Off-label use of atypical antipsychotics in personality disorders

Personality disorders are among the most persistent and challenging disorders to treat within psychiatry. There is emerging evidence that some personality disorders, particularly borderline personality disorder and, to a lesser extent, schizotypal personality disorder, may benefit from treatment with atypical antipsychotics as well as mood stabilizers. This review examines the evidence for atypical antipsychotics for personality disorders and discusses strengths and limitations of this approach.

Searches of Medline and PsycInfo yielded 57 articles related to use of atypical antipsychotics for treatment of personality disorders. Most were relatively small randomized, controlled trials examining atypical antipsychotics for borderline personality disorder; however, the search also yielded two Cochrane reviews examining pharmacotherapy for borderline personality disorder and antisocial personality disorder as well as three other meta-analyses.

There is some evidence that atypical antipsychotics are effective for treating symptom domains in personality disorders, in particular psychotic-like symptoms, impulsivity, aggression and anger. There is no evidence that they improve overall illness severity. Given the high rate of comorbidity between personality disorders and axis I disorders, atypical antipsychotics are best used when these symptom domains are prominent and there is a comorbid axis I condition for which an atypical antipsychotic is indicated.