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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.

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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.

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Figure 1. Treatment Priorities of Two Psychotherapeutic Approaches for Patients With Borderline Personality Disorder.a
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.

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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.

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a) Treatment of affective dysregulation symptoms

Affective dysregulation in patients with borderline personality disorder is manifested by symptoms such as mood lability, rejection sensitivity, inappropriate intense anger, depressive "mood crashes," and temper outbursts. As seen in Table 2, patients displaying these features should be treated initially with one of the SSRIs, since this recommendation has strong empirical support (44–49). SSRIs have a broad spectrum of therapeutic effects, are relatively safe in overdose (compared with the tricyclic antidepressants or MAOIs), and have a favorable side effect profile, which supports treatment adherence. For example, fluoxetine has been found to improve depressed mood, mood lability, rejection sensitivity, impulsive behavior, self-mutilation, hostility, and even psychotic features. Research trials of SSRIs for treatment of borderline personality disorder have ranged in duration from 6 to 14 weeks for acute treatment studies, with continuation studies lasting up to 12 months. Some patients have retained improvement with maintenance treatment of 1–3 years. Studies have been reported with fluoxetine (in doses of 20–80 mg/day), sertraline (in doses of 100–200 mg/day), and the mixed norepinephrine/serotonin reuptake blocker venlafaxine (in doses of up to 400 mg/day) (45). A reasonable trial of an SSRI for treatment of patients with borderline personality disorder is at least 12 weeks.

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Table Reference Number
Table 2. Psychopharmacological Treatment Recommendations for Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder

Empirical trials of tricyclic antidepressants have produced inconsistent results (50, 51). Patients with comorbid major depression and borderline personality disorder have shown improvement following treatment with tricyclic antidepressants. However, in one placebo-controlled study, amitriptyline had a paradoxical effect in patients with borderline personality disorder, increasing suicidal ideation, paranoid thinking, and assaultiveness (50).

Since affective dysregulation is a dimension of temperament in patients with borderline personality disorder and not an acute illness, the duration of continuation and maintenance phases of pharmacotherapy cannot presently be defined. Significant improvement in the quality of the patient's coping skills and interpersonal relationships may be required before medication can be discontinued. Clinical experience suggests caution in discontinuing a successful antidepressant trial, especially if prior medication trials have failed. In the event of a suboptimal response to an SSRI, consideration should be given to switching to a second SSRI or related antidepressant. In one study of patients with borderline personality disorder (45), one-half of the patients who failed to respond to fluoxetine subsequently responded to sertraline.

When affective dysregulation appears as anxiety, an SSRI may be insufficient. At this point, the use of a benzodiazepine should be considered, although there is little systematic research on the use of these medications in patients with borderline personality disorder. Use of benzodiazepines may be problematic, given the risk of abuse, tolerance, and even behavioral toxicity. Despite clinical use of benzodiazepines (52), the short-acting benzodiazepine alprazolam was associated in one study with serious behavioral dyscontrol (53). Case reports demonstrate some utility for the long half-life benzodiazepine clonazepam (54). Clinical experience suggests that this medication, if used over the longer term, is best used adjunctively with an SSRI.

In theory, buspirone may treat anxiety or impulsive aggression without the risk of abuse or tolerance. However, the absence of an immediate effect generally makes this drug less acceptable to patients with borderline personality disorder. Currently, there are no published data on the use of buspirone for the treatment of affective dysregulation symptoms in patients with borderline personality disorder.

When affective dysregulation appears as disinhibited anger that coexists with other affective symptoms, SSRIs are the treatment of first choice. Fluoxetine has been shown to be effective for anger in patients with borderline personality disorder independent of its effects on depressed mood (44). Effects of fluoxetine on anger and impulsivity may appear within days, much earlier than antidepressant effects. Clinical experience suggests that in patients with severe behavioral dyscontrol, low-dose neuroleptics can be added to the regimen for a rapid response; they may also improve affective symptoms (50). Augmentation with neuroleptics should be considered before trying an MAOI, which requires more patient cooperation and adherence.

The efficacy of MAOIs for affective dysregulation symptoms in patients with borderline personality disorder has strong empirical support (55, 56). However, they are not a first-line treatment because of concerns about adherence to required dietary restrictions and because of their more problematic side effects. The effectiveness of MAOIs is supported by randomized controlled studies in patients with a primary diagnosis of borderline personality disorder as well as syndromes (e.g., atypical depression) in which the diagnosis of borderline personality disorder is considered secondary (57). MAOI antidepressants have demonstrated efficacy for impulsivity, mood reactivity, rejection sensitivity, anger, and hostility. They may also be effective for atypical depression and "hysteroid dysphoria." If a psychiatrist wishes to use an MAOI as a second-line treatment for symptoms of affective dysregulation, care should be taken to allow an adequate washout period after discontinuing SSRIs, particularly those with a long half-life.

Mood stabilizers are another second-line (or adjunctive) treatment for affective dysregulation symptoms in patients with borderline personality disorder. Lithium carbonate, carbamazepine, and valproate have been used for treatment of mood instability in patients with an axis II disorder, but there is a surprising paucity of empirical support for their use in borderline personality disorder, although studies are currently under way. Lithium carbonate has the most research support in randomized controlled trials studying patients with personality disorders (although not specifically borderline personality disorder). However, these studies focused primarily on impulsivity and aggression rather than mood regulation (58–60). Nonetheless, lithium may be helpful for mood lability as a primary presentation in patients with a personality disorder (61). Lithium has the disadvantage of a narrow margin of safety in overdose and the risk of hypothyroidism with long-term use.

Carbamazepine has demonstrated efficacy for impulsivity, anger, suicidality, and anxiety in patients with borderline personality disorder and hysteroid dysphoria (62). However, a small, controlled study of patients with borderline personality disorder with no axis I affective disorder found no significant benefit for carbamazepine (63). Carbamazepine has been reported to precipitate melancholic depression in patients with borderline personality disorder who have a history of this disorder (64), and it has the potential to cause bone marrow suppression.

Valproate demonstrated modest efficacy for depressed mood in patients with borderline personality disorder in one small, randomized, controlled trial (65). Open-label case reports suggest that this medication may also decrease agitation, aggression, anxiety, impulsivity, rejection sensitivity, anger, and irritability in patients with borderline personality disorder (66). Although the use of carbamazepine and valproate is widespread, psychiatrists should be aware of the lack of solid research support for their use in patients with borderline personality disorder.

Although there is a paucity of data on the efficacy of ECT for patients with borderline personality disorder, much of the available data suggest that depressed patients with a personality disorder generally have a poorer outcome with ECT than depressed patients without a personality disorder. Clinical experience suggests that while ECT may sometimes be indicated for patients with borderline personality disorder and severe axis I depression that has been resistant to pharmacotherapy, affective features of the borderline diagnosis are unlikely to respond to ECT.

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b) Treatment of impulsive-behavioral dyscontrol symptoms

As seen in Table 3, SSRIs are the treatment of choice for impulsive, disinhibited behavior in patients with borderline personality disorder. Randomized controlled trials and open-label studies with fluoxetine and sertraline have shown that their effect on impulsive behavior is independent of their effect on depression and anxiety (67). The effect of SSRIs on impulsivity may appear earlier than the effect on depression, with onset of action within days in some reports. Similarly, discontinuation of an SSRI following successful treatment may result in the reemergence of impulsive aggression within days. Clinical experience suggests that the duration of treatment following improvement of impulsive aggression should be determined by the clinical state of the patient, including his or her risk of exposure to life stressors and progress in learning coping skills. When the target for treatment is a trait vulnerability, a predetermined limit on treatment duration cannot be set.

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Table Reference Number
Table 3. Psychopharmacological Treatment Recommendations for Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality Disorder

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. Although this combination has not been studied, randomized controlled trials of neuroleptics alone have demonstrated their efficacy for impulsivity in patients with borderline personality disorder. The effect is rapid in onset, often within hours with oral use (and more rapidly when given intramuscularly), providing immediate control of escalating impulsive-aggressive behavior.

If an SSRI is ineffective, a trial of another SSRI or related antidepressant may be considered, although there are no published studies of this approach with impulsivity as a target symptom.

Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium carbonate, although this combination has not been studied in patients with borderline personality disorder. Nonetheless, studies in impulsive adults and adolescents with criminal behavior (who were not selected for having borderline personality disorder) demonstrate that lithium alone is effective for impulsive-aggressive symptoms (58–60). If an SSRI is ineffective, switching to an MAOI antidepressant may be considered, although it is critical to have an adequate washout period. In a placebo-controlled crossover study of women with borderline personality disorder and hysteroid dysphoria, tranylcypromine was effective for the treatment of impulsive behavior (55). In another randomized controlled trial, phenelzine was effective for the treatment of anger and irritability (56, 68). On the basis of these findings, MAOIs are recommended for treatment of impulsivity, anger, and irritability in patients with borderline personality disorder. Combining MAOIs with valproate would also appear to be rational for selected patients, although there are no studies of these combinations.

Although the use of MAOIs in patients with borderline personality disorder is supported by randomized controlled trials, because of safety considerations many clinicians prefer to use mood stabilizers for treatment of impulsive behavior. The use of carbamazepine or valproate for impulse control in patients with borderline personality disorder appears to be widespread in clinical practice, although empirical evidence for their efficacy for impulsive aggression is limited and inconclusive. Carbamazepine has been shown to decrease behavioral impulsivity in patients with borderline personality disorder and hysteroid dysphoria. However, in a small controlled study that excluded patients with an affective disorder (63), carbamazepine proved no better than placebo for impulsivity in borderline personality disorder. Support for the use of valproate for impulsivity in borderline personality disorder is derived only from case reports, one small randomized control study, and one open-label trial in which impulsivity significantly improved (65, 66, 69, 70). Preliminary evidence suggests that the atypical neuroleptics may have some efficacy for impulsivity in patients with borderline personality disorder, especially severe self-mutilation and other impulsive behaviors arising from psychotic thinking. One open-label trial (71) and one case report (72) support the use of clozapine for this indication. The difficulties and risks involved in using clozapine (e.g., neutropenia) generally warrant its use only after other treatments have failed. The newer atypical neuroleptics have fewer risks, but there are few published data on their efficacy. Further investigation is warranted for their use as a treatment for refractory impulsive aggression in patients with borderline personality disorder.

Opioid antagonists (e.g., naltrexone) are sometimes used in an attempt to decrease self-injurious behavior in patients with borderline personality disorder. However, empirical support for this approach is very preliminary, since their efficacy has been demonstrated only in case reports and small case series.

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c) Treatment of cognitive-perceptual symptoms

As seen in Table 4, low-dose neuroleptics are the treatment of choice for these symptoms. This recommendation is strongly supported by randomized, double-blind controlled studies and open-label trials involving a variety of neuroleptics in both inpatient and outpatient settings and in adult and adolescent populations (50, 51, 55, 73–78).

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Table Reference Number
Table 4. Psychopharmacological Treatment Recommendations for Cognitive-Perceptual Symptoms in Patients With Borderline Personality Disorder

Low-dose neuroleptics appear to have a broad spectrum of efficacy in acute use, improving not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. Treatment effects appear within days to several weeks. Patients with cognitive symptoms as a primary complaint respond best to the use of low-dose neuroleptics. Patients with borderline personality disorder with prominent affective dysregulation and labile, depressive moods, in whom cognitive-perceptual distortions are secondary mood-congruent features, may do less well with neuroleptics alone. In this case, treatments more effective for affective dysregulation should be considered. Duration of treatment may be guided by the length of treatment trials in the literature, which are generally up to 12 weeks. Prolonged use of neuroleptic medication alone in patients with borderline personality disorder (i.e., up to 22 weeks in one study) has been associated with progressive nonadherence and dropout from treatment (68, 79). There is currently a paucity of research on the use of neuroleptic medication as long-term maintenance therapy for patients with borderline personality disorder, although many clinicians regularly use low-dose neuroleptics to help patients manage their vulnerability to disruptive anger. One longer-term study (80) found that a depot neuroleptic was effective for recurrent parasuicidal behaviors in patients with borderline personality disorder. The risk of tardive dyskinesia must be weighed carefully against perceived prophylactic benefit if maintenance strategies are considered (although this risk may be lessened by the use of atypical neuroleptics).

If response to treatment with low-dose neuroleptics is suboptimal after 4 to 6 weeks, the dose should be increased into a range suitable for treating axis I disorders and continued for a second trial period of 4–6 weeks. A suboptimal response at this point should prompt rereview of the etiology of the cognitive-perceptual symptoms. If the symptom presentation is truly part of a nonaffective presentation, atypical neuroleptics may be considered. Although there are no published randomized controlled trials of atypical neuroleptics in patients with borderline personality disorder, open-label trials and case studies support the use of clozapine for patients with severe, refractory psychotic symptoms "of an atypical nature" or for severe self-mutilation (71, 72, 81). However, clozapine is best used in patients with refractory borderline personality disorder, given the risk of agranulocytosis. Studies are currently under way with olanzapine and risperidone (82, 83). The generally favorable side effect profiles of risperidone and olanzapine, compared with those of traditional neuroleptics, indicate that these medications warrant careful empirical trials. As yet, there are no published data on the efficacy of quetiapine for borderline personality disorder.

Neuroleptics are often effective for anger and hostility regardless of whether these symptoms occur in the context of cognitive-perceptual symptoms or other types of symptoms. It is important to note that both MAOI and SSRI antidepressants have also been shown in randomized controlled trials to be effective for irritability and anger in some patients with borderline personality disorder with cognitive-perceptual symptoms.

Figure 1. Treatment Priorities of Two Psychotherapeutic Approaches for Patients With Borderline Personality Disorder.aaSpecific 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).
Table Reference Number
Table 2. Psychopharmacological Treatment Recommendations for Affective Dysregulation Symptoms in Patients With Borderline Personality Disorder
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Table 3. Psychopharmacological Treatment Recommendations for Impulsive-Behavioral Dyscontrol Symptoms in Patients With Borderline Personality Disorder
Table Reference Number
Table 4. Psychopharmacological Treatment Recommendations for Cognitive-Perceptual Symptoms in Patients With Borderline Personality Disorder

References

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