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==Overview==
==Overview==
No medical therapy is approved by [[Food and Drug administration]], FDA for treatment of personality disorders. [[Pharmacotherapy]] is utilised to manage symptoms during [[acute decompensation]] and trait vulnerabilities.
PD affects all aspects of individual life and causes interference with [[psychological]] and behavioral growth. It causes emotional distress and social impairment. It affects the quality of life grimly and has dire consequences on life years. Early recognition is crucial to start appropriate management and prevent complications from this debilitating condition.
 
Management of PDs lacks [[evidence-based]] guidelines, and health authorities across the world have formulated their independent guidelines. [[American Society of Psychiatry]] guidelines exists only for BPD, while European guidelines are present for BPD, ASPD, and PD general. It includes [[acute]] treatment by hospitalization if there is a risk of self or other people harm and [[chronic]] management of the disorder. Indications for [[inpatient management]] include; suicidal intent and plan, impulse control loss, imminent danger to self and others, and severe symptoms impairing functioning and unresponsive to outpatient treatment. An initial assessment should be performed.
The second step is designing a treatment plan and discussing it with the patient. Family support and patient education play a vital role in effective management.
Prior to starting the therapy, it is essential to rule out [[PTSD]], [[depression]], and [[anxiety]] and manage them if these conditions co-exist. [[Substance use disorder]] needs to be recognized and treated as well.


==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].  
*No medical therapy is approved by [[Food and Drug administration]], FDA for treatment of personality disorders. [[Pharmacotherapy]] is utilised to manage symptoms during [[acute decompensation]] and trait vulnerabilities.
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Mood dysregulatory symptoms like emotional lability, anger outbursts, depressive crashes, and other [[affective dysregulation]] symptoms are managed with (selective serotonin reuptake inhibitors) SSRIs or [[selective norepinephrine reuptake inhibitors]] (SNRIs) like [[venlafaxine]]. Mood stabilizers like [[lithium]], [[valproate]], [[carbamazepine]], [[lamotrigine]] or [[topiramate]] are used as second line.
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
 
===Disease Name===
*Impulse behavioural dyscontrol symptoms are self-mutilation, aggression, eroticism, reckless sex, extravagant spending and uncontrolled substance use. They are managed with SSRIs as first line and [[monoamine oxidase inhibitors]] (MAOIs) as second line <ref name="urlpsychiatryonline.org">{{cite web |url=https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf |title=psychiatryonline.org |format= |work= |accessdate=}}</ref>. British guidelines recommend against the use of medications for these symptoms <ref name="urlEuropean guidelines for personality disorders: past, present and future | Borderline Personality Disorder and Emotion Dysregulation | Full Text">{{cite web |url=https://bpded.biomedcentral.com/articles/10.1186/s40479-019-0106-3 |title=European guidelines for personality disorders: past, present and future &#124; Borderline Personality Disorder and Emotion Dysregulation &#124; Full Text |format= |work= |accessdate=}}</ref>. 
 
*Cognitive perceptual symptoms incorporate paranoia, [[delusions]], [[hallucination]], [[derealisation]], [[depersonalization]] and suspiciousness. Low dose [[neuroleptics]] or [[antipsychotic]] medications are used. They help with psychotic symptoms as well as mood issues.
 
===Administration===
The route of administration of medications used in personality disorders is oral in most cases. The doses of drugs (antidepressants and [[mood stabilisers]]) in PDs is same as used for [[clinical depression]] and [[bipolar disorder]]. As compared to this, the doses of [[antipsychotics]] like [[neuroleptics]] is lower than used for psychotic disorders like [[schizophrenia]].  
 
====Antidepressants====  
Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days
 
*Preferred regimen (1): [[Fluoxetine]] 20 mg PO qd initially, and then increase weekly by 20 mg up to a maximum of 80 mg/day.
*Preferred regimen (1): [[Escitalopram]]-10 mg PO qd initially, and then increased to 20 mg after a week.
*Preferred regimen (1): [[Sertraline]]-25 mg PO qd initially, and then increased weekly to 50 mg weekly to a maximum of 200 mg/day. Safer in pregnancy.
*Preferred regimen (1): [[Duloxetine]]-20-30 mg PO BID initially, and then increased to 60 mg qd after one week.
*Preferred regimen (1): [[Venlafaxine]] (extended release)-37.5 to 75 mg PO qd initially, and then increased by ≤75mg/day over 4-7 days, maximum dose is 225 mg/day.  (immediate release)- 75mg PO q8-12 hr and can be titrated over 4-7 days.


* '''1 Stage 1 - Name of stage'''
====Mood Stabilizers====
** 1.1 '''Specific Organ system involved 1'''
*Preferred regimen (1): [[Lamotrigine]]-25 mg/day PO for two weeks, 50 mg/day PO for next two weeks, 100 mg/day PO for next (5th week) and 200 mg/day POfrom next week (6th week) and onwards.  
*** 1.1.1 '''Adult'''
*Preferred regimen (1): [[Lithium]]-started at 100- 200 mg/day PO and titrated over next few months to 600 mg/day PO. Lower initial doses are used to prevent adverse effects and gradually it is increased to maintain the levels between therapeutic window of 0.8-1.0 mEq/L.
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
*Preferred regimen (1): [[Valproic acid]]-500-750 mg/day PO; started with 250 mg/day PO and increased over 1 to 3 days to 500-1000 mg/day PO.
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
====Antipsychotics====
** 2.1 '''Specific Organ system involved 1 '''
*Preferred regimen (1): [[Quietiapine]]-25 mg/day PO, initially increments in dosage is done daily and after day 4, it is done after days to maximum of 150 mg/day.
**: '''Note (1):'''
*Preferred regimen (1): [[Risperidone]]-0.5 mg/day PO initially, and increased to 1mg/day PO after a month.
**: '''Note (2)''':
*Preferred regimen (1): [[Aripiprazole]]-2.5 mg/day PO
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Latest revision as of 00:20, 14 September 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ayesha Anwar, M.B.B.S[2]

Overview

PD affects all aspects of individual life and causes interference with psychological and behavioral growth. It causes emotional distress and social impairment. It affects the quality of life grimly and has dire consequences on life years. Early recognition is crucial to start appropriate management and prevent complications from this debilitating condition.

Management of PDs lacks evidence-based guidelines, and health authorities across the world have formulated their independent guidelines. American Society of Psychiatry guidelines exists only for BPD, while European guidelines are present for BPD, ASPD, and PD general. It includes acute treatment by hospitalization if there is a risk of self or other people harm and chronic management of the disorder. Indications for inpatient management include; suicidal intent and plan, impulse control loss, imminent danger to self and others, and severe symptoms impairing functioning and unresponsive to outpatient treatment. An initial assessment should be performed. The second step is designing a treatment plan and discussing it with the patient. Family support and patient education play a vital role in effective management. Prior to starting the therapy, it is essential to rule out PTSD, depression, and anxiety and manage them if these conditions co-exist. Substance use disorder needs to be recognized and treated as well.

Medical Therapy

  • Impulse behavioural dyscontrol symptoms are self-mutilation, aggression, eroticism, reckless sex, extravagant spending and uncontrolled substance use. They are managed with SSRIs as first line and monoamine oxidase inhibitors (MAOIs) as second line [1]. British guidelines recommend against the use of medications for these symptoms [2].

Administration

The route of administration of medications used in personality disorders is oral in most cases. The doses of drugs (antidepressants and mood stabilisers) in PDs is same as used for clinical depression and bipolar disorder. As compared to this, the doses of antipsychotics like neuroleptics is lower than used for psychotic disorders like schizophrenia.

Antidepressants

Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days

  • Preferred regimen (1): Fluoxetine 20 mg PO qd initially, and then increase weekly by 20 mg up to a maximum of 80 mg/day.
  • Preferred regimen (1): Escitalopram-10 mg PO qd initially, and then increased to 20 mg after a week.
  • Preferred regimen (1): Sertraline-25 mg PO qd initially, and then increased weekly to 50 mg weekly to a maximum of 200 mg/day. Safer in pregnancy.
  • Preferred regimen (1): Duloxetine-20-30 mg PO BID initially, and then increased to 60 mg qd after one week.
  • Preferred regimen (1): Venlafaxine (extended release)-37.5 to 75 mg PO qd initially, and then increased by ≤75mg/day over 4-7 days, maximum dose is 225 mg/day. (immediate release)- 75mg PO q8-12 hr and can be titrated over 4-7 days.

Mood Stabilizers

  • Preferred regimen (1): Lamotrigine-25 mg/day PO for two weeks, 50 mg/day PO for next two weeks, 100 mg/day PO for next (5th week) and 200 mg/day POfrom next week (6th week) and onwards.
  • Preferred regimen (1): Lithium-started at 100- 200 mg/day PO and titrated over next few months to 600 mg/day PO. Lower initial doses are used to prevent adverse effects and gradually it is increased to maintain the levels between therapeutic window of 0.8-1.0 mEq/L.
  • Preferred regimen (1): Valproic acid-500-750 mg/day PO; started with 250 mg/day PO and increased over 1 to 3 days to 500-1000 mg/day PO.

Antipsychotics

  • Preferred regimen (1): Quietiapine-25 mg/day PO, initially increments in dosage is done daily and after day 4, it is done after days to maximum of 150 mg/day.
  • Preferred regimen (1): Risperidone-0.5 mg/day PO initially, and increased to 1mg/day PO after a month.
  • Preferred regimen (1): Aripiprazole-2.5 mg/day PO

References

  1. ↑ "psychiatryonline.org" (PDF).
  2. ↑ "European guidelines for personality disorders: past, present and future | Borderline Personality Disorder and Emotion Dysregulation | Full Text".

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