Borderline Personality Disorder Guidelines

Affective dysregulation in patients with borderline personality disorder is manifested by symptoms such as mood lability, rejection sensitivity, inappropriate intense anger, depressive "mood crashes," and temper outbursts. As seen in Table 2, patients displaying these features should be treated initially with one of the SSRIs, since this recommendation has strong empirical support (44–49). SSRIs have a broad spectrum of therapeutic effects, are relatively safe in overdose (compared with the tricyclic antidepressants or MAOIs), and have a favorable side effect profile, which supports treatment adherence. For example, fluoxetine has been found to improve depressed mood, mood lability, rejection sensitivity, impulsive behavior, self-mutilation, hostility, and even psychotic features. Research trials of SSRIs for treatment of borderline personality disorder have ranged in duration from 6 to 14 weeks for acute treatment studies, with continuation studies lasting up to 12 months. Some patients have retained improvement with maintenance treatment of 1–3 years. Studies have been reported with fluoxetine (in doses of 20–80 mg/day), sertraline (in doses of 100–200 mg/day), and the mixed norepinephrine/serotonin reuptake blocker venlafaxine (in doses of up to 400 mg/day) (45). A reasonable trial of an SSRI for treatment of patients with borderline personality disorder is at least 12 weeks.

Psychopharmacological Treatment Recommendations for Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder

Empirical trials of tricyclic antidepressants have produced inconsistent results (50, 51). Patients with comorbid major depression and borderline personality disorder have shown improvement following treatment with tricyclic antidepressants. However, in one placebo-controlled study, amitriptyline had a paradoxical effect in patients with borderline personality disorder, increasing suicidal ideation, paranoid thinking, and assaultiveness (50).

Since affective dysregulation is a dimension of temperament in patients with borderline personality disorder and not an acute illness, the duration of continuation and maintenance phases of pharmacotherapy cannot presently be defined. Significant improvement in the quality of the patient’s coping skills and interpersonal relationships may be required before medication can be discontinued. Clinical experience suggests caution in discontinuing a successful antidepressant trial, especially if prior medication trials have failed. In the event of a suboptimal response to an SSRI, consideration should be given to switching to a second SSRI or related antidepressant. In one study of patients with borderline personality disorder (45), one-half of the patients who failed to respond to fluoxetine subsequently responded to sertraline.

When affective dysregulation appears as anxiety, an SSRI may be insufficient. At this point, the use of a benzodiazepine should be considered, although there is little systematic research on the use of these medications in patients with borderline personality disorder. Use of benzodiazepines may be problematic, given the risk of abuse, tolerance, and even behavioral toxicity. Despite clinical use of benzodiazepines (52), the short-acting benzodiazepine alprazolam was associated in one study with serious behavioral dyscontrol (53). Case reports demonstrate some utility for the long half-life benzodiazepine clonazepam (54). Clinical experience suggests that this medication, if used over the longer term, is best used adjunctively with an SSRI.

In theory, buspirone may treat anxiety or impulsive aggression without the risk of abuse or tolerance. However, the absence of an immediate effect generally makes this drug less acceptable to patients with borderline personality disorder. Currently, there are no published data on the use of buspirone for the treatment of affective dysregulation symptoms in patients with borderline personality disorder.

When affective dysregulation appears as disinhibited anger that coexists with other affective symptoms, SSRIs are the treatment of first choice. Fluoxetine has been shown to be effective for anger in patients with borderline personality disorder independent of its effects on depressed mood (44). Effects of fluoxetine on anger and impulsivity may appear within days, much earlier than antidepressant effects. Clinical experience suggests that in patients with severe behavioral dyscontrol, low-dose neuroleptics can be added to the regimen for a rapid response; they may also improve affective symptoms (50). Augmentation with neuroleptics should be considered before trying an MAOI, which requires more patient cooperation and adherence.

The efficacy of MAOIs for affective dysregulation symptoms in patients with borderline personality disorder has strong empirical support (55, 56). However, they are not a first-line treatment because of concerns about adherence to required dietary restrictions and because of their more problematic side effects. The effectiveness of MAOIs is supported by randomized controlled studies in patients with a primary diagnosis of borderline personality disorder as well as syndromes (e.g., atypical depression) in which the diagnosis of borderline personality disorder is considered secondary (57). MAOI antidepressants have demonstrated efficacy for impulsivity, mood reactivity, rejection sensitivity, anger, and hostility. They may also be effective for atypical depression and "hysteroid dysphoria." If a psychiatrist wishes to use an MAOI as a second-line treatment for symptoms of affective dysregulation, care should be taken to allow an adequate washout period after discontinuing SSRIs, particularly those with a long half-life.

Mood stabilizers are another second-line (or adjunctive) treatment for affective dysregulation symptoms in patients with borderline personality disorder. Lithium carbonate, carbamazepine, and valproate have been used for treatment of mood instability in patients with an axis II disorder, but there is a surprising paucity of empirical support for their use in borderline personality disorder, although studies are currently under way. Lithium carbonate has the most research support in randomized controlled trials studying patients with personality disorders (although not specifically borderline personality disorder). However, these studies focused primarily on impulsivity and aggression rather than mood regulation (58–60). Nonetheless, lithium may be helpful for mood lability as a primary presentation in patients with a personality disorder (61). Lithium has the disadvantage of a narrow margin of safety in overdose and the risk of hypothyroidism with long-term use.

Carbamazepine has demonstrated efficacy for impulsivity, anger, suicidality, and anxiety in patients with borderline personality disorder and hysteroid dysphoria (62). However, a small, controlled study of patients with borderline personality disorder with no axis I affective disorder found no significant benefit for carbamazepine (63). Carbamazepine has been reported to precipitate melancholic depression in patients with borderline personality disorder who have a history of this disorder (64), and it has the potential to cause bone marrow suppression.

Valproate demonstrated modest efficacy for depressed mood in patients with borderline personality disorder in one small, randomized, controlled trial (65). Open-label case reports suggest that this medication may also decrease agitation, aggression, anxiety, impulsivity, rejection-sensitivity, anger, and irritability in patients with borderline personality disorder (66). Although the use of carbamazepine and valproate is widespread, psychiatrists should be aware of the lack of solid research support for their use in patients with borderline personality disorder.

Although there is a paucity of data on the efficacy of ECT for patients with borderline personality disorder, much of the available data suggest that depressed patients with a personality disorder generally have a poorer outcome with ECT than depressed patients without a personality disorder. Clinical experience suggests that while ECT may sometimes be indicated for patients with borderline personality disorder and severe axis I depression that has been resistant to pharmacotherapy, affective features of the borderline diagnosis are unlikely to respond to ECT.

As seen in Table 3, SSRIs are the treatment of choice for impulsive, disinhibited behavior in patients with borderline personality disorder. Randomized controlled trials and open-label studies with fluoxetine and sertraline have shown that their effect on impulsive behavior is independent of their effect on depression and anxiety (67). The effect of SSRIs on impulsivity may appear earlier than the effect on depression, with onset of action within days in some reports. Similarly, discontinuation of an SSRI following successful treatment may result in the reemergence of impulsive aggression within days. Clinical experience suggests that the duration of treatment following improvement of impulsive aggression should be determined by the clinical state of the patient, including his or her risk of exposure to life stressors and progress in learning coping skills. When the target for treatment is a trait vulnerability, a predetermined limit on treatment duration cannot be set.

Psychopharmacological Treatment Recommendations for Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality Disorder

Drug Class	Specific Medications Studied	Symptoms for Which Medication Is Recommended	Strength of Evidence^a	Issues
SSRIs and related antidepressants	Fluoxetine, sertraline	Impulsive aggression, anger, irritability, self-injurious behavior, poor global functioning	A	Effects on anger and impulsive aggression may appear earlier and independently of effects on depressed mood and anxiety; no published literature on second "salvage" trials if first trial fails to reduce impulsive behavior
MAOIs	Phenelzine, tranylcypromine	Anger, irritability; impulsivity in patients with hysteroid dysphoria	A	Second-line treatment after SSRI failure; complete elimination of initial SSRI required before MAOI treatment; adherence to required dietary restrictions problematic
Mood stabilizers	Lithium carbonate	Impulsive aggression in patients with related personality disorders, impulsive behavior in patients with borderline personality disorder	A	Can be used as primary or adjunctive treatment (overlaps with treatment of affective dysregulation domain); older literature does not address borderline personality disorder; toxicity a concern in overdose; blood monitoring necessary; risk of hypothyroidism with long-term use
	Carbamazepine	Impulsivity in patients with hysteroid dysphoria	C	Risk of precipitating melancholic depression reported; blood monitoring required
	Valproate	Impulsive aggression, agitation; for adolescents with disruptive behavior disorders: tension, anxiety, chronic temper outbursts, poor global functioning	C	Paucity of research support for this indication despite widespread use; one randomized, placebo-controlled, double-blind trial is under way
Atypical neuroleptics	Clozapine	Severe self-mutilation, psychoticism	C	Risk of agranulocytosis renders clozapine treatment a last resort for this indication; blood monitoring required
Typical neuroleptics (low-dose)^b	Haloperidol	Acute anger, hostility, assaultiveness, self-injury	A	Nonspecific effects on impulsivity as adjunctive agent; more specific effects on anger; rapid onset of effect provides immediate control of escalating impulsive symptoms
^{aRatings used by Jobson and Potter (2): A=supported by two or more randomized, placebo-controlled, double-blind trials; B=supported by at least one randomized, placebo-controlled, double-blind trial; C=supported by open-label studies, case reports, and studies that do not meet standards of randomized, placebo-controlled, double-blind trials. See text for specific supporting studies. ^{bAgents primarily used as adjunctive treatment.}}

When behavioral dyscontrol poses a serious threat to the patient’s safety, it may be necessary to add a low-dose neuroleptic to the SSRI. Although this combination has not been studied, randomized controlled trials of neuroleptics alone have demonstrated their efficacy for impulsivity in patients with borderline personality disorder. The effect is rapid in onset, often within hours with oral use (and more rapidly when given intramuscularly), providing immediate control of escalating impulsive-aggressive behavior.

If an SSRI is ineffective, a trial of another SSRI or related antidepressant may be considered, although there are no published studies of this approach with impulsivity as a target symptom.

Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium carbonate, although this combination has not been studied in patients with borderline personality disorder. Nonetheless, studies in impulsive adults and adolescents with criminal behavior (who were not selected for having borderline personality disorder) demonstrate that lithium alone is effective for impulsive-aggressive symptoms (58–60). If an SSRI is ineffective, switching to an MAOI antidepressant may be considered, although it is critical to have an adequate washout period. In a placebo-controlled crossover study of women with borderline personality disorder and hysteroid dysphoria, tranylcypromine was effective for the treatment of impulsive behavior (55). In another randomized controlled trial, phenelzine was effective for the treatment of anger and irritability (56, 68). On the basis of these findings, MAOIs are recommended for treatment of impulsivity, anger, and irritability in patients with borderline personality disorder. Combining MAOIs with valproate would also appear to be rational for selected patients, although there are no studies of these combinations.

Although the use of MAOIs in patients with borderline personality disorder is supported by randomized controlled trials, because of safety considerations many clinicians prefer to use mood stabilizers for treatment of impulsive behavior. The use of carbamazepine or valproate for impulse control in patients with borderline personality disorder appears to be widespread in clinical practice, although empirical evidence for their efficacy for impulsive aggression is limited and inconclusive. Carbamazepine has been shown to decrease behavioral impulsivity in patients with borderline personality disorder and hysteroid dysphoria. However, in a small controlled study that excluded patients with an affective disorder (63), carbamazepine proved no better than placebo for impulsivity in borderline personality disorder. Support for the use of valproate for impulsivity in borderline personality disorder is derived only from case reports, one small randomized control study, and one open-label trial in which impulsivity significantly improved (65, 66, 69, 70). Preliminary evidence suggests that the atypical neuroleptics may have some efficacy for impulsivity in patients with borderline personality disorder, especially severe self-mutilation and other impulsive behaviors arising from psychotic thinking. One open-label trial (71) and one case report (72) support the use of clozapine for this indication. The difficulties and risks involved in using clozapine (e.g., neutropenia) generally warrant its use only after other treatments have failed. The newer atypical neuroleptics have fewer risks, but there are few published data on their efficacy. Further investigation is warranted for their use as a treatment for refractory impulsive aggression in patients with borderline personality disorder.

Opioid antagonists (e.g., naltrexone) are sometimes used in an attempt to decrease self-injurious behavior in patients with borderline personality disorder. However, empirical support for this approach is very preliminary, since their efficacy has been demonstrated only in case reports and small case series.

As seen in Table 4, low-dose neuroleptics are the treatment of choice for these symptoms. This recommendation is strongly supported by randomized, double-blind controlled studies and open-label trials involving a variety of neuroleptics in both inpatient and outpatient settings and in adult and adolescent populations (50, 51, 55, 73–78).

Psychopharmacological Treatment Recommendations for Cognitive-Perceptual Symptoms in Patients With Borderline Personality Disorder

Drug Class	Specific Medications Studied	Symptoms for Which Medication Is Recommended	Strength of Evidence^a	Issues
Typical neuroleptics (low-dose)	Haloperidol, perphenazine, thiothixene, thioridazine, flupentixol, loxapine, chlorpromazine, trifluoperazine	Ideas of reference, illusions, and paranoid ideation (and associated anger/hostility); global symptom severity, depressed mood, anxiety, impulsivity, recurrent suicidal behavior	A	Effects demonstrated in short-term studies (e.g., 5–16 weeks); poor tolerance over longer trials (e.g., 22 weeks) with increased akinesia, depression; reduction of recurrent parasuicidal behaviors reported in one long-term (6-month) study; risk of tardive dyskinesia with maintenance treatment
Atypical neuroleptics	Clozapine, olanzapine, risperidone	In theory, same as for typical neuroleptics as well as self-mutilation and severe, neuroleptic-resistant psychoticism	C	No published randomized, placebo-controlled, double-blind trials in support of this indication despite widespread use; risk of agranulocytosis renders clozapine treatment a last resort for this indication
SSRIs^b		Irritability, anger/hostility, depressed mood, impulsive aggression	A	Especially effective if affective symptoms are present; overlaps with treatment of affective dysregulation and impulsive-behavioral dyscontrol domains
MAOIs^b		Same as for SSRIs	A	Adherence to required dietary restrictions problematic
^{aRatings used by Jobson and Potter (2): A=supported by two or more randomized, placebo-controlled, double-blind trials; B=supported by at least one randomized, placebo-controlled, double-blind trial; C=supported by open-label studies, case reports, and studies that do not meet standards of randomized, placebo-controlled, double-blind trials. See text for specific supporting studies. ^{bAgents primarily used as adjunctive treatment.}}

Low-dose neuroleptics appear to have a broad spectrum of efficacy in acute use, improving not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. Treatment effects appear within days to several weeks. Patients with cognitive symptoms as a primary complaint respond best to the use of low-dose neuroleptics. Patients with borderline personality disorder with prominent affective dysregulation and labile, depressive moods, in whom cognitive-perceptual distortions are secondary mood-congruent features, may do less well with neuroleptics alone. In this case, treatments more effective for affective dysregulation should be considered. Duration of treatment may be guided by the length of treatment trials in the literature, which are generally up to 12 weeks. Prolonged use of neuroleptic medication alone in patients with borderline personality disorder (i.e., up to 22 weeks in one study) has been associated with progressive nonadherence and dropout from treatment (68, 79). There is currently a paucity of research on the use of neuroleptic medication as long-term maintenance therapy for patients with borderline personality disorder, although many clinicians regularly use low-dose neuroleptics to help patients manage their vulnerability to disruptive anger. One longer-term study (80) found that a depot neuroleptic was effective for recurrent parasuicidal behaviors in patients with borderline personality disorder. The risk of tardive dyskinesia must be weighed carefully against perceived prophylactic benefit if maintenance strategies are considered (although this risk may be lessened by the use of atypical neuroleptics).

If response to treatment with low-dose neuroleptics is suboptimal after 4 to 6 weeks, the dose should be increased into a range suitable for treating axis I disorders and continued for a second trial period of 4 to 6 weeks. A suboptimal response at this point should prompt rereview of the etiology of the cognitive-perceptual symptoms. If the symptom presentation is truly part of a nonaffective presentation, atypical neuroleptics may be considered. Although there are no published randomized controlled trials of atypical neuroleptics in patients with borderline personality disorder, open-label trials and case studies support the use of clozapine for patients with severe, refractory psychotic symptoms "of an atypical nature" or for severe self-mutilation (71, 72, 81). However, clozapine is best used in patients with refractory borderline personality disorder, given the risk of agranulocytosis. Studies are currently under way with olanzapine and risperidone (82, 83). The generally favorable side effect profiles of risperidone and olanzapine, compared with those of traditional neuroleptics, indicate that these medications warrant careful empirical trials. As yet, there are no published data on the efficacy of quetiapine for borderline personality disorder.

Neuroleptics are often effective for anger and hostility regardless of whether these symptoms occur in the context of cognitive-perceptual symptoms or other types of symptoms. It is important to note that both MAOI and SSRI antidepressants have also been shown in randomized controlled trials to be effective for irritability and anger in some patients with borderline personality disorder with cognitive-perceptual symptoms.

Other disorders may be comorbid with borderline personality disorder, such as mood disorders, substance-related disorders, eating disorders (notably, bulimia), PTSD, other anxiety disorders, dissociative identity disorder, and attention deficit hyperactivity disorder (ADHD) (see section V.A.2., "Comorbidity," and refer to relevant APA Practice Guidelines [84–88]). These disorders can complicate the clinical picture and need to be addressed in treatment. Depression, often with atypical features, is particularly common in patients with borderline personality disorder (89, 90). Depressive features may meet criteria for major depressive disorder or dysthymic disorder, or they may be a manifestation of the borderline personality disorder itself. Although this distinction can be difficult to make, depressive features that appear particularly characteristic of borderline personality disorder are emptiness, self-condemnation, abandonment fears, hopelessness, self-destructiveness, and repeated suicidal gestures (91, 92). Depressive features that appear to be due to borderline personality disorder may respond to treatment approaches described in this practice guideline. Depressive features that meet criteria for major depression (especially if prominent neurovegetative symptoms are present) should be treated by using standard treatment approaches for major depression (see the APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder [84]) in combination with treatment targeted at the borderline personality disorder. Available evidence suggests that SSRIs and MAOIs are more effective than tricyclic antidepressants for depressive features in patients with borderline personality disorder (although safety issues must be particularly carefully considered when using MAOIs).

Substance use disorders are common in patients with borderline personality disorder. The presence of substance use has major implications for treatment, since patients with borderline personality disorder who abuse substances generally have a poor outcome and are at greatly higher risk for suicide and for death or injury resulting from accidents. Persons with borderline personality disorder often abuse substances in an impulsive fashion that contributes to lowering the threshold for other self-destructive behavior such as body mutilation, sexual promiscuity, or provocative behavior that incites assault (including homicidal assault).

Patients with borderline personality disorder who abuse substances are seldom candid and forthcoming about the nature and extent of their abuse, especially in the early phases of therapy. For this reason, therapists should inquire specifically about substance abuse at the beginning of treatment and educate patients about the risks involved.

Vigorous treatment of any substance use disorder is essential in working with patients with borderline personality disorder (87). Depending on the severity of the alcohol abuse, if outpatient treatment is ineffective, inpatient treatment may be needed for detoxification and participation in various alcohol-treatment interventions. Participation in Alcoholics Anonymous is often helpful on both an inpatient and an outpatient basis. Clinical experience suggests that the use of disulfiram may occasionally be helpful as adjunctive treatment for patients with borderline personality disorder who use alcohol, but it must be used with caution because of the risk of impulsivity or nonadherence. Other medications effective for the treatment of alcohol abuse or dependence (e.g., naltrexone) may also be considered. Twelve-step programs are also available for persons abusing narcotics or cocaine. Opioid antagonists (e.g., naltrexone) are effective in treating opiate overdoses and are occasionally used in an attempt to decrease opiate abuse. However, they require diligent patient adherence, and there is little empirical support for the effectiveness of this approach for addiction.

Drug counseling may be a useful component of treatment. However, except perhaps for mild marijuana use, psychotherapy alone is generally ineffective for treating substance use disorders.

To the extent that various substances may be abused in order to mask depression, anxiety, and other related states, clinical experience suggests that prescribed medications—antidepressants (especially SSRIs) or nonhabituating anxiolytics such as buspirone—may help to alleviate the underlying symptoms, thus lessening the temptation to resort to the use of alcohol or drugs.

Some patients with borderline personality disorder engage in violent behaviors. Violence may take such forms as hurling objects at family members—or at therapists— during moments of intense anger or frustration. Others may commit physical assaults. Some patients with borderline personality disorder are physically abusive toward their children. Patients with antisocial traits may engage in robbery, burglary, and car theft. Acts of this sort are often associated with an arrest record.

Therapeutic strategies optimal for dealing with antisocial features vary, depending on the severity of these features, and range from minor interventions to broader and more complex strategies suitable for a clinical picture in which antisociality is a major factor.

When antisocial features are mild (e.g., occasional shoplifting at times of severe stress), clinical experience suggests that individual cognitive therapy may be successful (e.g., encouraging the patient to weigh the risks versus the benefits—and the short-term versus the long-term consequences—of various antisocial choices the patient had been contemplating as well as identifying alternative coping strategies). This becomes in effect a psychoeducative approach in which the patient is helped to understand the advantages, in the long term, of socially appropriate alternatives (93).

When more severe antisocial features are present, residential treatment may be indicated. This may take the form of the "therapeutic community" as described by Losel (94) and by Dolan et al. (95). Various forms of group therapy are a mainstay of this approach. When episodic outbursts of violent behavior are present, the use of mood-stabilizing medications or an SSRI may be indicated (59, 96).

When antisocial features are even more severe and become dominant, and when the threat of violence is imminent, psychotherapy of any type may prove ineffective. In this situation hospitalization (involuntary, if necessary) may be required to help the patient regain control and, in cases in which a specific threat has been communicated by the patient, to reduce the risk to the potential victim(s).

Clinicians should be aware that some patients with borderline personality disorder with antisocial comorbidity may not be good candidates for therapy. This is especially true when the clinical picture is dominated by psychopathic traits (as described by Hare [97]) of the intensely narcissistic type: grandiosity, conning, lack of remorse, lying, and manipulativeness. Similarly, when underlying motives of jealousy or of revenge are of extreme intensity, therapy may prove ineffective (93).

A primary feature of borderline personality disorder is impulsive self-destructive behavior, including reckless driving and spending, shoplifting, bingeing and purging, substance abuse, risky sexual behavior, self-mutilation, and suicide attempts. This behavior is thought to reflect the difficulties patients with borderline personality disorder have with modulation and containment of intense emotions or impulses. Some clinicians who are expert in the treatment of borderline personality disorder (4, 17) suggest that the psychotherapist should approach each session with a hierarchy of priorities in mind (as exhibited in Figure 1). In other words, suicidal and self-destructive behaviors would be addressed as the highest priorities, with an effort to evaluate the patient’s risk for these behaviors and help the patient find ways to maintain safety. Alternatives to self-mutilation, for example, can be considered (12, 17), and insights might be offered about the meaning of self-defeating behavior. SSRIs might also be prescribed for the self-mutilating patient.

Most experts agree that some type of limit-setting is necessary at times in the treatment of patients with borderline personality disorder. Because patients engage in so many self-destructive and self-defeating behaviors, clinicians may find themselves spending a great deal of the therapy setting limits on the patient’s behaviors. The risk in these situations is that therapists may become entrenched in a countertransference posture of policing the patient’s behavior to the point that treatment goals are lost and the therapeutic alliance is compromised. Waldinger (18) has suggested that limit-setting should be targeted at a subgroup of behaviors, namely, those that are destructive to the patient, the therapist, or the therapy. Limit-setting is not necessarily an ultimatum involving a threat to discontinue the treatment. Therapists can indicate to the patient that certain conditions are necessary to make treatment viable.

It is also useful for psychiatrists to help the patient think through the consequences of chronic self-destructive behaviors. In this way the behavior may gradually shift from being ego syntonic to ego dystonic (i.e., the behavior becomes more distressing to the patient as he or she becomes more reflective about the adverse consequences). The patient and therapist can then form a stronger therapeutic alliance around strategies to control the behavior.

If self-destructive behaviors are relentless and out of control, and especially if patients are not willing to work on controlling such behaviors, patients may need referral to a more intensive level of care before they are able to resume outpatient treatment. Consultation may also be useful.

Childhood trauma is a common although not universal feature of borderline personality disorder (98–104). Recognizing trauma-related aspects of the patient’s affective instability, damaged self-image, relationship problems, fears of abandonment, self-injurious behavior, and impulsiveness is important and can facilitate psychotherapy in a variety of ways.

Recognizing a trauma history, if present, can help the therapist and patient understand current distortions in the patient’s view of self and others as an understandable residual of prior life experiences that would produce mistrust. Anger, impulsiveness, and self-defeating behavior in relationships take on different meanings when understood as, in part, displaced responses to abusive early life experiences. Discounting a trauma history has the potential to undermine the therapeutic alliance and the progress of treatment. It can also hamper patients’ ability to integrate and come to terms with the trauma. Not integrating traumatic material into the treatment can lead patients to experience the therapy as a form of collusion with the abuser.

Many traumatized patients expect others, including their therapists, to be malevolent, for example, inflicting harm in the guise of providing help, analogous to a parent or other caretaker exploiting and abusing a child. This core transference mistrust may become an ongoing issue to be worked on during psychotherapy.

Decisions about whether and when to focus on trauma, if present, during treatment should be based on the patient’s agitation, stability, fragility, evidence of psychotic symptoms, and potential for self-harm or disruption of current vocational, family, or other roles. It is generally thought that working through the residue of trauma is best done at a later phase of treatment, after solidifying the therapeutic alliance, achieving stabilization of symptoms, and establishing an understanding of the patient’s history and psychological structures (8).

In the later phase of treatment, one component of effective psychotherapy for patients with a trauma history involves exposure to, managing affect related to, and cognitively restructuring memories of the traumatic experience. This involves grief work (105), acknowledging, bearing, and putting into perspective the residue of traumatic experiences (106). This process helps to reduce the unbidden, intrusive, and alien nature of traumatic memories and differentiates affect associated with the trauma from that elicited by current relationships.

For patients with borderline personality disorder who have experienced trauma, group work can be particularly helpful in providing support and understanding from other trauma survivors as well as a milieu in which they can gain understanding about their self-defeating behaviors and interpersonal relationship patterns. Some patients with borderline personality disorder can be less defensive receiving feedback from peers, and at certain points in therapy this may be the only place they feel understood and safe.

The vulnerability of traumatized patients to revictimization, or their deliberate incurring of risk and reenactment of early trauma, has implications for patient safety and management of the transference. The therapist should address the possibility of current or future harm to the patient.

Even when full criteria for comorbid PTSD are not present, patients with borderline personality disorder may experience PTSD-like symptoms. For example, symptoms such as intrusion, avoidance, and hyperarousal may emerge during psychotherapy. Awareness of the trauma-related nature of these symptoms can facilitate both psychotherapeutic and pharmacological efforts in symptom relief.

Victims of trauma, especially early in life, typically blame themselves inappropriately for traumatic events over which they had no control (107). This may happen because the trauma was experienced during a developmental period when the child was unable to appreciate independent causation and therefore assumed he or she was responsible. Many adults blame themselves so that they avoid reexperiencing the helplessness associated with trauma. It is important in therapy to listen to a patient’s guilt and sense of responsibility for past trauma and, when appropriate, to clarify the patient’s lack of responsibility for past trauma as well as the importance of taking responsibility for present life circumstances.

Eye movement desensitization and reprocessing (108) has been presented as a treatment for trauma symptoms. It involves having patients discuss a traumatic memory and then move their eyes back and forth rapidly as though they were in rapid eye movement sleep. The specific effect of the eye movements has not been established, and the treatment may mainly involve exposure to and working through trauma-related cognition and affect (109, 110). This therapy is currently under investigation. There is currently no evidence of specific efficacy for this treatment in patients with borderline personality disorder.

Ignoring or discounting a trauma history can undermine the therapeutic alliance by aligning the therapist with individuals in the patient’s past who either inflicted harm or ignored it. On the other hand, memories of remote traumatic experiences may contain inaccuracies. Dissociative symptoms may complicate retrieval of traumatic memories in patients with borderline personality disorder (111, 112). The affect may be correct even when the details about events are wrong (113). Furthermore, confrontation of family members regarding possible abusive activity is likely to produce substantial emotional response and family disruption. Thus, the approach to traumatic origins of symptoms should be open-ended, sensitive to both the effects of possible trauma and the fallibility of memory.

There is considerable comorbidity between borderline personality disorder and various dissociative symptoms and disorders (100, 114–117). Transient dissociative symptoms, including depersonalization, derealization, and loss of reality testing, are not uncommon and may contribute to the psychotic-like symptoms that patients with borderline personality disorder may experience. The percentage of patients with borderline personality disorder who also have dissociative identity disorder is unknown, but it is estimated that one-third of patients with dissociative identity disorder also have borderline personality disorder (118). Dissociative symptoms and dissociative identity disorder may appear as or exacerbate other borderline personality disorder characteristics, including identity disturbance, impulsivity, recurrent suicidal behavior, and affective instability. Thus, to manage these symptoms, identification of and attention to comorbid dissociative identity disorder or prominent dissociative symptoms is mandated. This includes the following:

When borderline personality disorder and dissociative identity disorder coexist, clinical reports suggest that hypnosis may be useful for identifying and controlling dissociative symptoms (119–121). These symptoms can be reconceptualized as uncontrolled hypnotic-like states that can be elicited and modulated with hypnosis, both as a technique in therapy and as a self-hypnotic exercise to be practiced by patients under the therapist’s supervision.

A crucial element in working through issues of transference/countertransference and limit-setting is the extent to which the patient is consciously aware and in control of mental states in which impulsive behavior or strong emotion are experienced. Treatment of comorbid dissociative symptoms can help to delineate the areas of available control and expand the patient’s repertoire of adaptive symptom-control skills.

In borderline personality disorder, stress may be a contributing factor in the disorder’s etiology and a precipitant of symptomatic exacerbation (122). Physical or sexual abuse is not uncommon during childhood for these patients; histories of other forms of trauma, such as verbal abuse or neglect (123) and early parental separation or loss (124), are frequently elicited as well. In addition, most patients with borderline personality disorder are acutely sensitive to psychosocial stressors, particularly interpersonal stressors. Self-esteem is often fragile, and patients seek to shore up their sense of self by "borrowing" a stable, established identity from another (usually idealized) person. Relationships are intense, and everyday distractions or inattention can be interpreted as abandonment, resulting in panic-like anxiety, impulsive self-destructive acts, excessive anger, paranoia, or dissociative episodes. These sensitivities are important in therapy, since regardless of the type of treatment, once a therapeutic relationship has developed, it will take on this overdetermined, intense quality. The psychiatrist should be alert, nimble, flexible, and on the lookout for ways in which the limits of the therapeutic relationship may stimulate anxiety-driven reactions in the patient—reactions that may be confrontational, depressive, or invisible until revealed by self-destructive or impulsive acting out.

Borderline personality disorder is diagnosed predominantly in women, with an estimated gender ratio of 3:1. The disorder may be missed in men, who may instead receive diagnoses of antisocial or narcissistic personality disorder. Men should be as carefully assessed for borderline personality disorder as women. The diagnostic assessment of the patient should include a detailed inquiry regarding reproductive life history, including sexual practices and birth control.

Most treatment studies of borderline personality disorder primarily involve women. There has been little systematic investigation of gender differences in treatment response.

The treatment of pregnant and nursing women raises specific concerns regarding the use of psychotropic medications. The potential risks, which are highest during the first trimester of pregnancy, have been reviewed elsewhere (125). When treating women with borderline personality disorder who are pregnant or nursing, the risks of treatment with medication must be carefully weighed against the potential risks and benefits of alternative treatment (e.g., psychotherapy alone) as well as the risk to the women if the borderline personality disorder and comorbid conditions are not treated (125, 126). These potential risks and benefits should be discussed with the patient.

Because anticonvulsants are associated with a potential risk of birth defects, and the risk of birth defects from other psychotropic medications is unknown, psychiatrists should encourage careful contraceptive practices for all female patients of childbearing age who are receiving pharmacological treatment. Since carbamazepine can increase the metabolism of birth control pills, the dosage of oral contraceptives may need to be adjusted accordingly. Whenever possible, planned pregnancy should be pursued in consultation with the psychiatrist so that options, including maintenance of pharmacological treatment or discontinuation of these agents, can be thoughtfully pursued. For patients who become pregnant while on a maintenance regimen of psychiatric medications, a consultation for further consideration of the relative risks of continuing or discontinuing medications should also be considered (127, 128).

Gender issues, including psychotropic medication use during pregnancy, that are associated with certain comorbid conditions are discussed in other APA Practice Guidelines (84–86).

Borderline personality disorder has been reported in many cultures around the world (129). The cultural context of a patient’s presentation should be considered. Cultural factors may hamper the accurate assessment of borderline personality disorder. An appreciation by the clinician of cultural variables is critical in making an accurate diagnosis. Clinicians should be especially careful to avoid cultural bias when applying the diagnostic criteria and evaluating sexual behavior, expressions of emotion, or impulsiveness, which may have different norms in different cultures.

Ethnic groups may differ in their response to psychotropic medications. Although inconclusive, some studies have suggested that Asian patients may require lower doses of haloperidol and have higher serum levels of haloperidol after oral administration than Caucasian patients (130). Psychiatrists should be aware of this possibility when administering neuroleptic medication to Asian patients. Some studies also suggest that ethnic groups may differ in their response to antidepressant medications (131, 132).

Because the personality of adolescents is still developing, the diagnosis of borderline personality disorder should be made with care in this age group. Borderline personality disorder may be present in the elderly, although later in life a majority of individuals with this disorder attain greater stability in functioning. Virtually no treatment studies have been done in adolescents or elderly persons with borderline personality disorder. Although treatments effective in adults would be expected to be efficacious in these age groups, research that demonstrates this efficacy is needed, especially in adolescents. It should be kept in mind that elderly patients are particularly prone to certain medication side effects (e.g., orthostatic hypotension and anticholinergic effects) and therefore may tolerate certain medications less well than younger adults

When treating patients with any mental disorder, attention to risk management issues is important and often enhances patient care. Attention to these issues is particularly important when treating patients with borderline personality disorder, given the potential for self-injury, violent behavior, and suicide, as well as impulsivity, splitting, problems with the therapeutic alliance, and transference and countertransference problems (e.g., the mobilization of intense feelings in the clinician). The following are general risk management considerations for patients with borderline personality disorder:

Suicidal threats, gestures, and attempts are very common among patients with borderline personality disorder, and 8%–10% commit suicide. Managing suicide risk therefore poses important clinical and medicolegal challenges for clinicians. However, it can be difficult to address suicide risk in these patients for a number of reasons. First, suicidality can be acute, chronic, or both, and responses to these types of suicidality differ in some ways. Second, given the tendency of patients with borderline personality disorder to be chronically suicidal and to engage in self-destructive behaviors, it can be difficult to discern when a patient is at imminent risk of making a serious suicide attempt. Third, even with careful attention to suicide risk, it is often difficult to predict serious self-harm or suicide, since this behavior can occur impulsively and without warning. Fourth, given the potential for difficulties in forming a good therapeutic alliance, it may be difficult to work collaboratively with the patient to protect him or her from serious self-harm or suicide. Last, even with good treatment, some patients will commit suicide. The following are risk management considerations for suicidal behavior in patients with borderline personality disorder:

Anger and impulsivity are hallmarks of borderline personality disorder and can be directed at others, including the clinician. This is particularly likely to occur when there is a disruption in the patient’s relationships or when he or she feels abandoned (e.g., there is a change in clinicians) or when the patient feels betrayed, unjustly accused, or seriously misunderstood and blamed by the clinician or a significant other. Even with close monitoring and attention to these issues in the treatment, it is difficult to predict their occurrence. Another complicating factor is that the patient’s anger or behavior may produce anger in the therapist, which has the potential to adversely affect clinical judgment. The following are risk management considerations for anger, impulsivity, and violence in patients with borderline personality disorder:

With patients with borderline personality disorder there is a risk of boundary crossings and violations. The following are risk management considerations for boundary issues with patients with borderline personality disorder:

The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, affects, and self-image, as well as marked impulsivity that begins by early adulthood and appears in a variety of contexts. These characteristics are severe and persistent enough to result in clinically significant impairment in social, occupational, or other important areas of functioning. Common and important features of borderline personality disorder are a severely impaired capacity for attachment and predictably maladaptive behavior in response to separation. Individuals with this disorder are very sensitive to abandonment and make frantic efforts to avoid real or perceived abandonment. They often experience intense abandonment fears and anger in reaction to even realistic time-limited separation. Efforts to avoid abandonment may include inappropriate rage, unfair accusations, and impulsive behaviors such as self-mutilation or suicidal behaviors, which often elicit a guilty or fearful protective response from others.

The relationships of individuals with borderline personality disorder tend to be unstable, intense, and stormy. Their views of others may suddenly and dramatically shift, alternating between extremes of idealization and devaluation, or seeing others as beneficent and nurturing and then as cruel, punitive, and rejecting. These shifts are particularly likely to occur in response to disillusionment with a significant other or when a sustaining relationship is threatened or lost.

The disorder is usually characterized by identity disturbance, which consists of markedly and persistently unstable self-image or sense of self. Self-image (goals, values, type of friends, vocational goals) may suddenly and dramatically shift. Individuals with this disorder usually feel bad or evil, but they may also feel that they do not exist at all, especially when feeling unsupported and alone.

Many individuals with borderline personality disorder are impulsive in one or more potentially self-damaging areas, such as spending money irresponsibly, gambling, engaging in unsafe sexual behavior, abusing drugs or alcohol, driving recklessly, or binge eating. Self-mutilation (e.g., cutting or burning) and recurrent suicidal behaviors, gestures, or threats are common. These self-destructive acts are often precipitated by potential separation from others, perceived or actual rejection or abandonment, or the expectation from others that they assume more responsibility.

Affective instability is another common feature of the disorder. This consists of marked mood reactivity (e.g., intense episodic dysphoria, irritability, or anxiety that usually lasts for a few hours and only rarely for more than a few days). The usual dysphoric mood of these individuals is often punctuated by anger, panic, or despair and is only infrequently relieved by periods of well-being. These episodes may be triggered by the individual’s extreme reactivity to interpersonal stressors. Individuals with this disorder also typically have chronic feelings of emptiness. Many experience inappropriate, intense anger or have difficulty controlling their anger. For example, they may lose their temper, feel constant anger, have verbal outbursts, or engage in physical fights. This anger may be triggered by their perception that an important person is neglectful, withholding, uncaring, or abandoning. Expressions of anger may be followed by feelings of being evil or by feelings of shame and guilt. During periods of extreme stress (e.g., perceived or actual abandonment), these individuals may experience transient paranoid ideation or severe dissociative symptoms (e.g., depersonalization).

It is not necessary for an individual to have all of the above features for borderline personality disorder to be diagnosed. As indicated in Table 1, the diagnosis is given if at least five of the nine diagnostic criteria are present.

Transient psychotic-like symptoms (e.g., hearing their name called) may occur at times of stress. These episodes usually last for minutes or hours and are generally of insufficient duration or severity to warrant an additional diagnosis. Another common associated feature is a tendency for these individuals to undermine themselves when a goal is about to be reached (e.g., severely regressing after a discussion of how well therapy is going). Individuals with this disorder may feel more secure with transitional objects (e.g., a pet or inanimate object) than with interpersonal relationships. Despite their significant relationship problems, they may deny that they are responsible for such problems and may instead blame others for their difficulties.

Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with borderline personality disorder than in those without the disorder.

Axis I disorders and other axis II disorders are often comorbid with borderline personality disorder. Among the most commonly comorbid axis I disorders are mood disorders, substance-related disorders, eating disorders (notably bulimia), PTSD, panic disorder, and ADHD. Such axis I comorbidity can complicate and worsen the course of borderline personality disorder. Commonly co-occurring axis II disorders are antisocial, avoidant, histrionic, narcissistic, and schizotypal personality disorders.

Borderline personality disorder is characterized by notable distress and functional impairment. A majority of patients attempt suicide. Completed suicide occurs in 8%– 10% of individuals with this disorder, a rate that is approximately 50 times higher than in the general population. Risk of suicide appears to be highest when patients are in their 20s as well as in the presence of co-occurring mood disorders or substance-related disorders (87). Physical handicaps may result from self-inflicted injury or failed suicide attempts. These individuals often have notable difficulty with occupational, academic, or role functioning. Their functioning may deteriorate in unstructured work or school situations, and recurrent job loss and interrupted education are common. Difficulties in relationships, as well as divorce, are also common.

The social cost for patients with borderline personality disorder and their families is substantial. Longitudinal studies of patients with borderline personality disorder indicate that even though these patients may gradually attain functional roles 10–15 years after admission to psychiatric facilities, still only about one-half will have stable, full-time employment or stable marriages (40, 134). Recent data indicate that patients with borderline personality disorder show greater lifetime utilization of most major categories of medication and of most types of psychotherapy than do patients with schizotypal, avoidant, or obsessive-compulsive personality disorder or patients with major depressive disorder (135).

A skilled clinical interview is the mainstay of diagnosing borderline personality disorder. This approach should be complemented by knowledge of the DSM criteria and a longitudinal view of the clinical picture. The additional use of assessment instruments can be useful, especially when the diagnosis is unclear. Use of such instruments must be accompanied by clinical judgment.

Certain assessment issues relevant to all personality disorders should be considered when diagnosing borderline personality disorder. For the diagnosis to be made, the personality traits must cause subjective distress or significant impairment in functioning. The traits must also deviate markedly from the culturally expected and accepted range, or norm, and this deviation must be manifested in more than one of the following areas: cognition, affectivity, control over impulses, and ways of relating to others. Therefore, multiple domains of experience and behavior (i.e., cognition, affect, intrapsychic experience, and interpersonal interaction) must be assessed to determine whether borderline traits are distressing or impairing. The clinician should also ascertain that the personality traits are of early onset, pervasive, and enduring; they should not be transient or present in only one situation or in response to only one specific trigger. It is important that borderline personality disorder be assessed as carefully in men as in women.

The ego-syntonicity of the personality traits may complicate the assessment process; the use of multiple sources of information (e.g., medical records and informants who know the patient well) can be particularly helpful in establishing the diagnosis if the patient’s self-awareness is limited. Given the high comorbidity of axis I disorders with borderline personality disorder, it is important to do a full axis I evaluation. An attempt should be made to distinguish axis I states (e.g., mood disorder) from borderline personality disorder, which can be a complex process. Useful approaches are to obtain a description of the patient’s personality traits and coping styles when prominent axis I symptoms are absent and to use information provided by people who have known the patient without an axis I disorder. If axis I disorders are present, both the axis I disorders and borderline personality disorder should be diagnosed.

Because the personality of children and adolescents is still developing, borderline personality disorder should be diagnosed with care in this age group. Often, the presence of the disorder does not become clear until late adolescence or adulthood.

When assessing a patient with borderline personality disorder, the clinician should carefully look for the presence of risk-taking and impulsive behaviors, mood disturbance and reactivity, risk of suicide, risk of violence to persons or property, substance abuse, the patient’s ability to care for himself/herself or others (e.g., children), financial resources, psychosocial stressors, and psychosocial supports (e.g., family and friends).

Borderline personality disorder often co-occurs with mood disorders, and when criteria for both are met, both should be diagnosed. However, some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment. For example, the affective instability and impulsivity of borderline personality disorder may mimic features of bipolar disorder, especially bipolar II disorder. However, in borderline personality disorder, the mood swings are often triggered by interpersonal stressors (e.g., rejection), and a particular mood is usually less sustained than in bipolar disorder. Depressive features may meet criteria for major depressive disorder or may be features of the borderline personality disorder itself. Depressive features that appear particularly characteristic of borderline personality disorder are emptiness, self-condemnation, abandonment fears, self-destructiveness, and hopelessness (91, 92). It can be particularly difficult to differentiate dysthymic disorder from borderline personality disorder, given that chronic dysphoria is so common in individuals with borderline personality disorder. However, the presence of the aforementioned affective features (e.g., mood swings triggered by interpersonal stressors) should prompt consideration of the diagnosis of borderline personality disorder. In addition, the other features of borderline personality disorder (e.g., identity disturbance, chronic self-destructive behaviors, frantic efforts to avoid abandonment) are generally not characteristic of axis I mood disorders. In other cases, what appear to be features of borderline personality disorder may constitute symptoms of an axis I disorder (e.g., bipolar disorder). A more in-depth consideration of the differential diagnosis or treatment of the presumed axis I condition may help clarify such questions.

PTSD is a common comorbid condition in patients with borderline personality disorder, and, when present, should be diagnosed. However, a history of trauma is often characteristic of patients with borderline personality disorder and does not necessarily warrant an additional diagnosis of PTSD. PTSD should be diagnosed only when full criteria for the disorder are met. PTSD is characterized by rapid-onset symptoms that occur, usually in adulthood, in reaction to exposure to a recognizable and extreme stressor; in contrast, borderline personality disorder consists of the early-onset, enduring personality traits described elsewhere in this guideline.

Although borderline personality disorder may be comorbid with dissociative identity disorder, the latter (unlike borderline personality disorder) is characterized by the presence of two or more distinct identities or personality states that alternate, manifesting different patterns of behavior.

Borderline personality disorder is the most common personality disorder in clinical settings. It is present in 10% of individuals seen in outpatient mental health clinics, 15%–20% of psychiatric inpatients, and 30%–60% of clinical populations with a personality disorder. It occurs in an estimated 2% of the general population (1, 136).

Borderline personality disorder is diagnosed predominantly in women, with an estimated gender ratio of 3:1. The disorder is present in cultures around the world. It is approximately five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also a greater familial risk for substance-related disorders, antisocial personality disorder, and mood disorders.

Long-term follow-up studies of treated patients with borderline personality disorder indicate that the course is variable. Early adulthood is often characterized by chronic instability, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources. Later in life, a majority of individuals attain greater stability in social and occupational functioning.

In the largest follow-up study to date (137), about one-third of patients with borderline personality disorder had recovered by the follow-up evaluation, having solidified their identity during the intervening years and having replaced their tendency toward self-damaging acts, inordinate anger, and stormy relationships with more mature and more modulated behavior patterns. Longitudinal studies of hospitalized patients with borderline personality disorder indicate that even though they may gradually attain functional roles 10–15 years after admission to psychiatric facilities, only about one-half of the women and one-quarter of the men will have attained enduring success in intimacy (as indicated by marriage or long-term sexual partnership) (137). One-half to three-quarters will have by that time achieved stable full-time employment. These studies concentrated on patients with borderline personality disorder from middle-class or upper-middle-class families. Patients with borderline personality disorder from backgrounds of poverty have substantially lower success rates in the spheres of intimacy and work. Despite these somewhat favorable outcomes, the suicide rate among patients with borderline personality disorder is high—approximately 9%. The risk of suicide appears highest in the young-adult years.

The following issues should be considered when interpreting the literature presented in this guideline on the efficacy of treatments for borderline personality disorder. Virtually all of the studies involved adults with borderline personality disorder. While the results may be applicable to adolescents, there is a paucity of research that has examined the efficiency of these treatments for this age group. Although some of these treatments have been evaluated through randomized, placebo-controlled trials—the gold standard for determining treatment efficacy— information for other treatments is available only from case reports, case series, or retrospective studies, which limits the conclusions that can be drawn about treatment efficacy.

Another consideration is that efficacy studies (e.g., placebo-controlled trials) have notable strengths but also some limitations. Although such studies are necessary to establish that a particular treatment is effective, there may be limits to how generalizable the study findings are. For example, inclusion and exclusion criteria result in particular types of patients being involved in a study. When reviewing the data presented in this guideline, clinicians should consider how similar their patient is to the population included in a particular study. This is particularly important because of the heterogeneous nature of borderline personality disorder symptoms. Some studies, for example, select patients with marked impulsivity, whereas others include patients with prominent affective features. In addition, many studies have been relatively short term; longer-term treatment outcome studies are needed.

Another issue to consider is that some studies are done in specialized research settings with more expertise and training in the treatment modality than is generally available in the community. In addition, the amount of treatment provided in a study may be greater than is actually available in the community.

When evaluating studies of psychosocial treatments that consist of multiple elements, such as psychodynamic psychotherapy, it may be difficult to know which elements are responsible for the treatment outcome. Another factor to consider is that patients in certain studies of psychosocial treatment were also taking prescription medication, and no steps were taken to control for these effects. Conversely, patients in some studies of medication efficacy also received psychotherapy, and no steps were taken to control for these effects. Therefore, the literature on the efficacy of any one particular treatment is often confounded by the presence of other simultaneous treatments. It can be difficult, then, to isolate the impact of a single modality in most treatment efficacy studies involving patients with borderline personality disorder.

In clinical practice, a combination of treatment approaches is often used and appropriate. Few data are available on the complex treatment regimens often required by the realities of clinical practice (e.g., the use of multiple medications simultaneously). Many clinically important and complex treatment questions have not been (and are unlikely to ever be) addressed in research studies. For such questions, clinical consensus is the best available guide.

Psychodynamic psychotherapy has been defined as a therapy that involves careful attention to the therapist-patient interaction with, when indicated, thoughtfully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the therapist’s contribution to the two-person field. Psychodynamic psychotherapy draws from three major theoretical perspectives: ego psychology, object relations, and self psychology. Most therapeutic approaches to patients with borderline personality disorder do not adhere strictly to only one of these theoretical frameworks. The approach of Stevenson and Meares (20, 138), for example, encompasses the self-psychological ideas of Kohut and the object relations ideas of Winnicott, whereas the technique of Kernberg et al. (4, 13, 28) is based on an amalgamation of ego psychology and object relations theory.

Psychodynamic psychotherapy is usually conceptualized as operating on an exploratory-supportive (also called expressive-supportive) continuum of interventions (Figure 2). At the more exploratory end of the continuum, the goals of psychodynamic psychotherapy with patients with borderline personality disorder are to make unconscious patterns more consciously available, to increase affect tolerance, to build a capacity to delay impulsive action, to provide insight into relationship problems, and to develop reflective functioning so that there is greater appreciation of internal motivation in self and others. From the standpoint of object relations theory, one major goal is to integrate split-off aspects of self and object representations so that the patient’s perspective is more balanced (e.g., seeing others as simultaneously having both positive and negative qualities). From a self-psychological perspective, a major goal is to strengthen the self so that there is less fragmentation and a greater sense of cohesion or wholeness in the patient’s self-experience. On the supportive end of the continuum, the goals involve strengthening of defenses, the shoring up of self-esteem, the validation of feelings, the internalization of the therapeutic relationship, and creation of a greater capacity to cope with disturbing feelings.

Of these interventions, only interpretation is unique to the psychodynamic approach. The more exploratory interventions (interpretation, confrontation, and clarification) may be focused on either transference or extratransference issues.

The Exploratory-Supportive Intervention Continuum of Psychodynamic Psychotherapy^a

Among the most exploratory forms of treatment, interpretation is regarded as the therapist’s ultimate therapeutic tool. In its simplest form, interpretation involves making something conscious that was previously unconscious. An interpretation is an explanatory statement that links a feeling, thought, behavior, or symptom to its unconscious meaning or origin. For example, a therapist might make the following observation to a patient with borderline personality disorder: "I wonder if your tendency to undermine yourself when things are going better is a way to assure that your treatment with me will continue."

This exploratory intervention addresses something the patient does not want to accept or identifies the patient’s avoidance or minimization. A confrontation may be geared to clarifying how the patient’s behavior affects others or reflects a denied or suppressed feeling. An example might be, "I think talking exclusively about your medication problems may be a way of avoiding any discussion with me about your painful feelings that make you feel suicidal."

This intervention involves a reformulation or pulling together of the patient’s verbalizations to convey a more coherent view of what is being communicated. A therapist might say, "It sounds like what you’re saying is that in every relationship you have, no one seems to be adequately attuned to your needs."

Closer to the center of the continuum are interventions that are characteristic of both supportive and exploratory therapies. Encouragement to elaborate may be broadly defined as a request for information about a topic brought up by the patient. Simple comments like, "Tell me more about that," or, "What do you mean when you say you feel ‘empty’?" are examples of this intervention.

This intervention is a demonstration of the therapist’s empathic attunement with the patient’s internal state. This approach draws from self psychology, which emphasizes the value of empathy in strengthening the self. A typically validating comment is, "I can understand why you feel depressed about that," or, "It hurts when you’re treated that way."

This category includes two interventions that are linked by the fact that they both prescribe and reinforce certain activities. Advice involves direct suggestions to the patient regarding how to behave, while praise reinforces certain patient behaviors by expressing overt approval of them. An example of advice would be, "I don’t think you should see that man again because you get beaten up every time you’re with him." An example of praise would be, "I think you used excellent judgment in breaking off your relationship with that man."

This simple intervention involves succinct comments in support of the patient’s comments or behaviors such as, "Yes, I see what you mean," or, "What a good idea."

Some patients with borderline personality disorder receive a highly exploratory or interpretive therapy that is focused on the transference relationship. This approach is sometimes called transference-focused psychotherapy (4, 140). Patients who lack good abstraction capacity and psychological mindedness may require a therapy that is primarily supportive, even though it is psychodynamically informed by a careful analysis of the patient’s ego capacities, defenses, and weaknesses. Most psychotherapies involve both exploratory and supportive elements and include some, although not exclusive, focus on the transference. Hence, psychodynamic psychotherapy is often conceptualized as exploratory-supportive or expressive-supportive psychotherapy (16, 139, 141).

While there is a great deal of clinical literature on psychodynamic psychotherapy with patients who have borderline personality disorder, there are relatively few methodologically rigorous efficacy studies. One randomized controlled trial assessed the efficacy of psychoanalytically informed partial hospitalization treatment, of which dynamic therapy was the primary modality (9). In this study, 44 patients were randomly assigned to either the partial hospitalization program or general psychiatric care. Treatment in the partial hospitalization program consisted of weekly individual psychoanalytic psychotherapy, three-times-a-week group psychoanalytic psychotherapy, weekly expressive therapy informed by psychodrama, weekly community meetings, monthly meetings with a case administrator, and monthly medication review by a resident. The control group received general psychiatric care consisting of regular psychiatric review with a senior psychiatrist twice a month, inpatient admission as appropriate, outpatient and community follow-up, and no formal psychotherapy. The average length of stay in the partial hospitalization program was 1.5 years. Relative to the control group, the completers of the partial hospitalization program showed significant improvement: self-mutilation decreased, the proportion of patients who attempted suicide decreased from 95% before treatment to 5% after treatment, and patients improved in terms of state and trait anxiety, depression, global symptoms, social adjustment, and interpersonal problems. In the last 6 months of the study, the number of inpatient episodes and duration of inpatient length of stay dramatically increased for the control subjects, whereas these utilization variables remained stable for subjects in the partial hospitalization group.

One can conclude from this study that patients with borderline personality disorder treated with this program for 18 months showed significant improvement in terms of both symptoms and functioning. Reduction of symptoms and suicidal acts occurred after the first 6 months of treatment, but the differences in frequency and duration of inpatient treatment emerged only during the last 6 months of treatment. In addition, depressive symptoms were significantly reduced. Although the principal treatment received by subjects in the partial hospitalization group was psychoanalytic individual and group therapy, one cannot definitively attribute this group’s better outcome to the type of therapy received, since the overall community support and social network within which these therapies took place may have exerted significant effects. Pharmacotherapy received was similar in the two treatment groups, but subjects in the partial hospitalization program had a greater amount of psychotherapy than did the control subjects. In a subsequent report (10), patients who had received partial hospitalization treatment not only maintained their substantial gains at an 18-month follow-up evaluation but also showed statistically significant continued improvement on most measures, whereas the control group showed only limited change during the same period.

A study from Australia of twice-weekly psychodynamic therapy (20) prospectively compared the year before 12 months of psychodynamic therapy was given with the year after the therapy was received for a group of poorly functioning outpatients with borderline personality disorder. Among the 30 completers, there were significant reductions in violent behavior, use of illegal drugs, number of medical visits, self-harm, time away from work, severity of global symptoms, number of DSM-III symptoms of borderline personality disorder, number of hospital admissions, and time spent as an inpatient. Although this study did not include a control group, there were dramatic improvements in patients that support the value of the year-long treatment intervention.

In another study (21), this same group of 30 patients who received psychodynamic therapy was compared with 30 control subjects drawn from an outpatient waiting list who then received treatment as usual, consisting of supportive therapy, cognitive therapy, and crisis intervention. The control subjects were assessed at baseline and at varying intervals, with an average follow-up duration of 17.1 months. In this nonrandomized controlled study, the group receiving psychodynamic therapy had a significantly better outcome than the control subjects (i.e., fewer subjects in the treatment versus the control group still met DSM-III criteria for borderline personality disorder), even though the group that received psychodynamic therapy was more severely ill at baseline. This study suggests that psychodynamic therapy is efficacious, but the investigation has a number of limitations, including the lack of randomization, different follow-up durations for different subjects, nonblind assessment of outcome, and lack of detail about the amount of treatment received by the control subjects. Without more data on the amount of treatment received, it is unclear whether the better outcome of the subjects who received dynamic therapy was due to the type of therapy or the greater amount of treatment received.

Drug Class	Specific Medications Studied	Symptoms for Which Medication Is Recommended	Strength of Evidence^a	Issues
SSRIs and related antidepressants	Fluoxetine, sertraline, venlafaxine^b	Depressed mood, mood lability, rejection sensitivity, anxiety, impulsivity, self-mutilation, anger/hostility, psychoticism, and poor global functioning	A	Relatively safe in overdose; favorable side effect profile; evidence obtained from acute (6–14 weeks), continuation (up to 12 months), and maintenance (1–3 years) treatment trials; second SSRI trial may still be effective if first trial fails ("salvage strategy," strength of evidence=C)
MAOIs	Phenelzine, tranylcypromine	Mood reactivity, rejection sensitivity, impulsivity, irritability, anger/ hostility, atypical depression, hysteroid dysphoria	B	Second-line treatment after SSRI failure; complete elimination of initial SSRI required before MAOI treatment; adherence to required dietary restrictions problematic; effective for atypical depression only when borderline personality disorder is secondary, not primary, diagnosis
Mood stabilizers	Lithium carbonate	Mood lability, mood swings, anger, suicidality, impulsivity, poor global functioning	C	Can be used as primary or adjunctive treatment (overlaps with treatment of impulsive-behavioral domain); narrow margin of safety in overdose; blood level monitoring required; risk of hypothyroidism; to date, best studied of the mood stabilizers in treatment of personality disorders, but older literature focuses on reduction of impulsive behavior
	Carbamazepine	Suicidality, anxiety, anger, impulsivity	C	Efficacy in patients exhibiting hysteroid dysphoria; can precipitate melancholic depression; risk of bone marrow suppression; blood draws required to monitor WBC count
	Valproate	Global symptom severity, depressed mood, anger, impulsivity, rejection sensitivity, irritability, agitation, aggression, anxiety	C	Paucity of research support for this indication despite widespread use; blood draws required to monitor liver function
Benzodiazepines^c	Alprazolam, clonazepam	Refractory anxiety, impulsivity, agitation	C	Risk of abuse, tolerance; alprazolam associated with behavioral dyscontrol
Neuroleptics^c	Haloperidol	Behavioral dyscontrol, anger/hostility, assault, self-injury	A	Rapid onset of effect provides immediate control of behavior
^{aRatings used by Jobson and Potter (2): A=supported by two or more randomized, placebo-controlled, double-blind trials; B=supported by at least one randomized, placebo-controlled, double-blind trial; C=supported by open-label studies, case reports, and studies that do not meet standards of randomized, placebo-controlled, double-blind trials. See text for specific supporting studies. ^{bA mixed norepinephrine/serotonin reuptake blocker. ^{cAgents primarily used as adjunctive treatment.}}}