Low-Dose Clozapine in Acute and Continuation Treatment of Severe Borderline Personality Disorder

Background: Psychotic-like symptoms in patientsaffected by borderline personality disorder (BPD) are usuallytreated with low-dose neuroleptics, which show controversialacute effects and lead to a worsening of affective-relatedsymptoms and to severe neurologic side effects after prolongedadministration. Clozapine lacks the neurologic side effects oftraditional neuroleptics and has been shown to successfully treatpsychotic-like symptoms in BPD patients at medium dose. Weperformed an open-label trial of low-dose clozapine in severe BPDpatients.

Method: Twelve BPD inpatients (DSM-IV criteria)with severe psychotic-like symptoms were studied. Exclusioncriteria included comorbid Axis I and medical pathologies. Allpatients had followed a therapeutic program without improvementfor at least 4 months before admission. The clozapine dose wastitrated upward on an individual basis until the completedisappearance of psychotic-like symptoms was achieved.Clinician-rated scales were completed at the beginning of thestudy and after 4 and 16 weeks.

Results: All patients completed the 16-weekstudy. Individual clozapine doses ranged from 25 to 100 mg/day.Psychotic-like symptoms decreased within the first 3 weeks oftreatment, as confirmed by a statistically significant decreasein Brief Psychiatric Rating Scale scores. This amelioration wascoupled with an overall improvement, including a reduction inimpulsive behaviors and in affective-related symptoms (HamiltonRating Scale for Depression) and an increase in globalfunctioning (Global Assessment of Functioning).

Conclusion: Low-dose clozapine for acute andcontinuation treatment led to improvement in overallsymptomatology in a small sample of severe BPD patients.