Prescribing Topiramate in Patients With Borderline Personality Disorder and a History of Anorexia Nervosa

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To the Editor: Topiramate is an anticonvulsant that can induce weight loss. It also has been used for borderline personality disorder.1,2 At least 1 previous report suggested that persons with a history of anorexia nervosa should not be treated with topiramate.3 Case report. Ms A, a 26-year-old woman, had borderline personality disorder (according to The Diagnostic Interview for DSM-IV Personality Disorders4), with predominant self-harm, mood instability, and comorbid bulimia. Symptoms appeared first around the age of 10 years, with regular self-harm by age 12. Between the ages of 17 and 18, she developed severe anorectic behaviors, losing 77 pounds (35 kg) and reducing her body mass index (BMI) to 17.2 (kg/m2). When she left high school, the food restriction was replaced by bulimia, which she had for 3 years before seeking treatment (when she was 22 years old). For 4 years, she received some benefit from several different pharmacologic (serotonergic agents, benzodiazepines, and anticonvulsant agents) and psychotherapeutic treatments, but these were largely unsuccessful. At this time, she had severe mood instability, self-induced vomiting, and intense forms of self-harm including cutting, burning, and hitting herself in various locations such as forearms, chest, thighs, and abdomen. As no marketing authorization has been given yet in Europe for the use of topiramate, its introduction was carefully discussed with the patient. Topiramate (25 mg/d) therapy was started in March 2009, and the dosage was increased weekly to 200 mg/d. By end of March 2009, the maximum dosage had been reached, and Ms A's symptoms had disappeared. By that time, Ms A was stable and asymptomatic, with a BMI of 34, and she began seeing a nutritionist to lose weight. Over the next few weeks, her weight slowly decreased. Typical weight loss during topiramate treatment is around 20 lb (9 kg) at 6 months,5 and until this point she had lost more than 20 lb (9 kg), so her weight loss was not seen as cause for concern. Two months later (May 2009), weight loss continued, and Ms A began to describe the reappearance of the cognitive (“I am big and horrible”), behavioral (food restriction), and emotional (shame) aspects of her previous anorectic restrictive episode. The appearance of these symptoms called into question the pursuit of the medical treatment. The benefit/risk balance was judged favorable at this time, by both the nutritionist and the psychiatrist. Her BMI fell progressively to 21.6 in August 2009, 5 months after the introduction of topiramate. Gradual stabilization of weight was associated with a progressive disappearance of anorectic aspects. For the next 4 months, her weight remained stable. The cognitions, behaviors, and emotions associated with her eating disorder had now fully disappeared. We suggest that in patients with a history of anorexia nervosa, topiramate might induce relapse. However, this effect can disappear during the course of treatment and should not be a reason to end treatment.