Somatic and novel pharmacological treatments

Borderline personality disorder (BPD) is often comorbid with major depressive disorder and associated with more frequent hospitalizations, more extensive use of psychiatric resources and greater treatment-resistance compared to other personality disorders. Discussion of the entire range of somatic and pharmacological options that might be considered in the treatment-resistant patient with BPD is beyond the scope of this short chapter. We therefore limit our review to those more novel treatment modalities that we believe are either the most viable or the most topical for BPD given the information available at this time. We will focus on the treatment of the complex, seriously ill geriatric patient, typically diagnosed with comorbid psychiatric pathology and requiring treatment in an institutional setting. In the section on somatic therapies we discuss electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS) and deep brain stimulation (DBS). In the section on pharmacotherapies we discuss ketamine infusion and L-methylfolate. We conclude that ECT, rTMS and L-methylfolate could be useful treatment modalities for the complicated patient with BPD, particularly if there is comorbid major depressive disorder. DBS is highly invasive and the evidence supporting its utility for major depressive disorder is being questioned. The beneficial effect of ketamine is brief; the drug must be administered intravenously and can produce dissociation and cardiovascular effects that may be problematic for the geriatric patient with BPD.