Borderline personality disorder is a disorder with important social and clinical repercussions, which has

been treated mainly by psychotherapy. In recent years, the syndromic analysis of this disorder has allowed
us to identify different symptoms capable of being improved with psychopharmacology treatment. Thus,
its complex symptomatology could be included in four clinical dimensions: impulsive-aggressive,
affective instability, cognitive- perceptive and anxiety-inhibition. Antidepressants, mood stabilizers,
antipsychotics, anxiolytics, or more recently omega-3 fatty acids have shown efficacy in the treatment of
symptomatic dimensions of this disease. We have reviewed scientific articles (reviews, clinical trials or
clinical guidelines) published over the last ten years and have proposed therapeutic algorithms for
psychopharmacology management in these patients.

PSYCHOBIOLOGY OF PSYCHOTIC-LIKE SYMPTOMS

The schizophrenia-related personality disorders of DSM-III and DSM-IV include schizotypal, paranoid,
and schizoid personality disorders. Of these, schizotypal personality disorder is the best characterized and
the most severe of the schizophrenia-related personality disorders, and it is the most closely related to
schizophrenia biologically, phenomenologically, and genetically (53). In addition to psychotic-like
symptoms, patients with schizotypal personality disorder also manifest social detachment and other
deficit-related symptoms. Initial hypotheses centered around defining similarities between schizotypal
personality disorder patients and schizophrenic patients in these domains, whereas more recent studies
have pursued more specific correlates (particularly in the psychotic-like and deficit-like symptom
complexes) of underlying psychopathologic processes in schizotypal personality disorder to better
understand the fundamental pathophysiologic processes of the schizophrenia-related disorders (53).
Psychotic-like symptoms in these personality disorders include magical thinking, ideas of reference, and
perceptual distortions and are some of the most discriminating criteria for clinically identified schizotypal
personality disorder patients. Because psychotic symptoms in the schizophrenic disorders have been
linked to excessive dopaminergic activity, most studies have explored this hypothesis in order to
understand the biologic underpinnings of psychosis proneness in these individuals. The "dopamine
hypothesis" of schizophrenia was stimulated by (a) the observation that antipsychotic medications had
potent dopamine antagonist properties that correlate with their therapeutic efficacy (34) and (b) the
observation of psychotogenic effects of dopamine-releasing agents such as amphetamine when
administered over long periods of time. While studies measuring the dopamine metabolite homovanillic
acid (HVA) in cerebrospinal fluid (CSF) in schizophrenic patients and comparing them with controls have
been inconsistent (69), there are suggestions of increases in some paranoid subtypes and decreases
associated with deficit-like symptoms (52). However, current hypotheses regarding the dopaminergic
system in schizophrenia might suggest hypodopaminergia in frontal cortical areas and hyperdopaminergia
in subcortical areas. However, indices of dopaminergic activity such as CSF and plasma HVA depend on
contributions from multiple brain regions and the periphery, making interpretations of these measures
problematic.
The study of schizotypal patients affords an opportunity to disentangle these two processes. Both CSF and
plasma HVA levels are greater in clinically selected schizotypal patients than in normal and other
personality disorder controls, specifically associated with the psychotic-like symptoms of schizotypal

personality disorder (51, 52). In schizotypal relatives of schizophrenic patients, characterized more by
deficit-like symptoms, plasma HVA is reduced compared to relatives of nonschizotypal relatives (Amin et
al., 1993, unpublished data).
PSYCHOPHARMACOLOGY OF PSYCHOTIC-LIKE SYMPTOMS
These considerations imply that the psychotic-like symptoms of the schizophrenia-related personality
disorders may be ameliorated by neuroleptics and worsened by psychostimulants such as amphetamine.
In one study of borderline/schizotypal patients, amphetamine induced psychotic-like symptoms,
particularly in those patients with a schizotypal personality disorder diagnosis (48). In clinical
psychopharmacologic trials, neuroleptic treatment has generally been associated with global improvement
in patients with borderline and/or schizotypal personality disorder (7). In two relatively large placebocontrolled trials in patients with borderline and/or schizotypal personality disorder, psychotic-like
symptoms (as well as symptoms of anxiety) were reduced by treatment with a neuroleptic (thiothixene in
ref. 17, haloperidol in ref. 57). The generalizability of the data from one trial may be limited, however, to
personality-disordered patients with histories of brief transient psychotic-like symptoms prior to the start
of the trial. A smaller study involving only females with severe borderline personality disorder found only
modest efficacy for the neuroleptic (trifluroperizine) over placebo. While these data are in general
agreement with those of several other studies involving neuroleptic treatment in personality-disordered
patients, the most recent study found no efficacy for the neuroleptic (haloperidol) on psychotic-like
symptoms in borderline and/or schizotypal personality-disordered patients (56). The authors noted,
however, that the patients in their previous study, where haloperidol had been efficacious in treating
psychotic-like symptoms, had significantly higher ratings of "psychoticism," "schizotypal symptom
severity," and "global impairment" than in the more recent study. In conjunction with the finding that
"severity of schizotypal symptoms" was a favorable predictor of response to thiothixine (17), these results
suggest that low-dose neuroleptic treatment may be best indicated for moderately to severely impaired
patients with prominent histories of psychotic-like schizotypal symptoms.

PSYCHOBIOLOGY OF DEFICIT SYMPTOMS

The social detachment in interpersonal isolation of the schizophrenia spectrum personality disorders may
be rooted in biologic processes impairing cortical processing of complex interpersonal cues as well as
deficits in attachment behavior. Interpersonal relationships depend on selecting appropriate information
and cues from other people and synchronizing one's responses in a reciprocal interaction. These
interactional patterns might be set down in infancy and may be disrupted when there is neurologic
immaturity on the part of the developing infant (53). Offspring of schizophrenic patients show
pandevelopmental immaturities, raising the possibility that the diathesis to the schizophrenic disorders
may impair the development of mutually satisfying interactions (53). A variety of studies implicate
deficits in information processing, neuropsychological, and psychophysiologic tasks in the schizophreniarelated personality disorders, as in schizophrenia. These are often particularly associated with the deficitlike symptoms of the schizophrenic spectrum personality disorders and have been hypothesized to be
related to alterations in brain structure (53a). The cognitive impairment seems to be associated with

decreased indices of dopaminergic activity, consistent with the notion that adequate dopaminergic tone,
particularly at D1 receptors in frontal cortical areas, may be necessary for the integrity of working
memory and other executive cognitive functions. Preliminary evidence supporting this hypothesis comes
from psychophysiologic, neuropsychologic, and imaging studies (53a).
Impaired eye movements tracking a smoothly moving target is one of the most consistent findings in the
schizophrenia-related disorders. Abnormalities in smooth pursuit tracking are seen in schizophrenic
patients and in schizotypal personality-disordered patients. Eye-tracking impairment is specifically
associated with the "deficit-like" traits of schizotypal personality disorder (53).
In addition, patients with schizotypal personality disorder show abnormalities and other attentional tasks.
These include the Continuous Performance Task (CPT) and the Backward Masking Task (BMT). The
CPT is a test of sustained attention that involves identifying target stimuli from a continually presented
array. Poor performance on the CPT has been observed in studies of schizotypal volunteers, patients, and
offspring of schizophrenic patients (53a) and is correlated with social detachment in offspring of
schizophrenic patients (12). The BMT is a visual information processing task which has also been
reported to be abnormal in patients with schizotypal personality disorders as well as in volunteers selected
because of their schizotypal traits (36). Abnormalities in electroencephalographic (EEG) responses to an
unexpected stimuli provide a measure of brain responses to an attentional paradigm. Such evoked
potential studies suggest alterations in a positive wave at 300 msec following a stimulus (P300) in
schizotypal volunteers and patients similar to those demonstrated in schizophrenic patients. Abnormalities
in galvanic skin orienting response and visual reaction time similar to that observed in schizophrenic
patients also suggest altered information processing in schizotypal individuals (53a).
Imaging studies suggest that there may be increased ventricular size in the schizophrenia-related
personality disorders (5). In one study, lateral ventricles were enlarged (particularly on the left side), and
enlargement of the frontal horn and ventricle was associated with impaired performance on the Wisconsin
Card Sort Test. In contrast, no such abnormalities have been found in patients with borderline personality
disorder (53a). In exploratory analyses, increased ventricular size was associated with reduced
concentrations of plasma HVA and deficit-like symptoms (53a), raising the possibilities that frontal
cortical impairment may be associated with increased ventricular size and hypodopaminergia in this area.
Also consistent with this possibility are magnetic resonance imaging (MRI) studies suggesting reduced
frontal size correlated with schizotypal traits in volunteer subjects (44).
Schizotypal personality disorder patients or volunteers, like schizophrenic patients, also demonstrate
impaired performance on tests sensitive to prefrontal function, including the Wisconsin Card Sort Test
(WCST) (44, 53a). On the other hand, performance on the verbal fluency test and Wechsler Adult
Intelligence Scale (WAIS) vocabulary and block design that does not significantly differ from normal
controls suggests that cortical impairment is not global and may be more selective for brain circuits
including frontal and perhaps temporal regions.
Poor performance on the WCST as reflected in increased preseverative errors, as well as poor
performance on the Trails B Test, tends to be associated with reduced concentrations of plasma HVA, the
primary metabolite of dopamine in the brain (53a). Furthermore, increased ventricular size tends also to

be associated with decreased concentrations of plasma HVA. In personality disorder patients, plasma
HVA shows a trend to be negatively related to the deficit-like symptoms; that is, reduced concentrations
of plasma HVA are related to increased social withdrawal and constricted affect (53a). A significant
correlation between deficit-like symptoms and plasma HVA has been reported in relatives of
schizophrenic patients with schizotypal traits (Amin et al., 1993, unpublished data). These results contrast
with clinical studies suggesting that increases in plasma HVA are correlated with the psychotic-like
symptoms of schizotypal personality disorder.
Together, these findings suggest that schizotypal personality-disordered patients, particularly those with
deficit-like symptoms, are characterized by impairment on a variety of cortical processing tasks, increased
ventricular size, and reduced indices of dopaminergic activity. Because the dopamine system is implicated
in working memory via D1 receptors in frontal cortex, it is tempting to speculate that the cortical
dysfunction (in areas such as prefrontal cortex) associated with reduced dopaminergic function may
contribute to the "core" deficit-related psychopathology of the schizophrenia spectrum. Other factors must
modify this core diathesis in the direction of chronic psychosis for true schizophrenia to emerge.
Schizotypal patients with prominent deficit-like symptoms may, however, represent the most common
expression of a genetic susceptibility to a neurodevelopmental lesion which results in cortical
malfunction.

PSYCHOPHARMACOLOGY OF DEFICIT SYMPTOMS

If the theory discussed above is correct, deficits in cortical function and associated social deficits might be
improved with administration of agents that enhance dopaminergic activity. Preliminary data from our
laboratory suggests that amphetamine may improve cognitive performance on tests sensitive to prefrontal
function (such as the WCST) in schizotypal patients (53a). Therapeutic trials with dopamine reuptake
inhibitors such as mazindole, psychostimulants, L-DOPA, or monoamine oxidase (MAO) inhibitors might
be warranted. Also intriguing is the possibility that selective D1 agonists, when they become clinically
available, might more selectively enhance cognitive function in such patients. If, as correlational analyses
hint, social deficits are also related to these underlying cognitive impairments, these strategies may
improve the interpersonal functioning of the withdrawn, schizophrenia spectrum personality-disordered
patients.