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1. Individual Psychotherapeutic Approaches

  • Two psychotherapeutic approaches have been shown to have efficacy: psychoanalytic/psychodynamic therapies and dialectical behavior therapy. The key features shared by these approaches suggest that the following can help guide the psychiatrist treating a patient with borderline personality disorder, regardless of the specific type of therapy used:

  • Expect treatment to be long-term.

    Substantial improvement may not occur until at least 1 year of treatment, and many patients require longer treatment.

  • Create a hierarchy of priorities to be considered in the treatment (e.g., first focus on suicidal behavior).

    For examples, see Figure 1 in APA's Practice Guideline for the Treatment of Patients With Borderline Personality Disorder.

  • Monitor self-destructive and suicidal behaviors.

  • Build a strong therapeutic alliance that includes empathic validation of the patient's suffering and experience.

  • Help the patient take appropriate responsibility for his or her actions.

    • Minimize self-blame for past abuse.

    • Encourage responsibility for avoiding current self-destructive patterns.

    • Focus interventions more on the here and now than on the distant past.

  • Use a flexible strategy, depending on the current situation.

    • When appropriate, offer interpretations to help develop insight.

    • At other times, it may be more therapeutic to provide validation, empathy, and advice.

  • Appropriately manage intense feelings engendered in both thepatient and the therapist.

    • Consider the use of professional supervision and consultation.

    • Also consider personal psychotherapy.

  • Promote reflection rather than impulsive action.

    • Promote self-observation to generate a greater understanding of how behaviors may originate from internal motivations and affect states.

    • Encourage thinking through the consequences of actions.

  • Diminish splitting.

    • Help the patient integrate positive and negative aspects of self and others.

    • Encourage recognition that perceptions are representations rather than how things are.

  • Set limits on the patient's self-destructive behaviors and, if necessary, convey the limitations of the therapist's capacities (e.g., spell out minimal conditions necessary for therapy to be viable).

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2. Other Forms of Psychotherapy

  • Group therapy may be helpful but offers no clear advantage over individual therapy.

    • Group therapy is usually used in combination with individual therapy.

    • Relatively homogeneous groups are recommended. Exclude from groups patients with antisocial personality disorder, untreated substance abuse, or psychosis.

  • Couples therapy may be a useful adjunctive modality but is not recommended as the only form of treatment for patients with borderline personality disorder.

  • Family therapy is most helpful when the patient has significant involvement with family.

    • Whether to work with the family should depend on family pathology, strengths, and weaknesses.

    • Family therapy is not recommended as the only form of treatment for patients with borderline personality disorder.

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3. Pharmacotherapy and Other Somatic Treatments

  • Principles for choosing specific medications include the following:

    • Treatment is symptom specific, directed at particular behavioral dimensions.

    • Affective dysregulation and impulsivity/aggression are risk factors for suicidal behavior, self-injury, and assaultiveness and are given high priority in selecting pharmacological agents.

    • Medication targets both acute symptoms (e.g., anger treated with dopamine-blocking agents) and chronic vulnerabilities (e.g., temperamental impulsivity treated with serotonergic agents).

  • Symptoms to be targeted

    • Affective dysregulation symptoms (see Figure 1)

      Treat initially with a selective serotonin reuptake inhibitor (SSRI). A reasonable trial is at least 12 weeks.

      • Be cautious about discontinuing successful treatment, especially if the patient has failed to respond to prior medication trials.

      • If response is suboptimal, switch to a different SSRI or a related antidepressant.

      • Consider adding a benzodiazepine (especially clonazepam) when affective dysregulation presents as anxiety.

      • For disinhibited anger coexisting with other affective symptoms, SSRIs are the treatment of choice.

      • For severe behavioral dyscontrol, consider adding low-dose antipsychotics.

      • Monoamine oxidase inhibitors (MAOIs) are effective but are not a first-line treatment because of the risk of serious side effects and concerns about nonadherence with dietary restrictions.

      • Mood stabilizers (lithium, valproate, carbamazepine) are also a second-line treatment (or augmentation treatment).

      • Consider electroconvulsive therapy (ECT) for comorbid severe axis I depression refractory to pharmacotherapy.

    • Impulsive-behavioral symptoms (see Figure 2)

      SSRIs are the treatment of choice.

      • If a serious threat to the patient's safety is present, consider adding a low-dose antipsychotic to the SSRI. Onset of action is often within hours.

      • If an SSRI is ineffective, consider another SSRI or another class of antidepressant.

      • If the patient shows partial response to an SSRI, adding lithium may enhance the effectiveness of the SSRI.

      • If an SSRI is ineffective, switching to an MAOI may be considered after an appropriate drug washout period.

      • Consider valproate, carbamazepine, and second-generation (atypical) antipsychotics. There is widespread use of these agents despite limited data.

      • Clozapine may be warranted after other treatments have failed.

    • Cognitive-perceptual symptoms (see Figure 3)

      • Low-dose antipsychotics are the treatment of choice for psychotic-like symptoms.

      • Antipsychotics may also improve depressed mood, impulsivity, and anger-hostility.

      • Antipsychotics are most effective when cognitive-perceptual symptoms are primary.

      • If response is suboptimal in 4 to 6 weeks, increase dose to the range used for axis I disorders.

      • Clozapine may be useful for patients with severe, refractory psychotic-like symptoms.

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FIGURE 1. Psychopharmacological Treatment of Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder
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FIGURE 2. Psychopharmacological Treatment of Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality Disorder
aEspecially if serious threat to patient is present.bSSRI treatment must be discontinued and followed with an adequate washout period before initiating treatment with an MAOI.
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FIGURE 3. Psychopharmacological Treatment of Cognitive-Perceptual Symptoms in Patients With Borderline Personality Disorder
aThe generally favorable side effect profiles of the second-generation antipsychotics compared with those of first-generation antipsychotics underscore the need for careful empirical trials of these newer medications in the treatment of patients with borderline personality disorder.

FIGURE 1. Psychopharmacological Treatment of Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder

FIGURE 2. Psychopharmacological Treatment of Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality DisorderaEspecially if serious threat to patient is present.bSSRI treatment must be discontinued and followed with an adequate washout period before initiating treatment with an MAOI.

FIGURE 3. Psychopharmacological Treatment of Cognitive-Perceptual Symptoms in Patients With Borderline Personality DisorderaThe generally favorable side effect profiles of the second-generation antipsychotics compared with those of first-generation antipsychotics underscore the need for careful empirical trials of these newer medications in the treatment of patients with borderline personality disorder.

References

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