Management Approach to a Patient with Borderline Personality Disorder, Trichotillomania, and Alcohol Dependence Syndrome: Use of Endoxifen
Abstract
Borderline personality disorder (BPD) and alcohol abuse are both associated with impulsivity, while patients with trichotillomania demonstrate higher rates of co-morbid impulsive disorders. Impulsivity stems from overactive protein kinase C (PKC), and thus, targeting PKC can treat impulsivity. This case describes the effectiveness of endoxifen, a direct PKC inhibitor, in a patient with co-morbid BPD, alcohol dependence syndrome, and trichotillomania. There was reduced impulsivity and a motivation to cease alcohol consumption with endoxifen treatment. The patient transitioned from reluctance to disulfiram treatment to a willingness to take disulfiram. This case report adds valuable knowledge on the potential of endoxifen for patients with BPD and alcohol abuse.
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Introduction
Impulsivity is a core feature of borderline personality disorder (BPD), and manifests as irresponsible behavior, problematic substance abuse, self-harm, and disordered eating, which thus impact quality-of-life. The high-trait impulsivity characteristic of BPD patients involves rapid and unplanned behaviors.1 Trichotillomania was earlier classified as an impulse control disorder (involving an impaired ability to resist impulses to engage in ultimately self-destructive behavior), though it is now classified under obsessive-compulsive disorders. However, a higher prevalence rate of co-morbid impulsive disorders and alcohol use disorders has been reported in this population.2 Impulsivity is reported to arise from overactivity of protein kinase C (PKC), suggesting that PKC can be a treatment target.3,4
The case study described in this report demonstrates the use of endoxifen in a patient with BPD, trichotillomania, and alcohol dependence syndrome, who was not responsive to multiple therapies. The use of endoxifen, a direct PKC inhibitor, along with other antipsychotics led to symptomatic improvement, and the resulting reduction in impulsivity prompted a motivation to reduce alcohol consumption.
Conclusion
This case report describes the impact of endoxifen treatment in a patient with co-morbid BPD, alcohol dependence syndrome, and trichotillomania, all of which are known to be linked to impulsivity. Impulsivity is mediated by PKC overactivity, and endoxifen is a direct PKC inhibitor with known anti-manic action. The patient responded well to endoxifen as part of combination therapy. The addition of endoxifen led to reduced symptoms of BPD, trichotillomania, and alcohol abuse, and the patient was subsequently motivated to stop consuming alcohol and take up treatment with disulfiram. The key action of reducing impulsivity thus had an extended impact on the range of comorbid conditions in this patient. This case report adds to the pool of literature and enhances our knowledge of this molecule for the management of psychiatric conditions.