Practice Guideline for the Treatment of Patients With Borderline Personality Disorder

American Psychiatric Association

WORK GROUP ON BORDERLINE PERSONALITY DISORDER

John M. Oldham, M.D., Chair

Katharine A. Phillips, M.D., Consultant

Glen O. Gabbard, M.D.

Marcia K. Goin, M.D., Ph.D.

John Gunderson, M.D.

Paul Soloff, M.D.

David Spiegel, M.D.

Michael Stone, M.D.

STEERING COMMITTEE ON PRACTICE GUIDELINES

John S. McIntyre, M.D., Chair

Sara C. Charles, M.D., Vice-Chair

Kenneth Altshuler, M.D.

C. Deborah Cross, M.D.

Helen Egger, M.D.

Barry J. Landau, M.D.

Louis Alan Moench, M.D.

Allan Tasman, M.D.

Stuart W. Twemlow, M.D.

Sherwyn Woods, M.D., Ph.D.

Joel Yager, M.D.

CONSULTANTS AND LIAISONS

Paula Clayton, M.D. (Consultant)

Amarendra Das, M.D., Ph.D. (Liaison)

Marcia K. Goin, M.D., Ph.D. (Liaison)

Marion Goldstein, M.D. (Liaison)

Sheila Hafter Gray, M.D. (Consultant)

Margaret T. Lin, M.D. (Liaison)

Herbert Meltzer, M.D. (Consultant)

Grayson Norquist, M.D. (Consultant)

Susan Stabinsky, M.D. (Consultant)

Robert Johnston, M.D. (Area I)

James Nininger, M.D. (Area II)

Roger Peele, M.D. (Area III)

Anthony D�Agostino, M.D. (Area IV)

R. Scott Benson, M.D. (Area V)

Lawrence Lurie, M.D. (Area VI)

R. Dale Walker, M.D. (Area VII)

Michael B. First, M.D., Medical Editor, Quick Reference Guides

STAFF

Rebecca M. Thaler, M.P.H., C.H.E.S., Senior Project Manager

Robert Kunkle, M.A., Project Manager

Althea Simpson, Project Coordinator

Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services

Lloyd I. Sederer, M.D., Director, Division of Clinical Services

STATEMENT OF INTENT vii

GUIDE TO USING THIS PRACTICE GUIDELINE viii

INTRODUCTION ix

OVERVIEW OF GUIDELINE DEVELOPMENT PROCESS x

Part A: TREATMENT RECOMMENDATIONS FOR PATIENTS WITH
BORDERLINE PERSONALITY DISORDER 1

I. EXECUTIVE SUMMARY OF RECOMMENDATIONS 1

A. Coding System 1

B. General Considerations 1

C. Summary of Recommendations 1

II. FORMULATION AND IMPLEMENTATION OF A TREATMENT PLAN 6

A. The Initial Assessment 6

B. Principles of Psychiatric Management 8

C. Principles of Treatment Selection 12

D. Specific Treatment Strategies for the Clinical Features of Borderline Personality Disorder 14

III. SPECIAL FEATURES INFLUENCING TREATMENT 27

A. Comorbidity 27

B. Problematic Substance Use 27

C. Violent Behavior and Antisocial Traits 28

D. Chronic Self-Destructive Behavior 29

E. Childhood Trauma and PTSD 29

F. Dissociative Features 31

G. Psychosocial Stressors 32

H. Gender 33

I. Cultural Factors 34

J. Age 34

IV. RISK MANAGEMENT ISSUES 35

A. General Considerations 35

B. Suicide 35

C. Anger, Impulsivity, and Violence 36

D. Boundary Violations 37

Part B: BACKGROUND INFORMATION AND REVIEW OF AVAILABLE EVIDENCE 38

V. DISEASE DEFINITION, EPIDEMIOLOGY, AND NATURAL HISTORY 38

 

A. Definition and Core Clinical Features 38

B. Assessment 40

C. Differential Diagnosis 41

D. Epidemiology 41

E. Natural History and Course 42

VI. REVIEW AND SYNTHESIS OF AVAILABLE EVIDENCE 43

 

A. Issues in Interpreting the Literature 43

B. Review of Psychotherapy and Other Psychosocial Treatments 44

C. Review of Pharmacotherapy and Other Somatic Treatments 55

Part C: FUTURE RESEARCH NEEDS 69

VII.  PSYCHOTHERAPY 69

VIII.  Pharmacotherapy and Other Somatic Treatments 70

Appendixes: Psychopharmacological Treatment Algorithm 71

INDIVIDUALS AND ORGANIZATIONS That SUBMITTED COMMENTS 74

References 75

 

STATEMENT OF INTENT

This report is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.

This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors have received income related to treatments discussed in this guideline. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. The guideline has been extensively reviewed by members of APA as well as by representatives from related fields. Contributors and reviewers have all been asked to base their recommendations on an objective evaluation of available evidence. Any contributor or reviewer who has a potential conflict of interest that may bias (or appear to bias) his or her work has been asked to notify the APA Department of Quality Improvement and Psychiatric Services. This potential bias is then discussed with the work group chair and the chair of the Steering Committee on Practice Guidelines. Further action depends on the assessment of the potential bias.

This practice guideline was approved in July 2001 and published in October 2001.

GUIDE TO USING THIS PRACTICE GUIDELINE

This practice guideline offers treatment recommendations based on available evidence and clinical consensus to help psychiatrists develop plans for the care of adult patients with borderline personality disorder. This guideline contains many sections, not all of which will be equally useful for all readers. The following guide is designed to help readers find the sections that will be most useful to them.

Part A contains the treatment recommendations for patients with borderline personality disorder. Section I is the summary of treatment recommendations, which includes the main treatment recommendations along with codes that indicate the degree of clinical confidence in each recommendation. Section II is a guide to the formulation and implementation of a treatment plan for the individual patient. This section includes all of the treatment recommendations. Section III, "Special Features Influencing Treatment," discusses a range of clinical considerations that could alter the general recommendations discussed in Section II. Section IV addresses risk management issues that should be considered when treating patients with borderline personality disorder.

Part B, "Background Information and Review of Available Evidence," presents, in detail, the evidence underlying the treatment recommendations of Part A. Section V provides an overview of DSM-IV-TR criteria, prevalence rates for borderline personality disorder, and general information on its natural history and course. Section VI is a structured review and synthesis of published literature regarding the available treatments for borderline personality disorder.

Part C, "Future Research Needs," draws from the previous sections to summarize those areas in which better research data are needed to guide clinical decisions.

INTRODUCTION

This practice guideline summarizes data regarding the care of patients with borderline personality disorder.

Borderline personality disorder is the most common personality disorder in clinical settings, and it is present in cultures around the world. However, this disorder is often incorrectly diagnosed or underdiagnosed in clinical practice. Borderline personality disorder causes marked distress and impairment in social, occupational, and role functioning, and it is associated with high rates of self-destructive behavior (e.g., suicide attempts) and completed suicide.

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. These characteristics begin by early adulthood and are present in a variety of contexts. The diagnostic criteria are shown in . For the diagnosis to be given, five of nine criteria must be present. The polythetic nature of the criteria set reflects the heterogeneity of the disorder. The core features of borderline personality disorder can also be conceptualized as consisting of a number of psychopathological dimensions (e.g., impulsivity, affective instability). A more complete description of the disorder, including its clinical features, assessment, differential diagnosis, epidemiology, and natural history and course, is provided in Part B of this guideline.

This guideline reviews the treatment that patients with borderline personality disorder may need. Psychiatrists care for patients in many different settings and serve a variety of functions and thus should either provide or recommend the appropriate treatment for patients with borderline personality disorder. In addition, many patients have comorbid conditions that may need treatment. Therefore, psychiatrists caring for patients with borderline personality disorder should consider, but not be limited to, treatments recommended in this guideline.

Table 1

Diagnostic Criteria for Borderline Personality Disorder a

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) Frantic efforts to avoid real or imagined abandonmentb

(2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) Identity disturbance: markedly and persistently unstable self-image or sense of self

(4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)b

(5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) Chronic feelings of emptiness

(8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) Transient, stress-related paranoid ideation or severe dissociative symptoms

aFrom DSM-IV-TR (1).

bExcluding suicidal or self-mutilating behavior (covered in criterion 5).

OVERVIEW OF GUIDELINE DEVELOPMENT PROCESS

This document is a practical guide to the management of patients�primarily adults over the age of 18�with borderline personality disorder and represents a synthesis of current scientific knowledge and rational clinical practice. This guideline strives to be as free as possible of bias toward any theoretical approach to treatment.

This practice guideline was developed under the auspices of the Steering Committee on Practice Guidelines. The process is detailed in a document available from the APA Department of Quality Improvement and Psychiatric Services: the "APA Guideline Development Process." Key features of the process include the following

A comprehensive literature review and development of evidence tables
Initial drafting by a work group that included psychiatrists with clinical and research expertise in borderline personality disorder
The production of multiple drafts with widespread review, in which 13 organizations and more than 60 individuals submitted significant comments
Approval by the APA Assembly and Board of Trustees
Planned revisions at regular intervals.
A computerized search of the relevant literature from MEDLINE and PsycINFO was conducted.

The first literature search was conducted by searching MEDLINE for the period from 1966 to December 1998 and used the key words "borderline personality disorder," "therapy," "drug therapy," "psychotherapy," "pharmacotherapy," "psychopharmacology," "group psychotherapy," "hysteroid dysphoria," "parasuicidal," "emotionally unstable," and "treatment." A total of 1,562 citations were found.

The literature search conducted by using PsycINFO covered the period from 1967 to November 1998 and used the key words "borderline personality disorder," "hysteroid dysphoria," "parasuicidal," "emotionally unstable," "therapy," "treatment," "psychopharmacology," "pharmacotherapy," "borderline states," "cognitive therapy," "drug therapy," "electroconvulsive shock therapy," "family therapy," "group therapy," "insulin shock therapy," "milieu therapy," "occupational therapy," "psychoanalysis," and "somatic treatment." A total of 2,460 citations were found.

An additional literature search was conducted by using MEDLINE for the period from 1990 to 1999 and the key words "self mutilation" and "mental retardation." A total of 182 citations were found.

Additional, less formal literature searches were conducted by APA staff and individual members of the work group on borderline personality disorder.

The recommendations are based on the best available data and clinical consensus. The summary of treatment recommendations is keyed according to the level of confidence with which each recommendation is made. In addition, each reference is followed by a letter code in brackets that indicates the nature of the supporting evidence.

PART A:
Treatment RECOMMENDATIONS FOR PATIENTS WITH BORDERLINE PERSONALITY DISORDER

I. EXECUTIVE SUMMARY OF RECOMMENDATIONS

A. Coding System

Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation:

Recommended with substantial clinical confidence
Recommended with moderate clinical confidence
May be recommended on the basis of individual circumstances.

B. General Considerations

Borderline personality disorder is the most common personality disorder in clinical settings. It is characterized by marked distress and functional impairment, and it is associated with high rates of self-destructive behavior (e.g., suicide attempts) and completed suicide. The care of patients with borderline personality disorder involves a comprehensive array of approaches. This guideline presents treatment options and addresses factors that need to be considered when treating a patient with borderline personality disorder.

C. Summary of Recommendations

1. The initial assessment

The psychiatrist first performs an initial assessment of the patient to determine the treatment setting [I]. Because suicidal ideation and suicide attempts are common, safety issues should be given priority, and a thorough safety evaluation should be done. This evaluation, as well as consideration of other clinical factors, will determine the necessary treatment setting (e.g., outpatient or inpatient). A more comprehensive evaluation of the patient should then be completed [I]. It is important at the outset of treatment to establish a clear and explicit treatment framework [I], which includes establishing agreement with the patient about the treatment goals.

2. Psychiatric management

Psychiatric management forms the foundation of treatment for all patients. The primary treatment for borderline personality disorder is psychotherapy, complemented by symptom-targeted pharmacotherapy [I]. In addition, psychiatric management consists of a broad array of ongoing activities and interventions that should be instituted by the psychiatrist for all patients with borderline personality disorder [I]. Regardless of the specific primary and adjunctive treatment modalities selected, it is important to continue providing psychiatric management throughout the course of treatment. The components of psychiatric management for patients with borderline personality disorder include responding to crises and monitoring the patient�s safety, establishing and maintaining a therapeutic framework and alliance, providing education about borderline personality disorder and its treatment, coordinating treatment provided by multiple clinicians, monitoring the patient�s progress, and reassessing the effectiveness of the treatment plan. The psychiatrist must also be aware of and manage potential problems involving splitting (see section II.B.6.a.) and boundaries (see section II.B.6.b.).

3. Principles of treatment selection

a) Type

Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective in the treatment of borderline personality disorder [I]. Although it has not been empirically established that one approach is more effective than another, clinical experience suggests that most patients with borderline personality disorder will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning [II]. Pharmacotherapy often has an important adjunctive role, especially for diminution of symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior [I]. No studies have compared a combination of psychotherapy and pharmacotherapy to either treatment alone, but clinical experience indicates that many patients will benefit most from a combination of these treatments [II].

b) Focus

Treatment planning should address borderline personality disorder as well as comorbid axis I and axis II disorders, with priority established according to risk or predominant symptoms [I].

c) Flexibility

Because comorbid disorders are often present and each patient�s history is unique, and because of the heterogeneous nature of borderline personality disorder, the treatment plan needs to be flexible, adapted to the needs of the individual patient [I]. Flexibility is also needed to respond to the changing characteristics of patients over time.

d) Role of patient preference

Treatment should be a collaborative process between patient and clinician(s), and patient preference is an important factor to consider when developing an individual treatment plan [I].

e) Multiple- versus single-clinician treatment

Treatment by a single clinician and treatment by more than one clinician are both viable approaches [II]. Treatment by multiple clinicians has potential advantages but may become fragmented; good collaboration among treatment team members and clarity of roles are essential [I].

4. Specific treatment strategies

a) Psychotherapy

Two psychotherapeutic approaches have been shown in randomized controlled trials to have efficacy: psychoanalytic/psychodynamic therapy and dialectical behavior therapy [I]. The treatment provided in these trials has three key features: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/supervision. No results are available from direct comparisons of these two approaches to suggest which patients may respond better to which type of treatment. Although brief therapy for borderline personality disorder has not been systematically examined, studies of more extended treatment suggest that substantial improvement may not occur until after approximately 1 year of psychotherapeutic intervention has been provided; many patients require even longer treatment.

Clinical experience suggests that there are a number of common features that help guide the psychotherapist, regardless of the specific type of therapy used [I]. These features include building a strong therapeutic alliance and monitoring self-destructive and suicidal behaviors. Some therapists create a hierarchy of priorities to consider in the treatment (e.g., first focusing on suicidal behavior). Other valuable interventions include validating the patient�s suffering and experience as well as helping the patient take responsibility for his or her actions. Because patients with borderline personality disorder may exhibit a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy. Other components of effective therapy for patients with borderline personality disorder include managing feelings (in both patient and therapist), promoting reflection rather than impulsive action, diminishing the patient�s tendency to engage in splitting, and setting limits on any self-destructive behaviors.

Individual psychodynamic psychotherapy without concomitant group therapy or other partial hospital modalities has some empirical support [II]. The literature on group therapy or group skills training for patients with borderline personality disorder is limited but indicates that this treatment may be helpful [II]. Group approaches are usually used in combination with individual therapy and other types of treatment. The published literature on couples therapy is limited but suggests that it may be a useful and, at times, essential adjunctive treatment modality. However, it is not recommended as the only form of treatment for patients with borderline personality disorder [II]. While data on family therapy are also limited, they suggest that a psychoeducational approach may be beneficial [II]. Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment; family therapy is not recommended as the only form of treatment for patients with borderline personality disorder [II].

b) Pharmacotherapy and other somatic treatment

Pharmacotherapy is used to treat state symptoms during periods of acute decompensation as well as trait vulnerabilities. Symptoms exhibited by patients with borderline personality disorder often fall within three behavioral dimensions�affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual difficulties�for which specific pharmacological treatment strategies can be used.

i) Treatment of affective dysregulation symptoms

Patients with borderline personality disorder displaying this dimension exhibit mood lability, rejection sensitivity, inappropriate intense anger, depressive "mood crashes," or outbursts of temper. These symptoms should be treated initially with a selective serotonin reuptake inhibitor (SSRI) or related antidepressant such as venlafaxine [I]. Studies of tricyclic antidepressants have produced inconsistent results. When affective dysregulation appears as anxiety, treatment with an SSRI may be insufficient, and addition of a benzodiazepine should be considered, although research on these medications in patients with borderline personality disorder is limited, and their use carries some potential risk [III].

When affective dysregulation appears as disinhibited anger that coexists with other affective symptoms, SSRIs are also the treatment of choice [II]. Clinical experience suggests that for patients with severe behavioral dyscontrol, low-dose neuroleptics can be added to the regimen for rapid response and improvement of affective symptoms [II].

Although the efficacy of monoamine oxidase inhibitors (MAOIs) for affective dysregulation in patients with borderline personality disorder has strong empirical support, MAOIs are not a first-line treatment because of the risk of serious side effects and the difficulties with adherence to required dietary restrictions [I]. Mood stabilizers (lithium, valproate, carbamazepine) are another second-line (or adjunctive) treatment for affective dysregulation, although studies of these approaches are limited [II]. There is a paucity of data on the efficacy of ECT for treatment of affective dysregulation symptoms in patients with borderline personality disorder. Clinical experience suggests that while ECT may sometimes be indicated for patients with comorbid severe axis I depression that is resistant to pharmacotherapy, affective features of borderline personality disorder are unlikely to respond to ECT [II].

An algorithm depicting steps that can be taken in treating symptoms of affective dysregulation in patients with borderline personality disorder is shown in Appendix 1.

ii) Treatment of impulsive-behavioral dyscontrol symptoms

Patients with borderline personality disorder displaying this dimension exhibit impulsive aggression, self-mutilation, or self-damaging behavior (e.g., promiscuous sex, substance abuse, reckless spending). As seen in Appendix 2, SSRIs are the initial treatment of choice [I]. 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 [II]. Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium [II]. If an SSRI is ineffective, switching to an MAOI may be considered [II]. Use of valproate or carbamazepine may also be considered for impulse control, although there are few studies of these treatments for impulsive aggression in patients with borderline personality disorder [II]. Preliminary evidence suggests that atypical neuroleptics may have some efficacy for impulsivity in patients with borderline personality disorder [II].

iii) Treatment of cognitive-perceptual symptoms

Patients with borderline personality disorder displaying this dimension exhibit suspiciousness, referential thinking, paranoid ideation, illusions, derealization, depersonalization, or hallucination-like symptoms. As seen in Appendix 3, low-dose neuroleptics are the treatment of choice for these symptoms [I]. These medications may improve not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. If response is suboptimal, the dose should be increased to a range suitable for treating axis I disorders [II].

5. Special features influencing treatment

Treatment planning and implementation should reflect consideration of the following characteristics: comorbidity with axis I and other axis II disorders, problematic substance use, violent behavior and antisocial traits, chronic self-destructive behavior, trauma and posttraumatic stress disorder (PTSD), dissociative features, psychosocial stressors, gender, age, and cultural factors [I]

6. Risk management issues

Attention to risk management issues is important [I]. Risk management considerations include the need for collaboration and communication with any other treating clinicians as well as the need for careful and adequate documentation. Any problems with transference and countertransference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. Standard guidelines for terminating treatment should be followed in all cases. Psychoeducation about the disorder is often appropriate and helpful. Other clinical features requiring particular consideration of risk management issues are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behavior.

II. FORMULATION AND IMPLEMENTATION OF A TREATMENT PLAN

When the psychiatrist first meets with a patient who may have borderline personality disorder, a number of important issues related to differential diagnosis, etiology, the formulation, and treatment planning need to be considered. The psychiatrist performs an initial assessment to determine the treatment setting, completes a comprehensive evaluation (including differential diagnosis), and works with the patient to mutually establish the treatment framework. The psychiatrist also attends to a number of principles of psychiatric management that form the foundation of care for patients with borderline personality disorder. The psychiatrist next considers several principles of treatment selection (e.g., type, focus, number of clinicians to involve). Finally, the psychiatrist selects specific treatment strategies for the clinical features of borderline personality disorder.

A. The Initial Assessment

1. Initial assessment and determination of the treatment setting

The psychiatrist first performs an initial assessment of the patient and determines the treatment setting (e.g., inpatient or outpatient). Since patients with borderline personality disorder commonly experience suicidal ideation (and 8%�10% commit suicide), safety issues should be given priority in the initial assessment (see section II.B.1., "Responding to Crises and Safety Monitoring," for a further discussion of this issue). A thorough safety evaluation should be done before a decision can be reached about whether outpatient, inpatient, or another level of care (e.g., partial hospitalization or residential care) is needed. Presented here are some of the more common indications for particular levels of care. However, this list is not intended to be exhaustive. Since indications for level of care are difficult to empirically investigate and studies are lacking, these recommendations are derived primarily from expert clinical opinion.

Indications for partial hospitalization (or brief inpatient hospitalization if partial hospitalization is not available) include the following:

Dangerous, impulsive behavior unable to be managed with outpatient treatment
Nonadherence with outpatient treatment and a deteriorating clinical picture
Complex comorbidity that requires more intensive clinical assessment of response to treatment
Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment
Indications for brief inpatient hospitalization include the following:

Imminent danger to others
Loss of control of suicidal impulses or serious suicide attempt
Transient psychotic episodes associated with loss of impulse control or impaired judgment
Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment and partial hospitalization
Indications for extended inpatient hospitalization include the following:

Persistent and severe suicidality, self-destructiveness, or nonadherence to outpatient treatment or partial hospitalization

Comorbid refractory axis I disorder (e.g., eating disorder, mood disorder) that presents a potential threat to life

Comorbid substance abuse or dependence that is severe and unresponsive to outpatient treatment or partial hospitalization

Continued risk of assaultive behavior toward others despite brief hospitalization
Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment, partial hospitalization, and brief hospitalization
2. Comprehensive evaluation

Once an initial assessment has been done and the treatment setting determined, a more comprehensive evaluation should be completed as soon as clinically feasible. Such an evaluation includes assessing the presence of comorbid disorders, degree and type of functional impairment, needs and goals, intrapsychic conflicts and defenses, developmental progress and arrests, adaptive and maladaptive coping styles, psychosocial stressors, and strengths in the face of stressors (see Part B, section V.B., "Assessment"). The psychiatrist should attempt to understand the biological, interpersonal, familial, social, and cultural factors that affect the patient (3).

Special attention should be paid to the differential diagnosis of borderline personality disorder versus axis I conditions (see Part B, sections V.A.2., "Comorbidity," and V.C., "Differential Diagnosis"). Treatment planning should address comorbid disorders from axis I (e.g., substance use disorders, depressive disorders, PTSD) and axis II as well as borderline personality disorder, with priority established according to risk or predominant symptoms. When priority is given to treating comorbid conditions (e.g., substance abuse, depression, PTSD, or an eating disorder), it may be helpful to caution patients or their families about the expected rate of response or extent of improvement. The prognosis for treatment of these axis I disorders is often poorer when borderline personality disorder is present. It is usually better to anticipate realistic problems than to encourage unrealistically high hopes.

3. Establishing the treatment framework

It is important at the outset of treatment to establish a clear and explicit treatment framework. This is sometimes called "contract setting." While this process is generally applicable to the treatment of all patients, regardless of diagnosis, such an agreement is particularly important for patients with borderline personality disorder. The clinician and the patient can then refer to this agreement later in the treatment if the patient challenges it.

Patients and clinicians should establish agreements about goals of treatment sessions (e.g., symptom reduction, personal growth, improvement in functioning) and what role each is expected to perform to achieve these goals. Patients, for example, are expected to report on such issues as conflicts, dysfunction, and impending life changes. Clinicians are expected to offer understanding, explanations for treatment interventions, undistracted attention, and respectful, compassionate attitudes, with judicious feedback to patients that can help them attain their goals. In addition, it is essential for patients and clinicians to work toward establishing agreements about 1) when, where, and with what frequency sessions will be held; 2) a plan for crises management; 3) clarification of the clinician�s after-hours availability; and 4) the fee, billing, and payment schedule.

B. Principles of Psychiatric Management

Psychiatric management forms the foundation of psychiatric treatment for patients with borderline personality disorder. It consists of an array of ongoing activities and interventions that should be instituted for all patients. These include providing education about borderline personality disorder, facilitating adherence to a psychotherapeutic or psychopharmacological regimen that is satisfactory to both the patient and psychiatrist, and attempting to help the patient solve practical problems, giving advice and guidance when needed.

Specific components of psychiatric management are discussed here as well as additional important issues�such as the potential for splitting and boundary problems� that may complicate treatment and of which the clinician must be aware and manage.

1. Responding to crises and safety monitoring

Psychiatrists should assume that crises, such as interpersonal crises or self-destructive behavior, will occur. Psychiatrists may wish to establish an explicit understanding about what they expect a patient to do during crises and may want to be explicit about what the patient can expect from them. While some clinicians believe that this is of critical importance (4, 5), others believe that this approach is too inflexible and potentially adversarial. From the latter perspective, there is often a tension between the psychiatrist�s role in helping patients to understand their behavior and the psychiatrist�s role in ensuring patients� safety and in managing problematic behaviors. This tension may be particularly prominent when the psychiatrist is using a psychodynamic approach that relies heavily on interpretation and exploration. Regardless of the psychotherapeutic strategy, however, the psychiatrist has a fundamental responsibility to monitor this tension as part of the treatment process.

Patients with borderline personality disorder commonly experience suicidal ideation and are prone to make suicide attempts or engage in self-injurious behavior (e.g., cutting). Monitoring patients� safety is a critically important task. It is important that psychiatrists always evaluate indicators of self-injurious or suicidal ideas and reformulate the treatment plan as appropriate. Serious self-harm can occur if the potential danger is ignored or minimized. Before intervening to prevent self-endangering behaviors, the psychiatrist should first assess the potential danger, the patient�s motivations, and to what extent the patient can manage his or her safety without external interventions (6). When the patient�s safety is judged to be at serious risk, hospitalization may be indicated. Even in the context of appropriate treatment, some patients with borderline personality disorder will commit suicide.

2. Establishing and maintaining a therapeutic framework and alliance

Patients with borderline personality disorder have difficulty developing and sustaining trusting relationships. This issue may be a focus of treatment as well as a significant barrier to the development of the treatment alliance necessary to carry out the treatment plan. Therefore, the psychiatrist should pay particular attention to ascertaining that the patient agrees with and accepts the treatment plan; adherence or agreement cannot be assumed. Agreements should be explicit.

The first aspect of alliance building, referred to earlier as "contract setting," is establishing an agreement about respective roles and responsibilities and treatment goals. The next aspect of alliance building is to encourage patients to be actively engaged in the treatment, both in their tasks (e.g., monitoring medication effects or noting and reflecting on their feelings) and in the relationship (e.g., disclosing reactions or wishes to the clinician). This can be accomplished by focusing attention on whether the patient 1) understands and accepts what the psychiatrist says and 2) seems to feel understood and accepted by the psychiatrist. Techniques such as confrontation or interpretation may be appropriate over the long term after a "working alliance" (collaboration over a task) has been established. Psychotherapeutic approaches are often helpful in developing a working alliance for a pharmacotherapy component of the treatment plan. Reciprocally, the experience of being helped by medication that the psychiatrist prescribed can help a patient develop trust in his or her psychotherapeutic interventions.

3. Providing education about the disorder and its treatment

Psychoeducational methods often are helpful and generally are welcomed by patients and, when appropriate, their families. At an appropriate point in treatment, patients should be familiarized with the diagnosis, including its expected course, responsiveness to treatment, and, when appropriate, pathogenic factors. Many patients with borderline personality disorder profit from ongoing education about self-care (e.g., safe sex, potential legal problems, balanced diet). Formal psychoeducational approaches may include having the patient read the text of DSM-IV-TR or books on borderline personality disorder written for laypersons. Some clinicians prefer to frame psychoeducational discussions in everyday terms and use the patient�s own language to negotiate a shared understanding of the major areas of difficulty without turning to a text or manual. More extensive psychoeducational intervention, consisting of workshops, lectures, or seminars, may also be helpful.

Families or others�especially those who are younger�living with individuals with borderline personality disorder will also often benefit from psychoeducation about the disorder, its course, and its treatment. It is wise to introduce information about pathogenic issues that may involve family members with sensitivity to the information�s likely effects (e.g., it may evoke undesirable reactions of guilt, anger, or defensiveness). Psychoeducation for families should be distinguished from family therapy, which is sometimes a desirable part of the treatment plan and sometimes not, depending on the patient�s history and status of current relationships.

4. Coordinating the treatment effort

Providing optimal treatment for patients with borderline personality disorder who may be dangerously self-destructive frequently requires a treatment team that involves several clinicians. If the team members work collaboratively, the overall treatment will usually be enhanced by being better able to help patients contain their acting out (via fight or flight) and their projections onto others. It is essential that ongoing coordination of the overall treatment plan is assured by clear role definitions, plans for management of crises, and regular communication among the clinicians.

The team members must also have a clear agreement about which clinician is assuming the primary overall responsibility for the patient�s safety and treatment. This individual serves as a gatekeeper for the appropriate level of care (whether it be hospitalization, residential treatment, or day hospitalization), oversees the family involvement, makes decisions regarding which potential treatment modalities are useful or should be discontinued, helps assess the impact of medications, and monitors the patient�s safety. Because of the diversity of knowledge and expertise required for this oversight function, a psychiatrist is usually optimal for this role.

5. Monitoring and reassessing the patient�s clinical status and treatment plan

With all forms of treatment, it is important to monitor the treatment�s effectiveness in an ongoing way. Often the course of treatment is uneven, with periodic setbacks (e.g., at times of stress). Such setbacks do not necessarily indicate that the treatment is ineffective. Nonetheless, ultimate improvement should be a reasonably expected outcome.

a) Recognizing functional regression

Patients with borderline personality disorder sometimes regress early in treatment as they begin to engage in the treatment process, getting somewhat worse before they get better. However, sustained deterioration is a problem that requires attention. Examples of such regressive phenomena include dysfunctional behavior (e.g., cessation of work, increased suicidality, onset of compulsive overeating) or immature behavior. This may occur when patients believe that they no longer need to be as responsible for taking care of themselves, thinking that their needs can and will now be met by those providing treatment.

Clinicians should be prepared to recognize this effect and then explore with patients whether their hope for such care is realistic and, if so, whether it is good for their long-term welfare. When the decline of functioning is sustained, it may mean that the focus of treatment needs to shift from exploration to other strategies (e.g., behavioral modification, vocational counseling, family education, or limit setting). Of special significance is that such declines in function are likely to occur when patients with borderline personality disorder have reductions in the intensity or amount of support they receive, such as moving to a less intensive level of care. Clinicians need to be alert to the fact that such regressions may reflect the need to add support or structure temporarily to the treatment by way of easing the transition to less intensive treatment. Regressions may also occur when patients perceive particularly sympathetic, nurturant, or protective inclinations in those who are providing their care. Under these circumstances, clinicians need to clarify that these inclinations do not signify a readiness to take on a parenting role.

b) Treating symptoms that reappear despite continued pharmacotherapy

An issue that frequently requires assessment and response by psychiatrists is the sustained return of symptoms, the previous remission of which had been attributed, at least in part, to medications (although placebo effects may also have been involved). Assessment of such symptom "breakthroughs" requires knowledge of the patient�s symptom presentation before the use of medication. Has the full symptom presentation returned? Are the current symptoms sustained over time, or do they reflect transitory and reactive moods in response to an interpersonal crisis? Medications can modulate the intensity of affective, cognitive, and impulsive symptoms, but they should not be expected to extinguish feelings of anger, sadness, and pain in response to separations, rejections, or other life stressors. When situational precipitants are identified, the clinician�s primary focus should be to facilitate improved coping. Frequent medication changes in pursuit of improving transient mood states are unnecessary and generally ineffective. The patient should not be given the erroneous message that emotional responses to life events are merely biologic symptoms to be regulated by medications.

c) Obtaining consultations

Clinicians with overall or primary responsibilities for patients with borderline personality disorder should have a low threshold for seeking consultation because of 1) the high frequency of countertransference reactions and medicolegal liability complications; 2) the high frequency of complicated multitreater, multimodality treatments; and 3) the particularly high level of inference, subjectivity, and life/death significance that clinical judgments involve. The principle that should guide whether a consultation is obtained is that improvement (e.g., less distress, more adaptive behaviors, greater trust) is to be expected during treatment. Thus, failure to show improvement in targeted goals by 6�12 months should raise considerations of introducing changes in the treatment. When a patient continues to do poorly after the treatment has been modified, consultation is indicated as a way of introducing and implementing treatment changes. When a consultant believes that the existing treatment cannot be improved, this offers support for continuing this treatment.

6. Special issues

a) Splitting

The phenomenon of "splitting" signifies an inability to reconcile alternative or opposing perceptions or feelings within the self or others, which is characteristic of borderline personality disorder. As a result, patients with borderline personality disorder tend to see people or situations in "black or white," "all or nothing," "good or bad" terms. In clinical settings, this phenomenon may be evident in their polarized but alternating views of others as either idealized (i.e., "all good") or devalued (i.e., "all bad"). When they perceive primary clinicians as "all bad" (usually prompted by feeling frustrated), this may precipitate flight from treatment. When splitting threatens continuation of the treatment, clinicians should be prepared to examine the transference and countertransference and consider altering treatment. This can be done by offering increased support, by seeking consultation, or by otherwise suggesting changes in the treatment. Clinicians should always arrange to communicate regularly about their patients to avoid splitting within the treatment team (i.e., one clinician or treatment is idealized while another is devalued). Integration of the clinicians helps patients integrate their internal splits.

b) Boundaries

Clinicians/therapists vary considerably in their tolerance for patient behaviors (e.g., phone calls, silences) and in their expectations of the patient (e.g., promptness, personal disclosures, homework between sessions). It is important to be explicit about these issues, thereby establishing "boundaries" around the treatment relationship and task. It is also important to be consistent with agreed-upon boundaries. Although patients may agree to such boundaries, some patients with borderline personality disorder will attempt to cross them (e.g., request between-session contacts or seek a personal, nonprofessional relationship). It remains the therapist�s responsibility to monitor and sustain the treatment boundaries. Certain situations�e.g., practicing in a small community, rural area, or military setting�may complicate the task of maintaining treatment boundaries (7).

To diminish the problems associated with boundary issues, clinicians should be alert to their occurrence. Clinicians should then be proactive in exploring the meaning of the boundary crossing�whether it originated in their own behavior or that of the patient. After efforts are made to examine the meaning, whether the outcome is satisfactory or not, clinicians should restate their expectations about the treatment boundaries and their rationale. If the patient keeps testing the agreed-upon framework of therapy, clinicians should explicate its rationale. An example of this rationale is, "There are times when I may not answer your personal questions if I think it would be better for us to know why you�ve inquired." If a patient continues to challenge the framework despite exploration and clarification, a limit will eventually need to be set. An example of setting a limit is, "You recall that we agreed that if you feel suicidal, then you will go to an emergency room. If you cannot do this then your treatment may need to be changed."

When a boundary is crossed by the clinician/therapist, it is called a boundary "violation." The boundary can usually be restored with comments like the following: "If I were to call you every time I�m worried, your safety might come to depend too much on my intuition," or "Whenever I tell you something about my personal life, it limits our opportunity to understand more about what you imagine in the absence of knowing." When therapists find themselves making exceptions to their usual treatment boundaries, it is important to examine their motives (see section IV., "Risk Management Issues"). It often signals the need for consultation or supervision.

Any consideration of sexual boundary violations by therapists must begin with a caveat: Patients can never be blamed for ethical transgressions by their therapists. It is the therapist�s responsibility to act ethically, no matter how the patient may behave. Nevertheless, specific transference-countertransference enactments are at high risk for occurring with patients with borderline personality disorder. If a patient has experienced neglect and abuse in childhood, he or she may wish for the therapist to provide the love the patient missed from parents. Therapists may have rescue fantasies that lead them to collude with the patient�s wish for the therapist to offer that love. This collusion in some cases leads to physical contact and even inappropriate physical contact between therapist and patient. Clinicians should be alert to these dynamics and seek consultation or personal psychotherapy or both whenever there is a risk of a boundary violation. Sexual interactions between a therapist and a patient are always unethical. When this type of boundary violation occurs, the therapist should immediately refer the patient to another therapist and seek consultation or personal psychotherapy.

C. Principles of Treatment Selection

1. Type

Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective for the treatment of borderline personality disorder. Although it has not been empirically established that one approach is more effective than another, clinical experience suggests that most patients with borderline personality disorder will need some form of extended psychotherapy in order to resolve interpersonal problems and attain and maintain lasting improvements in their personality and overall functioning. Pharmacotherapy often has an important adjunctive role, especially for diminution of targeted symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior. However, pharmacotherapy is unlikely to have substantial effects on some interpersonal problems and some of the other primary features of the disorder. Although no studies have compared a combination of psychotherapy and pharmacotherapy with either treatment alone, clinical experience indicates that many patients will benefit most from a combination of psychotherapy and pharmacotherapy.

2. Focus

Patients with borderline personality disorder frequently have comorbid axis I and other axis II conditions. The nature of certain borderline characteristics often complicates the treatment provided, even when treatment is focused on a comorbid axis I condition. For example, chronic self-destructive behaviors in response to perceived abandonment, marked impulsivity, or difficulties in establishing a therapeutic alliance have been referred to as "therapy-interfering behaviors." Treatment planning should address comorbid axis I and axis II disorders as well as borderline personality disorder, with priority established according to risk or predominant symptoms. The coexisting presence of borderline personality disorder with axis I disorders is associated with a poorer outcome of a number of axis I conditions. Treatment should usually be focused on both axis I and axis II disorders to facilitate the treatment of axis I conditions as well as address problematic, treatment-interfering personality features of borderline personality disorder itself. For patients with axis I conditions and coexisting borderline traits who do not meet full criteria for borderline personality disorder, it may be sufficient to focus treatment on the axis I conditions alone, although the therapy should be monitored and the focus changed to include the borderline traits if necessary to ensure the success of the treatment.

3. Flexibility

Features of borderline personality disorder are of a heterogeneous nature. Some patients, for example, display prominent affective instability, whereas others exhibit marked impulsivity or antisocial traits. The many possible combinations of comorbid axis I and axis II disorders further contribute to the heterogeneity of the clinical picture. Because of this heterogeneity, and because of each patient�s unique history, the treatment plan needs to be flexible, adapted to the needs of the individual patient. Flexibility is also needed to respond to the changing characteristics of patients over time (e.g., at one point, the treatment focus may be on safety, whereas at another, it may be on improving relationships and functioning at work). Similarly, the psychiatrist may need to use different treatment modalities or refer the patient for adjunctive treatments (e.g., behavioral, supportive, or psychodynamic psychotherapy) at different times during the treatment.

4. Role of patient preference

Successful treatment is a collaborative process between the patient and the clinician. Patient preference is an important factor to consider when developing an individual treatment plan. The psychiatrist should explain and discuss the range of treatments available for the patient�s condition, the modalities he or she recommends, and the rationale for having selected them. He or she should take time to elicit the patient�s views about this provisional treatment plan and modify it to the extent feasible to take into account the patient�s views and preferences. The hazard of nonadherence makes it worthwhile to spend whatever time may be required to gain the patient�s assent to a viable treatment plan and his or her agreement to collaborate with the clinician(s) before any therapy is instituted.

5. Multiple- versus single-clinician treatment

Treatment can be provided by more than one clinician, each performing separate treatment tasks, or by a single clinician performing multiple tasks; both are viable approaches to treating borderline personality disorder. When there are multiple clinicians on the treatment team, they may be involved in a number of tasks, including individual psychotherapy, pharmacotherapy, group therapy, family therapy, or couples therapy or be involved as administrators on an inpatient unit, partial hospital setting, halfway house, or other living situation. Such treatment has a number of potential advantages. For example, it brings more types of expertise to the patient�s treatment, and multiple clinicians may better contain the patient�s self-destructive tendencies. However, because of patients� propensity for engaging in "splitting" (i.e., seeing one clinician as "good" and another as "bad") as well as the real-world difficulties of maintaining good collaboration with all other clinicians, the treatment has the potential to become fragmented. For this type of treatment to be successful, good collaboration of the entire treatment team and clarity of roles are essential (7). Regardless of whether treatment involves multiple clinicians or a single therapist, its effectiveness should be monitored over time, and it should be changed if the patient is not improving.

D. Specific Treatment Strategies for the Clinical Features of Borderline Personality Disorder

Although there is a long clinical tradition of treating borderline personality disorder, there are no well-designed studies comparing pharmacotherapy with psychotherapy. Nor are there any systematic investigations of the effects of combined medication and psychotherapy to either modality alone. Hence, in this section we will consider psychotherapy and pharmacotherapy separately, knowing that in clinical practice the two treatments are frequently combined. Indeed, many of the pharmacotherapy studies included patients with borderline personality disorder who were also in psychotherapy, and many patients in psychotherapy studies were also taking medication. A good deal of clinical wisdom supports the notion that carefully focused pharmacotherapy may enhance the patient�s capacity to engage in psychotherapy.

1. Psychotherapy

Two psychotherapeutic approaches have been shown to have efficacy in randomized controlled trials: psychoanalytic/psychodynamic therapy and dialectical behavior therapy. We emphasize that these are psychotherapeutic approaches because the trials that have demonstrated efficacy (8�10) have involved sophisticated therapeutic programs rather than simply the provision of individual psychotherapy. Both approaches have three key features: 1) weekly meetings with an individual therapist, 2) one or more weekly group sessions, and 3) meetings between therapists for consultation/supervision. No results are available from direct comparisons of the two approaches to suggest which patients may respond better to which modality.

Psychoanalytic/psychodynamic therapy and dialectical behavior therapy are described in more detail in Part B of this guideline (see section VI.B., "Review of Psychotherapy and Other Psychosocial Treatments"). One characteristic of both dialectical behavior therapy and psychoanalytic/psychodynamic therapy involves the length of treatment. Although brief therapy has not been systematically tested for patients with borderline personality disorder, the studies of extended treatment suggest that substantial improvement may not occur until after approximately 1 year of psychotherapeutic intervention has been provided and that many patients require even longer treatment.

In addition, clinical experience suggests that there are a number of "common features" that help guide the psychotherapist who is treating a patient with borderline personality disorder, regardless of the specific type of therapy used. The psychotherapist must emphasize the building of a strong therapeutic alliance with the patient to withstand the frequent affective storms within the treatment (11, 12). This process of building a positive working relationship is greatly enhanced by careful attention to specific goals for the treatment that both patient and therapist view as reasonable and attainable. Consolidation of a therapeutic alliance is facilitated as well by the establishment of clear boundaries within and around the treatment. Clinicians may find it useful to keep in mind that often patients will attempt to redefine, cross, or even violate boundaries as a test to see whether the treatment situation is safe enough for them to reveal their feelings to the therapist. Regular meeting times with firm expectation of attendance and participation are important as well as an understanding of the relative contributions of patient and therapist to the treatment process (12).

Therapists need to be active, interactive, and responsive to the patient. Self-destructive and suicidal behaviors need to be actively monitored. As seen in Figure 1, some therapists create a hierarchy of priorities to be considered in the treatment. For example, practitioners of dialectical behavior therapy (5) might consider suicidal behaviors first, followed by behaviors that interfere with therapy and then behaviors that interfere with quality of life. Practitioners of psychoanalytic or psychodynamic therapy (4, 13) might construct a similar hierarchy.

Figure 1

Treatment Priorities of Two Psychotherapeutic Approaches for Patients With Borderline Personality Disordera

aSpecific behaviors that practitioners of each approach may encounter in patients with borderline personality disorder are presented, with those of highest priority sitting atop the "ladder"; treatment priority lessens as one goes down the ladder.

bAs described by Linehan et al. (5).

cAs described by Kernberg et al. (4) and Clarkin et al. (13).

Many patients with borderline personality disorder have experienced considerable childhood neglect and abuse, so an empathic validation of the reality of that mistreatment and the suffering it has caused is a valuable intervention (12, 14�17). This process of empathizing with the patient�s experience is also valuable in building a stronger therapeutic alliance (11) and paving the way for interpretive comments.

While validating patients� suffering, therapists must also help them take appropriate responsibility for their actions. Many patients with borderline personality disorder who have experienced trauma in the past blame themselves. Effective therapy helps patients realize that while they were not responsible for the neglect and abuse they experienced in childhood, they are currently responsible for controlling and preventing self-destructive patterns in the present. Psychotherapy can become derailed if there is too much focus on past trauma instead of attention to current functioning and problems in relating to others. Most therapists believe that interventions like interpretation, confrontation, and clarification should focus more on here-and-now situations than on the distant past (18). Interpretations of the here and now as it links to events in the past is a particularly useful form of interpretation for helping patients learn about the tendency toward repetition of maladaptive behavior patterns throughout their lives. Moreover, therapists must have a clear expectation of change as they help patients understand the origins of their suffering.

Because patients with borderline personality disorder possess a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy. At times therapists may be able to offer interpretations of unconscious patterns that help the patient develop insight. At other times, support and empathy may be more therapeutic. Supportive strategies should not be misconstrued as simply offering a friendly relationship. Validation or affirmation of the patient�s experience, strengthening of adaptive defenses, and specific advice are examples of useful supportive approaches. Interpretive or exploratory comments often work synergistically with supportive interventions. Much of the action of the therapy is focused in the therapeutic relationship, and therapists must directly address unrealistic negative and, at times, unrealistic positive perceptions that patients have about the therapist to keep these perceptions from disrupting the treatment.

Appropriate management of intense feelings in both patient and therapist is a cornerstone of good psychotherapy (15). Consulting with other therapists, enlisting the help of a supervisor, and engaging in personal psychotherapy are useful methods of increasing one�s capacity to contain these powerful feelings.

Clinical experience suggests that effective therapy for patients with borderline personality disorder also involves promoting reflection rather than impulsive action. Therapists should encourage the patient to engage in a process of self-observation to generate a greater understanding of how behaviors originate from internal motivations and affect states rather than coming from "out of the blue." Similarly, psychotherapy involves helping patients think through the consequences of their actions so that their judgment improves.

As previously noted, splitting is a major defense mechanism of patients with borderline personality disorder. The self and others are often regarded as "all good" or "all bad." This phenomenon is closely related to what Beck and Freeman (19) call "dichotomous thinking" and what Linehan (17) refers to as "all or none thinking." Psychotherapy must be geared to helping the patient begin to experience the shades of gray between the extremes and integrate the positive and negative aspects of the self and others. A major thrust of psychotherapy is to help patients recognize that their perception of others, including the therapist, is a representation rather than how they really are.

Because of the potential for impulsive behavior, therapists must be comfortable with setting limits on self-destructive behaviors. Similarly, at times therapists may need to convey to patients the limits of the therapist�s own capacities. For example, therapists may need to lay out what they see as the necessary conditions to make therapy viable, with the understanding that the particular therapy may not be able to continue if the patient cannot adhere to minimal conditions that make psychotherapy possible.

Individual psychodynamic therapy without concomitant group therapy or other partial hospital modalities has some empirical support (20, 21). These studies, which used nonrandomized waiting list control conditions and "pre-post" comparisons, suggested that twice-weekly psychodynamic therapy for 1 year may be helpful for many patients with borderline personality disorder. In these studies, as in the randomized controlled trials, the therapists met regularly for group consultation.

There is a large clinical literature describing psychoanalytic/psychodynamic individual therapy for patients with borderline personality disorder (12, 14, 15, 18, 22�38). Most of these clinical reports document the difficult transference and countertransference aspects of the treatment, but they also provide considerable encouragement regarding the ultimate treatability of borderline personality disorder. Therapists who persevere describe substantial improvement in well-suited patients. Some of these skilled clinicians have reported success with the use of psychoanalysis four or five times weekly (22, 24, 34, 39). These cases may have involved "higher level" patients with borderline personality disorder who more likely fit into the Kernberg category of borderline personality organization (a broader theoretical rubric that describes a specific intrapsychic structural organization [27]). Some exceptional patients who do meet criteria for borderline personality disorder may be analyzable in the hands of gifted and well-trained clinicians, but most psychotherapists and psychoanalysts agree that psychoanalytic psychotherapy, at a frequency of one to three times a week face-to-face with the patient, is a more suitable treatment than psychoanalysis.

The limited literature on group therapy for patients with borderline personality disorder indicates that group treatment is not harmful and may be helpful, but it does not provide evidence of any clear advantage over individual psychotherapy. In general, group therapy is usually used in combination with individual therapy and other types of treatment, reflecting clinical wisdom that the combination is more effective than group therapy alone. Studies of combined individual dynamic therapy plus group therapy suggest that nonspecified components of combined interventions may have the greatest therapeutic power (40). Clinical experience suggests that a relatively homogeneous group of patients with borderline personality disorder is generally recommended for group therapy, although patients with dependent, schizoid, and narcissistic personality disorders or chronic depression also mix well with patients with borderline personality disorder (12). It is generally recommended that patients with antisocial personality disorder, untreated substance abuse, or psychosis not be included in groups designed for patients with borderline personality disorder.

The published literature on couples therapy with patients with borderline personality disorder consists only of reported clinical experience and case reports. This clinical literature suggests that couples therapy may be a useful and at times essential adjunctive treatment modality, since inherent in the very nature of the illness is the potential for chaotic interpersonal relationships. However, couples therapy is not recommended as the only form of treatment for patients with borderline personality disorder. Clinical experience suggests that it is relatively contraindicated when either partner is unable to listen to the other�s criticisms or complaints without becoming too enraged, terrified, or despairing (41).

There is only one published study of family therapy for patients with borderline personality disorder (12), which found that a psychoeducational approach could greatly enhance communication and diminish conflict about independence. Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment. Whereas some clinicians recommend removing the patient�s treatment from the family setting and not attempting family therapy (12), others recommend working with the patient and family together (42).

Clinical experience suggests that family work is most apt to be helpful and can be of critical importance when patients with borderline personality disorder have significant involvement with, or are financially dependent on, the family. Failure to enlist family support is a common reason for treatment dropout. The decision about whether to work with the family should depend on the degree of pathology within the family and strengths and weaknesses of the family members. Clinical experience suggests that a psychoeducational approach may lay the groundwork for the small subset of families for whom subsequent dynamic family therapy may be effective. Family therapy is not recommended as the only form of treatment for patients with borderline personality disorder.

2. Pharmacotherapy and other somatic treatments

A pharmacological approach to the treatment of borderline personality disorder is based upon evidence that some personality dimensions of patients appear to be mediated by dysregulation of neurotransmitter physiology and are responsive to medication (43). Pharmacotherapy is used to treat state symptoms during periods of acute decompensation as well as trait vulnerabilities. Although medications are widely used to treat patients who have borderline personality disorder, the Food and Drug Administration has not approved any medications specifically for the treatment of this disorder.

Pharmacotherapy may be guided by a set of basic assumptions that provide the theoretical rationale and empirical basis for choosing specific treatments. First, borderline personality disorder is a chronic disorder. Pharmacotherapy has demonstrated significant efficacy in many studies in diminishing symptom severity and optimizing functioning. However, cure is not a realistic goal�medications do not cure character. Second, borderline personality disorder is characterized by a number of dimensions; treatment is symptom-specific, directed at particular behavioral dimensions, rather than the disorder as a whole. Third, affective dysregulation and impulsive aggression are dimensions that require particular attention because they are risk factors for suicidal behavior, self-injury, and assaultiveness and are thus given high priority in selecting pharmacological agents. Fourth, pharmacotherapy targets the neurotransmitter basis of behavioral dimensions, affecting both acute symptomatic expression (e.g., anger treated with dopamine-blocking agents) and chronic vulnerability (e.g., temperamental impulsivity treated with serotonergic agents). Last, symptoms common to both axis I and II disorders may respond similarly to the same medication.

Symptoms exhibited within three behavioral dimensions seen in patients with borderline personality disorder are targeted for pharmacotherapy: affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual difficulties.