今日の臨床サポート

境界性パーソナリティ障害/ボーダーラインパターン

著者: 平島奈津子 国際医療福祉大学三田病院 精神科

監修: 上島国利 昭和大学

著者校正済:2021/12/01
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 多くの境界性パーソナリティ障害/ボーダーラインパターン(BP)患者に対して薬物療法が行われているが、その有効性についてのエビデンスは確立されていない。複数のメタ解析で、気分安定薬や非定型抗精神病薬がBPの攻撃性や衝動性の有効性を示している。有効性と安全性のバランスから、第1選択薬として非定型抗精神病薬が推奨されることが多い。
  1. BP患者では、ベンゾジアゼピン系抗不安薬によって容易に脱抑制を起こし、攻撃性や衝動性が増悪する傾向があり、また、乱用や依存性形成の危険もあるため、その使用は控えるべきである。したがって、睡眠障害に対しては、やむをえない場合に限り、非ベンゾジアゼピン系睡眠導入薬(ラメルテオン・スボレキサントなど)の投与を考えるにとどめることが望ましい。
  1. 選択的セロトニン再取り込み阻害薬(SSRI)が有効な場合もあるが、かえって攻撃性や衝動性が高まる場合もあるため、その使用は慎重であるべきである。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
平島奈津子 : 特に申告事項無し[2021年]
監修:上島国利 : 原稿料(大日本住友製薬)[2021年]

改訂のポイント:
● WHOによる診断分類ICD-11に基づいた記述を追記した。
● BP患者に有効性が期待できる精神療法について追記した。

病態・疫学・診察

疾患情報  
  1. 境界性パーソナリティ障害(米国精神医学会による精神疾患診断分類DSM-5)/ボーダーラインパターン(WHOによる診断分類ICD-11)(以下、BPと略)では、①現実の、あるいは想像上の見捨てられる体験を回避するための死にものぐるいの努力、②理想化と脱価値化との両極端を揺れ動く不安定な対人関係、③不安定な情緒、④不適切で、制御困難な怒りの爆発、⑤慢性的な空虚感、⑥同一性障害、⑦衝動的自己破壊的行動、⑧一過性のストレス関連性の妄想様観念・重篤な解離性症状、⑨反復する自殺の脅し、ほのめかし、自傷、自殺行動――が長期にわたってみられる。DSM-5では、これらのうち5つ以上が認められる場合にBPと診断できるとしている。DSM-5とICD-11は共に、このようなカテゴリー診断に加えて、パーソナリティ特性や機能水準についても診断することを求めている。特に、ICD-11では、将来的には、他のパーソナリティ障害と同様に、「否定的な情動」、「離脱」、「非社会性」、「脱抑制」、「制縛性」の5つのパーソナリティ特性に基づいて診断することを求めている。
  1. BPは、米国における調査では有病率は一般人口の約2%で、その約7割が女性患者であり、わが国でも同程度と考えられている。
  1. 米国における長期予後調査では、治療BPD患者の8割以上が中等度以上の改善を示しており、この割合はうつ病患者とほぼ同等である。未治療BPD患者の長期予後に関するデータはない。自殺率は3~10%と、調査によって幅がある[1][2][3]
問診・診察のポイント  
  1. 重要な他者との関係における情緒や行動の変動、衝動性の制御不良や自己破壊的行動の有無、その持続期間などを確認する。

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文献 

著者: John G Gunderson, Robert L Stout, Thomas H McGlashan, M Tracie Shea, Leslie C Morey, Carlos M Grilo, Mary C Zanarini, Shirley Yen, John C Markowitz, Charles Sanislow, Emily Ansell, Anthony Pinto, Andrew E Skodol
雑誌名: Arch Gen Psychiatry. 2011 Aug;68(8):827-37. doi: 10.1001/archgenpsychiatry.2011.37. Epub 2011 Apr 4.
Abstract/Text CONTEXT: Borderline personality disorder (BPD) is traditionally considered chronic and intractable.
OBJECTIVE: To compare the course of BPD's psychopathology and social function with that of other personality disorders and with major depressive disorder (MDD) over 10 years.
DESIGN: A collaborative study of treatment-seeking, 18- to 45-year-old patients followed up with standardized, reliable, and repeated measures of diagnostic remission and relapse and of both global social functioning and subtypes of social functioning.
SETTING: Nineteen clinical settings (hospital and outpatient) in 4 northeastern US cities.
PARTICIPANTS: Three study groups, including 175 patients with BPD, 312 with cluster C personality disorders, and 95 with MDD but no personality disorder.
MAIN OUTCOME MEASURES: The Diagnostic Interview for DSM-IV Personality Disorders and its follow-along version (the Diagnostic Interview for DSM-IV Personality Disorders-Follow-Along Version) were used to diagnose personality disorders and assess changes in them. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Longitudinal Interval Follow-up Evaluation were used to diagnose MDD and assess changes in MDD and in social function.
RESULTS: Eighty-five percent of patients with BPD remitted. Remission of BPD was slower than for MDD (P < .001) and minimally slower than for other personality disorders (P < .03). Twelve percent of patients with BPD relapsed, a rate less frequent and slower than for patients with MDD (P < .001) and other personality disorders (P = .008). All BPD criteria declined at similar rates. Social function scores showed severe impairment with only modest albeit statistically significant improvement; patients with BPD remained persistently more dysfunctional than the other 2 groups (P < .001). Reductions in criteria predicted subsequent improvements in DSM-IV Axis V Global Assessment of Functioning scores (P < .001).
CONCLUSIONS: The 10-year course of BPD is characterized by high rates of remission, low rates of relapse, and severe and persistent impairment in social functioning. These results inform expectations of patients, families, and clinicians and document the severe public health burden of this disorder.

PMID 21464343  Arch Gen Psychiatry. 2011 Aug;68(8):827-37. doi: 10.100・・・
著者: Mary C Zanarini, Frances R Frankenburg, D Bradford Reich, Garrett Fitzmaurice
雑誌名: Am J Psychiatry. 2012 May;169(5):476-83. doi: 10.1176/appi.ajp.2011.11101550.
Abstract/Text OBJECTIVE: The purposes of this study were to determine time to attainment of symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and comparison subjects with other personality disorders and to determine the stability of these outcomes.
METHOD: A total of 290 inpatients with borderline personality disorder and 72 comparison subjects with other axis II disorders were assessed during their index admission using a series of semistructured interviews, which were administered again at eight successive 2-year follow-up sessions. For inclusion in the study, patients with borderline personality disorder had to meet criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R.
RESULTS: Borderline patients were significantly slower to achieve remission or recovery (which involved good social and vocational functioning as well as symptomatic remission) than axis II comparison subjects. However, by the time of the 16-year follow-up assessment, both groups had achieved similarly high rates of remission (range for borderline patients: 78%-99%; range for axis II comparison subjects: 97%-99%) but not recovery (40%-60% compared with 75%-85%). In contrast, symptomatic recurrence and loss of recovery occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects (recurrence: 10%-36% compared with 4%-7%; loss of recovery: 20%-44% compared with 9%-28%).
CONCLUSIONS: Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.

PMID 22737693  Am J Psychiatry. 2012 May;169(5):476-83. doi: 10.1176/a・・・
著者: Anthony Bateman, Peter Fonagy
雑誌名: Am J Psychiatry. 2009 Dec;166(12):1355-64. doi: 10.1176/appi.ajp.2009.09040539. Epub 2009 Oct 15.
Abstract/Text OBJECTIVE: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.
METHOD: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.
RESULTS: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.
CONCLUSIONS: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

PMID 19833787  Am J Psychiatry. 2009 Dec;166(12):1355-64. doi: 10.1176・・・
著者: Klaus Lieb, Birgit Völlm, Gerta Rücker, Antje Timmer, Jutta M Stoffers
雑誌名: Br J Psychiatry. 2010 Jan;196(1):4-12. doi: 10.1192/bjp.bp.108.062984.
Abstract/Text BACKGROUND: Many patients with borderline personality disorder receive pharmacological treatment, but there is uncertainty about the usefulness of such therapies.
AIMS: To evaluate the evidence of effectiveness of pharmacotherapy in treating different facets of the psychopathology of borderline personality disorder.
METHOD: A Cochrane Collaboration systematic review and meta-analysis of randomised comparisons of drug v. placebo, drug v. drug, or single drug v. combined drug treatment in adult patients with borderline personality disorder was conducted. Primary outcomes were overall disorder severity as well as specific core symptoms. Secondary outcomes comprised associated psychiatric pathology and drug tolerability.
RESULTS: Twenty-seven trials were included in which first- and second-generation antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids were tested. Most beneficial effects were found for the mood stabilisers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine. However, the robustness of findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness.
CONCLUSIONS: The current evidence from randomised controlled trials suggests that drug treatment, especially with mood stabilisers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

PMID 20044651  Br J Psychiatry. 2010 Jan;196(1):4-12. doi: 10.1192/bjp・・・
著者: National Collaborating Centre for Mental Health (UK)
Abstract/Text The guideline on Borderline Personality Disorder, commissioned by NICE and developed by the National Collaborating Centre for Mental Health, sets out clear, evidence- and consensus-based recommendations for healthcare staff on how to treat and manage borderline personality disorder. Personality disorder now accounts for a substantial portion of the workload of most community mental health teams in the UK and borderline personality disorder is associated with significant functional impairments for the individual. The NICE guideline takes the first comprehensive view of the disorder and is an important resource for healthcare professionals to improve people’s long-term outcomes. Recent years have seen an exponential rise in available treatments for personality disorder and the guideline on borderline personality disorder covers the available evidence on all of those interventions. It also includes management of crises, configuration and organisation of services and experience of care. The primary focus is on adults, but the guideline looks at emerging characteristics of borderline personality disorder in younger people. The guideline also considers the needs of those with learning disabilities and contains a useful overview of borderline personality disorder.
PMID 21796831  
著者: Sabine C Herpertz, Mary Zanarini, Charles S Schulz, Larry Siever, Klaus Lieb, Hans-Jürgen Möller, WFSBP Task Force on Personality Disorders, World Federation of Societies of Biological Psychiatry (WFSBP)
雑誌名: World J Biol Psychiatry. 2007;8(4):212-44. doi: 10.1080/15622970701685224.
Abstract/Text These practical guidelines for the biological treatment of personality disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the biological treatment of three specific personality disorders, namely borderline, schizotypal and anxious/avoidant personality disorder in addition to some general recommendations for the whole field. The guidelines cover disease definition, classification, epidemiology, course and current knowledge on biological underpinnings, and provide a detailed overview on the state of the art of clinical management. They deal primarily with biological treatment (including antidepressants, neuroleptics, mood stabilizers and some further pharmacological agents) and discuss the relative significance of medication within the spectrum of treatment strategies that have been tested for patients with personality disorders, up to now. The recommendations should help the clinician to evaluate the efficacy spectrum of psychotropic drugs and therefore to select the drug best suited to the specific psychopathology of an individual patient diagnosed for a personality disorder.

PMID 17963189  World J Biol Psychiatry. 2007;8(4):212-44. doi: 10.1080・・・
著者: R W Cowdry, D L Gardner
雑誌名: Arch Gen Psychiatry. 1988 Feb;45(2):111-9.
Abstract/Text Sixteen female outpatients with borderline personality disorder and prominent behavioral dyscontrol, but without a current episode of major depression, were studied in a double-blind, crossover trial of placebo and the following four active medications: alprazolam (average dose, 4.7 mg/d); carbamazepine (average dose, 820 mg/d); trifluoperazine hydrochloride (average dose, 7.8 mg/d); and tranylcypromine sulfate (average dose, 40 mg/d). Each trial was designed to last six weeks. Tranylcypromine and carbamazepine trials had the highest completion rates. Physicians rated patients as significantly improved relative to placebo while receiving tranylcypromine and carbamazepine. Patients rated themselves as significantly improved relative to placebo only while receiving tranylcypromine. Patients who tolerated a full trial of trifluoperazine showed improvement, those receiving carbamazepine demonstrated a marked decrease in the severity of behavioral dyscontrol, and those receiving alprazolam had an increase in the severity of the episodes of serious dyscontrol. As an adjunct to psychotherapy, pharmacotherapy can produce modest but clinically important improvement in the mood and behavior of patients with borderline personality disorder. As a research tool, patterns of pharmacological response may provide clues to biological mechanisms underlying dysphoria and behavioral dyscontrol.

PMID 3276280  Arch Gen Psychiatry. 1988 Feb;45(2):111-9.
著者: D L Gardner, R W Cowdry
雑誌名: Am J Psychiatry. 1985 Jan;142(1):98-100.
Abstract/Text The authors report a significant increase in dyscontrol in patients with borderline personality disorder who were taking alprazolam during a double-blind, placebo-controlled crossover study. They suggest that caution be used in prescribing alprazolam to patients with similar histories.

PMID 2857071  Am J Psychiatry. 1985 Jan;142(1):98-100.
著者: D Ebert, R Albert, A May, A Merz, H Murata, I Stosiek, B Zahner
雑誌名: Eur Neuropsychopharmacol. 1997 Feb;7(1):71-4.
Abstract/Text OBJECTIVE: The incidence of the serotonin syndrome or serotonin-syndrome-like side effects during treatment with the selective serotonin reuptake inhibitor (SSRI) fluvoxamine should be evaluated.
METHOD: 200 inpatients treated for the first time with fluvoxamine were prospectively evaluated for the occurrence of a serotonin syndrome over a period of 8200 treatment days. Retrospective follow-up data of outpatient treatment covered 8891 days.
RESULTS: No full-blown serotonin syndrome occurred, but 3 patients developed a reversible change of mental status with insomnia, agitation, confusion and incoherent thoughts without other symptoms of the serotonin syndrome.
CONCLUSIONS: It is concluded that the occurrence of a potentially lethal serotonin syndrome is rare in fluvoxamine treatment psychosis-like syndromes as a side effect of serotonergic stimulation might occur. In the investigated sample the rate was 0.006-0.04 per 100 treatment days.

PMID 9088888  Eur Neuropsychopharmacol. 1997 Feb;7(1):71-4.

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