Borderline Personality Disorder

Borderline personality disorder is characterized by a pervasives

patern of instability that affects mood, interpersonal relationships, and
self-image. Some patients with severe forms of this disorder may
experience transient psychotic states particularly when they are under
stress. These states may be characterized by suspiciousness, ideas of
reference, impulsiveness, and aggressiveness.
Low dosages of thiothixene and haloperidol have been found to be
effective in some of these patients, although there is no evidence
indicating that other FGAs are less effectiv. Unfortunately, most trials have
been relatively brief, and it is unclear how medications affect the overall
course of this disorder and how medications interact with
psychotherapeutic management that these patients usually require.
Substance-Induced Psychotic Disorder
A number of drugs including amphetamines, cocain, alcohol, and
phencyclidine can cause psychotic symptoms that occur while the patient
is intoxicated or during drug withdrawal. These symptoms are usually
time limited and remit within hours or days depending on the
concentration of drug ingested and the rate elimination of the agent.
Althought FGAs may reduce psychotics symptoms, most of these episodes
do not require treatment with antipsychotics unless the symptoms are
causing dangerous behaviors or unusual suffering. Benzodiazepines may
be helpful in calming the patients until psycotics symptoms remit. Some
authors recommend prescribing benzodiazepines rather than dopamine
receptor antagonists for phencyclidine intoxications. In some
circumstances it may be helpful to follow the patients untreated course in
order to differentiate drug-induced syndromes from schizophrenia or
bipolar disorder.
FGAs are also useful for patients with hallucinations or delusions
that occur with alcoholism, particularly for chronic alcoholic hallucinosis.
They should be prescribed carefully since these drugs may increase the
likelihood of seizures that occur during alcohol withdrawal. As a result,
benzodiazepines are more appropriate than antipsychotics for
uncomplicated alcohol withdrawal.
Impulse Control Disorder
There is a long-standing, but controversial, practice of prescribing
dopamine receptor antagonists for individuals with extremely poor
impulse control and a propensity for violent behavior. This practice is not
supported by controlled clinical trials and may be appropriate only when

other masures such as the use of selective serotonin reuptake inhibitors

(SSRIs), carbamazepine, lithium, or -blockers has failed. In such
instances, non-weight gain-inducing SGAs may be more appropriate than
FGAs.

Delirium And Dementia

Low doss of high-potency FGAs can be useful in the treatment of the
pschotic symptoms and agitation associated with delirium that may be
due to organic conditions. Interactions with the anticholinergic properties
of low-potency drugs may exacerbate or prolong toxic deliriums caused by
anticholinergic agents.
FGAs can be useful for reducing agitation and psychotic symptoms
that are related to dementia, Wernickes syndrome, and Korsakoffs
syndrome. A number of carefully done double-blind studies have found
that FGAs are superior to placebo for treating agitated elderly patients. A
review by Janicak found that 66 percent of geriatric patients with organic
psychosis improved on a placebo. Low dosages of high-potency
medications can result in orthostatics hypotension and falling episodes. In
addition, the anticholinergic effect of low-potency FGAs can worsen
cognitive and memory impairments. The treatment of elderly patients is
complicated since many take multiple medications and are vulnerable to
drug-drug interactions. Nevertheless, the adverse effects of these drug
should be weighed against the dangers of agitation in elderly patients.
Clinicians should be aware that akathisia can present itself as agitation in
these patients.
Childhood Schizophrenia
Schizophrenia infrequently has its onset during ahildhood. Children
with schizophrenia may have symptoms that are similar to those in adults
with schizophrenia. Although clinical experience indicates that children
improve with antipsychotics, there are few controlled trials available to
demonstrate this effect. It is particularly important to treat children with
the lowest effective dosage of an antipsychotic since these drugs may
impair learning.
Pervasive Developmental Disorder
patients with pervasive developmental disorders may demonstrate
periods of hyperactivity, screaming, and agitation with combativeness.
Although there are few controlled studies for this disorder, patients tend

to improve with high-potency agents. Since these agents may impair

learning, there is concern that they are overprescribed in some settings.
Tourettes Syndrome
Tourettes Syndrome is a neurobehavioral disorder that is associated
with motor and vocal tics. Motor tics may involve a single muscle group or
several, thus appearing as purposeful movements. Similarly , vocal tics
may involve an inarticulate sound or actual words. Often the words are
socially inappropriate or even obscene. Milder tics may not require
pharmacotherapy. However, when the tics are disabling, an antipsychotic
medication can be effective in reducing the severity of both motor and
vocal tics. Although haloperidol and pimozide are the most commonly sed
agents, there is no evidence indicating that other agents are less
effective.
Huntingtons Disease
Huntingtons Disease is a genetically transmitted disease that
follows an autosomal dominant type of heritability with 100 percent
penetrance. The median age of onset is 35 to 40 years, but childhood
onset (high number of CAG repeats) and much later onsets also occur.
Once the diagnosis is made, death will follow in 15 to 20 years. Patients
who eventually develope Huntingtons Disease may display psychiatric
symptoms and cognitive impairment years before the diagnosis of
Huntingtons Disease is made. The most common psychiatric symptoms
are cognitive impairment, depression, irritability, apathy, obsessivecompulsive symptoms, and suicidality. These may progress to a psychotic
delusional state or sometimes are followed by manic or hypomanic
episodes. Some individuals may demonstrate symptoms that closely
resemble schizophrenia with delusions and hallucinations (less than 10
percent).
Antipsychotics are belived to be useful during the early stages of the
illness to reduce chorea. However, double-blind studies are lacking. They
also may be effective in managing irritability, paranoia, hallucinations,
violent tendencies, and bizarre behaviors. High-potency agents are usually
preferred, but all agents appear to be effective. Clinicians should be aware
of acute EPS, particularly in the rigid forms of the disorder. There is no
dosing guidance. At present it is believed that the long-term use does not
merit their use, particularly as TD, other EPS, and akathisia may resemble
Huntingtons Diseases later stage symptomatology. Recently, the U.S.
Food and Drug Administration (FDA) approved tetrabenazine (Xenazine, an
amine depletor, like reserpine) for the treatment of chorea in Huntingtons
Disease. Tetrabenazine should not be used to prevent occurence of

choreatic symptoms as there is evidence that tetrabenazine has no

neuroprotective benefits. However, dysphoria, depression, suicidality, and
dysphagia have been noted. No long-term studies are available.
Parkinsons Psychosis And Lewy Body Disease
FGAs are contraindicated in these conditions, as they worsen the
parkinsonian syndromes.