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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:
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
Monitor self-destructive and suicidal
Build a strong therapeutic alliance that
includes empathic validation of the patient's suffering
Help the patient take appropriate responsibility
for his or her actions.
for past abuse.
Encourage responsibility for avoiding current
Focus interventions more on the here and
now than on the distant past.
Use a flexible strategy, depending on
the current situation.
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.
use of professional supervision and consultation.
Also consider personal psychotherapy.
Promote reflection rather than impulsive
to generate a greater understanding of how behaviors may originate from
internal motivations and affect states.
Encourage thinking through the consequences
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).
Group therapy may
be helpful but offers no clear advantage over individual 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
Family therapy is not recommended as the
only form of treatment for patients with borderline personality
for choosing specific medications include the following:
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
dysregulation symptoms (see Figure 1)
Treat initially with a selective serotonin reuptake inhibitor
(SSRI). A reasonable trial is at least 12 weeks.
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
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
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
Clozapine may be warranted after other treatments
Cognitive-perceptual symptoms (see Figure 3)
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.