Worsening of Borderline Symptoms Under Reboxetine Treatment

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J Neuropsychiatry Clin Neurosci 17:559-560, November 2005

doi: 10.1176/appi.neuropsych.17.4.559

© 2005 American Psychiatric Publishing, Inc.

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Letter

Worsening of Borderline Symptoms Under Reboxetine Treatment

Ion Anghelescu, M.D., Britta Jänen, M.D., Schindler, M.D. and

Claas-Hinrich Lammers, M.D., Department of Psychiatry, University

Medicine Berlin, Germany

SIR: Reboxetine, a norepinephrine reuptake inhibitor, is a potent

antidepressant for patients with major depressive disorder or

dysthymia.1 Borderline patients do not only show symptoms such as

self-mutilation, suicidality, dissociative symptoms, aversive

tension and instability of mood but also very often depressive

symptoms which require a psychopharmacological treatment. Here we

report the clinical observation in two patients that the use of

reboxetine as an antidepressant in borderline patients does provoke

an increase in borderline symptoms such as dissociative symptoms,

aversive tension and irritability.

Case Reports

Ms. A. is a 23-year-old female with the diagnosis of dysthymia who

was admitted because of acute suicidality. The diagnoses made over

the past few years were borderline personality disorder, cannabis

and alcohol abuse, panic disorder with agoraphobia and anorexia

nervosa. Her major complaints were affective lability,

depersonalisation and concentration difficulties. Self-injuries have

occurred for about 7 years, her childhood history was remarkable for

sexual abuse by her father. Because of insufficient efficacy and

sedation as a side effect the premedication with mirtazapine 30 mg

daily was switched to reboxetine, because she refused to take an

SSRI. Already with reboxetine 4 mg daily she suffered from severe

irritability and aversive tension with increased suicidality and

dissociative symptoms, which could also be translated into a visual

analogue scale. Three days after discontinuation the symptoms

completely remitted.

Ms. B. is a 32-year-old female with the diagnosis of a major

depressive episode (HDRS-17 of 17 at admission). Her major complaint

was sadness and feelings of guilt with insomnia. She was treated

with quetiapine (200 mg daily) because of its sedating effects and

because of galactorrhea associated with amisulpride intake before.

Moreover, she suggested the substitution of venlafaxine, which had

caused significant weight gain of about 5 kg in 4 weeks. Therefore,

reboxetine was initiated, and increased from 2 to 6 mg daily over 3

days. With this dosage she developed severe affective lability and

impulsivity with acute suicidality (HDRS-17: 21). Two days after

discontination and switch to 50 mg sertraline she remitted

completely from these new symptoms. She then reported—what was

denied at the beginning—recurrent states of aversive tension,

identity problems and flashback intrusions since the age of 14. This

led to the supplementary diagnosis of borderline personality

disorder.

Discussion

We report for the first time worsening of borderline symptoms,

especially dissociative symptoms and aversive tension, under the

treatment with reboxetine in two patients with borderline

personality disorder. We interpret this clinical observation as an

increased noradrenergic sensitivity with an hyperresponsiveness of

the adrenergic system under stimulation. An heightened and

dysregulated adrenergic function and a symptom provocation through

increase of noradrenergic neurotransmission is a robust finding in

patients with post traumatic stress disorder (PTSD).2 Since

borderline personality disorder has been conceptualized as a chronic

complex PTSD, our clinical observation indicates that noradrenergic

hyperresponsitivity is a neurobiological mechanism for borderline

symptoms. This observation is supported by the finding of reduction

of aversive tension and dissociation by clonidine, an inhibitor of

the central noradrenergic system.3

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