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2006, Número 5

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Salud Mental 2006; 29 (5)


Tratamiento farmacológico del trastorno límite de personalidad

Chávez-León E, Ng B, Ontiveros-Uribe MP

Idioma: Español
Referencias bibliográficas: 84
Paginas: 16-24
Archivo PDF: 70.94 Kb.


RESUMEN

El trastorno límite de personalidad es un trastorno caracterizado por impulsividad grave e inestabilidad en las relaciones interpersonales, en la autoimagen y la afectividad. Frecuentemente presente en la práctica clínica, se puede asociar o no a otros trastornos mentales (11 y 40.4%). Este artículo tiene por objetivo describir las pautas para el uso de psicofármacos como parte del tratamiento integral del paciente con trastorno límite a partir de una revisión de los ensayos clínicos publicados hasta la fecha. Para ello se describe un modelo psicobiológico y se presentan los hallazgos obtenidos primordialmente en los ensayos clínicos controlados doble ciego con grupos asignados de manera aleatoria. El fin es aportar elementos a la actividad profesional del psiquiatra que faciliten su juicio clínico.
El trastorno límite muestra alteración en las cuatro dimensiones propuestas en el modelo psicobiológico de la personalidad: 1. La organización cognitivo-perceptual. 2. La regulación afectiva. 3. La impulsividad-agresividad. 4. La ansiedad e inhibición. La alteración en la dimensión de la regulación afectiva se manifiesta en cambios rápidos en el estado afectivo (relaciones tormentosas, fluctuaciones en la autoimagen y la autoestima, mal genio y enojo constantes, peleas físicas y sentimientos de vacío), y se debe a una sensibilidad excesiva a la separación, la frustración y la crítica, por un defecto del sistema serotoninérgico sobre los sistemas dopaminérgico y noradrenérgico. La mayoría de los estudios señala la relación inversa entre los niveles de serotonina y la impulsividad, la agresividad, las conductas autodestructivas y de automutilación.
El paciente con trastorno límite de personalidad se beneficia con el uso de medicamentos para la impulsividad, los estados psicóticos, la inestabilidad afectiva y la depresión. Los inhibidores selectivos de recaptura de serotonina son útiles para disminuir la irritabilidad y la agresividad y, en menor grado, la depresión (fluoxetina) y la labilidad emocional (fluvoxamina). Los antipsicóticos (haloperidol y olanzapina) disminuyen en algún grado los síntomas depresivos, la impulsividad y la agresividad. Los anticonvulsivantes (carbamazepina, valproato y topiramato) mejoran los síntomas de depresión y el control sobre la agresión. A partir de una revisión de ensayos clínicos controlados se puede concluir que los pacientes con trastorno límite de personalidad en quienes la agresividad, la automutilación y la disforia crónica forman parte de la problemática sobresaliente, debe iniciarse con un neuroléptico atípico y como segunda opción un anticonvulsivante, quedando la clozapina y el litio para los casos resistentes. En pacientes en que predomina la depresión, la ansiedad o la impulsividad, es mejor usar, como primera opción, un antidepresivo inhibidor selectivo de recaptura de serotonina. Como segunda opción, se recomiendan los antidepresivos tricíclicos y, como último recurso, un inhibidor de la MAO. Debe iniciarse el tratamiento con dosis bajas y aumentarlas progresivamente, sin cambiar o agregar medicamentos antes de haber esperado un lapso razonable.


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