Psychopharmakologische Behandlung von und bei Persönlichkeitsstörungen

Zusammenfassung

Bis heute gibt es keine Zulassung eines Psychopharmakons für die Behandlung einer einzelnen Persönlichkeitsstörung. Lediglich für die Borderline-Persönlichkeitsstörung existiert eine Datenlage, auf deren Grundlage die Amerikanische Psychiatrische Gesellschaft die Pharmakotherapie als eine Option aufführt. Dies liegt zum einen am Mangel an doppelblinden randomisierten Studien, zum anderen an den Störungsbildern selbst. Die Persönlichkeitsstörungen zeigen eine hohe Komorbidität untereinander und eine hohe Prävalenzrate verschiedener Achse-I-Störungen (z. B. Abhängigkeitserkrankungen). Somit richtet sich eine psychopharmakologische Therapie häufig gegen bestimmte Symptome des Störungsbildes (z. B. Impulsivität) oder begleitende Achse-I-Störungen (z. B. Depressive Störungen). Dem weitgehenden Fehlen empirischer Befunde steht der häufige Einsatz von Psychopharmaka bei Persönlichkeitsstörungen gegenüber. Klinische Empfehlungen sind somit immer mit dieser Einschränkung zu beurteilen.

Grundsätzlich sollte bei der Therapie von Patienten mit einer Persönlichkeitsstörung die pharmakologische Behandlung immer gemeinsam mit einer psychotherapeutischen Intervention erfolgen. Besonders die schwerwiegenden Symptome wie unkontrollierbare Impulsivität, Aggressivität, depressive, dissoziative, ängstliche oder psychotische Symptome können Zielsymptomatik einer Pharmakotherapie sein. So wird derzeit empfohlen, depressive Syndrome und auch Impulsivität mit Serotoninwiederaufnahmehemmern, aggressives und impulsives Verhalten unter anderem mit Stimmungsstabilisierern und psychotische Syndrome mit atypischen Antipsychotika zu behandeln, während der Einsatz von Benzodiazepinen und die Bedarfsmedikation mit niederpotenten, sedierenden Antipsychotika vermieden werden sollte. Weiterhin kommen je nach Syndrom beispielsweise α2-Agonisten, µ-Opiat-Antagonisten und Omega-3-Fettsäuren zum Einsatz. Es ist weiterhin zu beachten, dass die aktuellen empirischen Befunde nicht für eine Polypragmasie sprechen. Sehr wichtig ist auch, dass bei der pharmakologischen Behandlung potenzielle Nebenwirkungen (z. B. sexuelle Funktionsstörungen oder Gewichtszunahme) mit den Patienten besprochen werden. Es sollte immer eine sorgfältige Nutzen/Risiko-Abwägung erfolgen.

Dieser Übersichtsartikel soll die derzeitigen pharmakologischen Interventionsmöglichkeiten in Abhängigkeit von den im Vordergrund stehenden Symptomen aufzeigen.

Abstract

There is only a paucity of studies concerning the pharmacological treatment of personality disorders per se. On the other hand the clinical use of medication in these conditions is quite high, although there is no effective psychopharmacological treatment of distinct personality disorders. The psychopharmacological treatment of patients suffering from a personality disorder focuses on distinct symptoms and its comorbidity. Some symptoms could also be associated with other disorders like depression or psychosis, which often makes an exact differentiation of these disorders and a personality disorder difficult.

Since symptoms of personality disorders are ego-syntonic, chronic and very often dependent on psychosocial factors, it is unlikely that a solely psychopharmacological treatment will be successful in most patients with a personality disorder. However, severe syndromes like depressive, impulsive, aggressive, dissociative, anxious or psychotic features may render a pharmacotherapy necessary. For the treatment of depressive syndromes or impulsivity a medical therapy with serotonin reuptake inhibitors, for the treatment of psychotic syndromes a medication with atypical antipsychotics is recommended. Impulsive or aggressive behaviour could be treated with mood stabilizers as well. Furthermore, there are indications for the use of α2-agonists, µ-opiate-antagonists and omega-3 fatty acid. The general use of benzodiazepines should be avoided as well as polypragmasy. Advantages versus potential damage of a high dose pharmacotherapy should be carefully weighed against each other.

This article gives an overview over the today’s most common psychopharmacological treatment possibilities in patients with a personality disorder.

Schlüsselwörter

Persönlichkeitsstörung - Psychopharmakotherapie - Antidepressiva - atypische Antipsychotika

Key words

personality disorder - psychopharmacotherapy - antidepressives - atypical neuroleptics

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