avoid use of benzodiazepines and tricyclic antidepressants.
Impulsivity	For acute treatment (hours, days), short-term use of low-dose antipsychotic drugs. For medium term effects, anti-epileptic drugs should be considered, with topiramate and lamotrigine being first choice and valproic acid being second choice. In case of treatment resistance, low-dose antipsychotic drugs can be considered (third choice). Avoid use of benzodiazepines and tricyclic antidepressants.
Affective liability	For persistent and invalidating mood swings, an SSRI, lamotrigine or an atypical antipsychotic drug can be considered. In case of a depressive disorder, an SSRI or SNRI is first choice, but in case treatment resistance, subsequent steps should be based on treatment algorithms for depressive disorder. In case of a low/depressed mood without a depressive disorder, treatment with an atypical antipsychotic drug or lamotrigine should be considered. In case of persistent anger/hostility, the anti-epileptics topiramate and lamotrigine are first choice and in case of treatment resistance, valproic acid or atypical antipsychotics are second choice. In case of persistent anxiety an SSRI or low-dose antipsychotic drug can be considered. With some reservations, benzodiazepines can also be considered.
Dissociation	No evidence for any drug. Avoid use of benzodiazepine and tricyclic antidepressants.

Indication	Recommendations
Perceptual disturbances	Short-term use of low-dose antipsychotic drugs are considered first choice with no preference for typical or atypical antipsychotics. Dosages typically one third to a half of those required for antipsychotic treatment. Choice based on predicted side-effects (weight gain, lethargy, parkinsonism, cardiac side effects). Avoid use of benzodiazepines and tricyclic antidepressants.
Impulsivity	For acute treatment (hours, days), short-term use of low-dose antipsychotic drugs. For medium term effects, anti-epileptic drugs should be considered, with topiramate and lamotrigine being first choice and valproic acid being second choice. In case of treatment resistance, low-dose antipsychotic drugs can be considered (third choice). Avoid use of benzodiazepines and tricyclic antidepressants.
Affective liability	For persistent and invalidating mood swings, an SSRI, lamotrigine or an atypical antipsychotic drug can be considered. In case of a depressive disorder, an SSRI or SNRI is first choice, but in case treatment resistance, subsequent steps should be based on treatment algorithms for depressive disorder. In case of a low/depressed mood without a depressive disorder, treatment with an atypical antipsychotic drug or lamotrigine should be considered. In case of persistent anger/hostility, the anti-epileptics topiramate and lamotrigine are first choice and in case of treatment resistance, valproic acid or atypical antipsychotics are second choice. In case of persistent anxiety an SSRI or low-dose antipsychotic drug can be considered. With some reservations, benzodiazepines can also be considered.
Dissociation	No evidence for any drug. Avoid use of benzodiazepine and tricyclic antidepressants.

^aBased on guidelines for borderline personality disorders of the APA (USA) and NICE (UK), and the Dutch Interdisciplinary Guidelines for personality disorders [36–38].

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