- What is the relative efficacy of different pharmacological augmentation and combination strategies, and what is their efficacy compared with treatment with single agents?
- How does the presence of certain clinical features (for example, prominent self-destructive behavior or dissociative features) affect response to pharmacotherapy?
- What is the minimal dose and duration of an adequate trial for different medications in patients with borderline personality disorder?
- What is the optimal duration of different types of medication treatment?
- What are the indications for discontinuation of effective pharmacological treatment?
- Are atypical neuroleptics or typical neuroleptics more effective or better tolerated in patients with borderline personality disorder?
- How efficacious are mood stabilizers for patients with borderline personality disorder, and which patients are most likely to benefit from this treatment? Are certain mood stabilizers more effective than others?
- What role should ECT have in the treatment of patients with refractory or severe borderline personality disorder?
Appendixes:
Psychopharmacological Treatment AlgorithmsAppendix 1
Psychopharmacological Treatment of Affective Dysregulation Symptoms in Patients With Borderline Personality Disordera
�Algorithm based on clinical judgment that uses evidence currently in the literature, following the format of the International Psychopharmacology Algorithm Project (2). The first step in the algorithm is generally supported by the best empirical evidence. Recommendations may not be applicable to all patients or take individual needs into account. The empirical research studies on which these recommendations are based may be "first trials" involving previously untreated patients and may not take into account previous patient nonresponse to one, two, or even three levels of the algorithm (i.e., patients who, by definition, have more refractory disorders). There are no empirical trials of the complete algorithm.
Appendix 2
Psychopharmacological Treatment of Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality Disordera
�Algorithm based on clinical judgment that uses evidence currently in the literature, following the format of the International Psychopharmacology Algorithm Project (2). The first step in the algorithm is generally supported by the best empirical evidence. Recommendations may not be applicable to all patients or take individual needs into account. The empirical research studies on which these recommendations are based may be "first trials" involving previously untreated patients and may not take into account previous patient nonresponse to one, two, or even three levels of the algorithm (i.e., patients who, by definition, have more refractory disorders). There are no empirical trials of the complete algorithm.
bSSRI treatment must be discontinued and followed with an adequate washout period before initiating treatment with an MAOI.
Appendix 3
Psychopharmacological Treatment of Cognitive-Perceptual Symptoms in Patients With Borderline Personality Disorder�
�Algorithm based on clinical judgment that uses evidence currently in the literature, following the format of the International Psychopharmacology Algorithm Project (2). The first step in the algorithm is generally supported by the best empirical evidence. Recommendations may not be applicable to all patients or take individual needs into account. The empirical research studies on which these recommendations are based may be "first trials" involving previously untreated patients and may not take into account previous patient nonresponse to one, two, or even three levels of the algorithm (i.e., patients who, by definition, have more refractory disorders). There are no empirical trials of the complete algorithm.
bThe generally favorable side effect profiles of the newer atypical neuroleptic medications compared with those of conventional neuroleptics underscore the need for careful empirical trials of these newer medications in the treatment of patients with borderline personality disorder.
INDIVIDUALS AND ORGANIZATIONS THAT SUBMITTED COMMENTS
Gerald Adler, M.D.
Hagop Akiskal, M.D.
Deborah Antai-Otong, M.S., R.N., P.M.H.N.P., C.S.
Lorna Benjamin, Ph.D.
Sandra Smith Bjork, R.N., J.D.
Nashaat N. Boutros, M.D.
Daniel Buie, M.D.
Kenneth Busch, M.D.
Carlyle H. Chan, M.D.
Richard D. Chessick, M.D., Ph.D.
Diego Cohen, M.D.
Nancy Collins, R.N., M.P.H.
Alv A. Dahl, M.D.
Dave M. Davis, M.D.
Diana Dell, M.D.
Anita S. Everett, M.D.
Robert Findling, M.D.
Douglas H. Finestone, M.D.
Arnold Goldberg, M.D.
William M. Greenberg, M.D.
Elliot A. Harris, M.D.
Al Herzog, M.D.
Eric Hollander, M.D.
Patricia Hoffman Judd, Ph.D.
Morten Kjolbye, M.D.
Ronald Koegler, M.D.
Paul S. Links, M.D.
Cesare Maffei, M.D.
Paul Markovitz, M.D., Ph.D.
John C. Markowitz, M.D.
James F. Masterson, M.D.
William Meissner, M.D.
Mary D. Moller, M.S.N., C.S., P.M.H.N.P.
Robert Michels, M.D.
Richard Munich, M.D.
Nathan A. Munn, M.D.
Andrei Novac, M.D.
Stefano Pallanti, M.D.
Joel Paris, M.D.
Jane L. Pearson, Ph.D.
Gary Peterson, M.D.
Eric M. Plakun, M.D.
Charles W. Portney, M.D.
Lawrence H. Rockland, M.D.
Barbara Rosenfeld, M.D.
Marc Rothman, M.D.
Marian Scheinholtz, M.S., O.T.R.L.
Judy Sigmund, M.D.
Kenneth R. Silk, M.D.
Andrew E. Skodol, M.D.
Robert Stern, M.D., Ph.D.
Nada L. Stotland, M.D., M.P.H.
Richard T. Suchinsky, M.D.
Peter J. Sukin, M.D.
Arthur Summer, M.D.
Marijo Tamburrino, M.D.
William R. Tatomer, M.D.
Per Vaglum, M.D.
Robert S. Wallerstein, M.D.
Sidney Weissman, M.D.
Drew Westen, Ph.D.
Jerome Winer, M.D.
American Academy of Ophthalmology
American College of Obstetrics and Gynecology
American College of Radiology
American Occupational Therapy Association
American Psychiatric Nurses Association
American Psychoanalytic Association
Commonwealth of Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services
Illinois Psychiatric Society
International Society for the Study of Personality Disorders
New Jersey Psychiatric Association
Norwegian Psychiatric Association
Royal Australian and New Zealand College of Psychiatrists
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This article is provided for educational purposes only. No profit comes from this article. The more exposure I feel this article gets, the less people with the BPD will suffer. Clinicians need this training. Consumers and families desperately need to be educated. I am deeply grateful to the researchers that provide us with valuable information in assisting us with treatment and etiology.
