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.
Definition of grades of recommendation are presented at the end of the Major Recommendations field.
- 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.
- 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 and boundaries.
- Principles of Treatment Selection
- 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].
- 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].
- 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.
- 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].
- 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].
- Specific Treatment Strategies
- 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].
- 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.
- 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 selective serotonin reuptake inhibitor 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, selective serotonin reuptake inhibitors 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, monoamine reuptake inhibitors 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 electroconvulsive therapy (ECT) for treatment of affective dysregulation symptoms in patients with borderline personality disorder. Clinical experience suggests that while electroconvulsive therapy 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 electroconvulsive therapy [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 of the original guideline document.
- 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). Selective serotonin reuptake inhibitors (see Appendix 2 of the original guideline document) 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 selective serotonin reuptake inhibitor [II]. Clinical experience suggests that partial efficacy of a selective serotonin reuptake inhibitor may be enhanced by adding lithium [II]. If a selective serotonin reuptake inhibitor is ineffective, switching to a monoamine oxidase inhibitor 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].
- 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. Low-dose neuroleptics (see Appendix 3 of original guideline) 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].
- 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].
- 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.
