Can drugs support emotional developement in personality disorders?

Question

Some personality disorders are associated with a degree of emotional blindness or coldness with narcissistic PD being such an example. I wonder whether there are drugs that - in addition to psychotherapy - aid in the process of learning to feel, express and cope with emotions.

Particularly, I wonder if antidepressants might be effective in this task. Serotonin ADs help to handle anxiety and depression and taken long-term might even heal things like social anxiety and generalized anxiety. Depression is also linked to somewhat reduced brain activity. The same holds for norepinephrine. Dopamine antagonists are also said to support the feelings of pleasure and motivation. The question is if these effects are permanent or tend to disappear or worsen upon discontinuation.

Moreover, some ADs are believed to induce "emotional flatness" which would possibly hinder the process of healing through psychotherapy.

It is known that SSRI (selective serotonin reuptake inhibitor) antidepressants, after taken for a while or taken one after another (if the doctor is trying to see what works), can cause what is called "emotional blunting". In this instance, the individual in question is often unable to cry, even if he or she wants to. In other cases, the person may seem fully present but operate merely intellectually when emotional connection would be appropriate. This may present an extreme difficulty in giving or receiving empathy and can be related to the spectrum of narcissistic personality disorder.[1]

As far as I know the amygdala is the part of the brain responsible for handling emotions. My question is if there are drugs that directly stimulate neuronal growth in amygdala to improve emotional processing.

[1] Johnson, Stephen M (1987), Humanizing the Narcissistic Style, NY: Norton and Co., p. 125, ISBN 0-393-70037-2

Answer 1

This question is a bit broad. The main reason it can be easily answered is that the answer is mostly no. According to a 2016 recent review:

• for cluster A personality disorders, which among other things feature low empathy and social aversion there's not a lot going on regarding pharmacotherapy:

Patients with schizotypal personality disorder have been analyzed in few small open-label studies using typical and atypical antipsychotics. There are no randomized controlled trials for patients with schizoid or paranoid personality disorder, and there is not a robust evidence about the efficacy of psychoactive drugs in these patients.

• for cluster B (which include narcissistic and borderline PD) there is more pharmacotherapy in practice, in particular for the latter:

Antidepressants, anxiolytics, antipsychotics, and mood stabilizers are used by a significantly higher percentage of borderline patients than other people with personality disorders [...] Cochrane review found that second-generation antipsychotics, mood stabilizers, and dietary supplementation with omega-3 fatty acids have some beneficial effects in these patients, while antidepressants may be helpful when comorbid conditions are present.

They don't say anything about narcissistic PD, so my guess is pharmacotherapy is not much of much help there.

• for cluster C (which includes avoidant and obsessive-compulsive) they also note briefly that

There are no randomized controlled trials of drug treatment for cluster C personality disorders, although it can be argued that antidepressants might be of some help. Particularly, in patients with obsessive–compulsive personality disorder, use of SSRIs may be helpful, especially if anxiety is present

Answer 2

I have also found this 2016 presentation on Medications for Borderline Personality disorder. I think it summarizes the topic nicely.

Summary

• Medications can have a role in treating BPD
  • No evidence for monotherapy for BPD
  • Symptomatic treatment has a limited evidence base
    • some evidence for medications for several core BPD symptoms
    • no evidence for medications for some important core symptoms
  • I prefer to treat comorbidities rather than engaging in symptomatic treatment

• Be sensitive to the impact of medications on the therapeutic alliance

  • There will be transference issues around you and your medications
  • Address negative attitudes when you see them
  • Positive transference to sedating medications can be a problem

• Work to establish a collaborative relationship with your patient and the team

• When prescribing:
  • Be clear what you are using each medication for
  • Consider risks (side effects) vs. benefits (evidence base)
  • Avoid disinhibiting and addictive medications wherever possible
  • Consider risk in overdose
  • Be planful about decreasing and/or discontinuing medications

Interestingly, the omega-3 supplements have also been recommended in this source. I wonder how it might possibly work. Also more info on dosage and EPA/DHA ratio would be appropriate.