Introduction

The goal of this guideline is to improve the quality of care and treatment outcomes for patients with borderline personality disorder (BPD) as defined in Section II of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR; American Psychiatric Association 2022a). Since publication of the last American Psychiatric Association (APA) practice guideline (American Psychiatric Association 2001) and guideline watch on BPD (Oldham 2005), there have been many studies on psychotherapies for individuals with BPD as well as some studies on pharmacotherapies. Despite this, there are still misconceptions about BPD (Baker and Beazley 2022; Masland et al. 2023; Proctor et al. 2021; Sheehan et al. 2016; Stiles et al. 2023) and substantial gaps in the availability of evidence-based treatments for individuals with BPD (Iliakis et al. 2019; Lohman et al. 2017). This practice guideline aims to help clinicians improve the care and well-being of their patients by reviewing current evidence and providing evidence-based statements intended to enhance knowledge and optimize treatment of BPD.

BPD is characterized in DSM-5-TR as being associated with a long-term pattern of instability of interpersonal relationships, unstable self-image, marked impulsivity, and/or affective instability (American Psychiatric Association 2022a). In addition, these features can be evidenced by efforts to avoid real or feared abandonment, chronic feelings of emptiness, mood reactivity, recurrent self-injurious or suicidal behavior, other impulsive behaviors with potential for self-damaging effects, intense anger or difficulty with anger control, and transient paranoid ideation or stress-related dissociative symptoms (American Psychiatric Association 2022a).

As with personality disorders in general, the pattern of inner experience and behavior with BPD can be quite heterogeneous but is relatively pervasive and enduring (American Psychiatric Association 2022a). Symptom onset may extend back to early adolescence, although the diagnosis of BPD may not be made until later in adolescence or adulthood (American Psychiatric Association 2022a). In addition, it occurs across a broad range of personal and social situations, is markedly different from the expectations of the individual’s cultural or societal norms, and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association 2022a). Although co-occurring conditions are common, the specific features of the personality disorder are not better explained by the effects of a substance, another psychiatric disorder, or another medical disorder (American Psychiatric Association 2022a).

The lifetime prevalence of BPD in the United States is approximately 1.4%–2.7%, although estimates can vary depending on the study location, sample demographic characteristics, and case finding and diagnostic approaches (Ellison et al. 2018; Grant et al. 2008; Leichsenring et al. 2023; Lenzenweger et al. 2007; Trull et al. 2010; Volkert et al. 2018; Winsper et al. 2020). In clinical populations, women are more frequently diagnosed with BPD and tend to seek treatment more often than men; however, nonclinical samples suggest that the prevalence of BPD is likely to be comparable in men and women (Busch et al. 2016; Lenzenweger et al. 2007; Zanarini et al. 2011a). Few studies have assessed the prevalence of BPD in LGBTQ+ individuals (Denning et al. 2022; Rodriguez-Seijas et al. 2021). An estimated three-quarters of patients with BPD seek help from professional mental health services (Tomko et al. 2014). In clinical psychiatric populations, the prevalence of BPD is high and estimated at 10%–18% for outpatients and 9%–25% for inpatients (Doering 2019; Ellison et al. 2018; Gunderson 2009; Torgersen 2005; Volkert et al. 2018; Zimmerman et al. 2017). Individuals with BPD are also frequent users of primary care (Doering 2019) and have elevated rates of chronic pain and other somatic conditions (El-Gabalawy et al. 2010; Heath et al. 2018b; Sansone and Sansone 2012; Tate et al. 2022). The lifetime prevalence of BPD among primary care patients is about four times as high as in the general population (Gross et al. 2002). A high prevalence of BPD (21%) was also found among veterans receiving care in U.S. Veterans Health Centers (Edwards et al. 2022).

Individuals with BPD commonly have other psychiatric disorders such as major depressive disorder (MDD), bipolar disorder, posttraumatic stress disorder (PTSD), anxiety disorders, eating disorders, attention-deficit/hyperactivity disorder (ADHD), substance use disorders (SUDs), and other personality disorders (Choi-Kain et al. 2022; Friborg et al. 2014; Geluk Rouwhorst et al. 2023; Grant et al. 2016; Gunderson et al. 2014; Keuroghlian et al. 2015; Leichsenring et al. 2011; Lenzenweger et al. 2007; McDermid et al. 2015; McGlashan et al. 2000; Miller et al. 2022; Momen et al. 2022; Philipsen et al. 2008; Santo et al. 2022; Tate et al. 2022; Trull et al. 2018; Zanarini et al. 2004a, 2010, 2019; Zimmerman et al. 2017). Most individuals with BPD will usually present first for treatment of another disorder, such as a mood or anxiety disorder (Zimmerman et al. 2017). Furthermore, when a co-occurring disorder is present, the clinical presentation may be more severe, and symptom remission is often more difficult to achieve in the co-occurring disorder (Ceresa et al. 2021; Geluk Rouwhorst et al. 2023; Gunderson et al. 2014; Keuroghlian et al. 2015; Skodol et al. 2011).

The lifetime burden and psychosocial impairment associated with BPD can be substantial because it typically has an onset in adolescence or early adulthood and can persist for many years (American Psychiatric Association 2022a; Doering 2019; Leichsenring et al. 2011; Oldham 2006). The lived experience of BPD can be associated with significant emotional pain and a diminished quality of life (Botter et al. 2021; Miller et al. 2021; Ng et al. 2019a, 2019b). Disruptions in relationships, including those with family, friends, and intimate partners, are common (Ng et al. 2019a, 2019b). Individuals with BPD may also experience disruptions in schooling, employment, and housing (Juurlink et al. 2019; Ng et al. 2019a, 2019b; Soloff 2021). Economic stability and productivity can be affected for those with BPD as well as for family members (Hastrup et al. 2019; Kay et al. 2018; Soloff 2021). In addition, individuals with BPD experience increases in health care costs related to BPD and to other physical conditions (Hastrup et al. 2019). These increases in costs can affect access to treatment and, in turn, affect health and quality of life (Lohman et al. 2017). Some studies suggest that individuals with BPD have an increased possibility of contacts with the criminal justice system (Dean et al. 2020; Nakic et al. 2022; Tate et al. 2022). Conversely, there are strong associations between having a diagnosis of BPD and being the victim of a violent crime (Tate et al. 2022). These significant consequences of BPD support a need for early identification and treatment.

In contrast to earlier views on BPD, this condition can remit, and symptoms can be reduced and managed. Most individuals with BPD will experience some decline in symptoms during adulthood (Gunderson et al. 2011; Stone 2017; Zanarini et al. 2012), and in clinical samples, about 85% of individuals with BPD will no longer meet the threshold for diagnosis within 10 years of longitudinal follow-up (Gunderson et al. 2011; Stone 2017; Zanarini et al. 2012). Nevertheless, specific symptoms such as fear of abandonment, impulsivity, intense anger, and an unstable self-image may persist. Individuals with BPD may also continue to experience impairments in social (Gunderson et al. 2011) and occupational functioning (Niesten et al. 2016) and may have a need for ongoing treatment.

Rates of suicide attempts and episodes of self-harm also decline over time (Zanarini et al. 2008), but they continue to occur more often than in individuals without BPD (Grilo and Udo 2021; Yen et al. 2021; Zanarini et al. 2008). Furthermore, in longitudinal studies, BPD is associated with increases in deaths due to suicide as well as with all-cause mortality (Kjær et al. 2020; Paris 2019; Schneider et al. 2019; Temes et al. 2019). Accordingly, an overall goal of this guideline is to enhance the assessment and treatment of BPD, thereby reducing the mortality, morbidity, and significant psychosocial and health consequences of this important psychiatric condition.

An additional rationale for this practice guideline is to provide clinicians with the necessary knowledge to feel confident in their skills for treating patients with BPD. A considerable amount of stigma exists in relation to BPD, including self-stigma, and patients with BPD often experience discrimination within the health care system (Baker and Beazley 2022; Masland et al. 2023; Proctor et al. 2021; Stiles et al. 2023). Bias about BPD is lessened and empathy for patients is increased when clinicians have received education about working with patients with this diagnosis (e.g., through seminars on good psychiatric management [GPM]; Keuroghlian et al. 2016; Klein et al. 2022b; Masland et al. 2018). It is also important for clinicians to gain perspectives on the lived experiences of these individuals. Other misconceptions about BPD can also be corrected through education. For example, one misconception is that BPD only occurs in adults; however, adolescents can meet criteria for the disorder and can benefit from treatment aimed at addressing its core features and symptoms (Bo et al. 2021; Ilagan and Choi-Kain 2021; Sharp 2017; Weiner et al. 2018; Winsper 2021). Education can also be helpful in emphasizing that treatment of BPD is effective and that many patients with BPD will improve with treatment (Bohus et al. 2021; Gunderson et al. 2011; Leichsenring et al. 2023; Stone 2017; Zanarini et al. 2012). Consequently, this guideline also aims to improve the quality of care for patients by providing clinicians with up-to-date knowledge about treating BPD.

This practice guideline focuses on evidence-based treatments for BPD. In addition, it includes statements related to assessment and treatment planning, which are an integral part of patient-centered care.

Since the publication of the Institute of Medicine (now known as the National Academy of Medicine) report Clinical Practice Guidelines We Can Trust (Institute of Medicine 2011), there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. This guideline was developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011) and the “Principles for the Development of Specialty Society Clinical Guidelines” of the Council of Medical Specialty Societies (2017). Parameters used for the guideline’s systematic review are included with the full text and the appendices of the guideline; the development process is fully described in the following document available on the APA Web site: www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines/guideline-development-process

Development of guideline statements entails weighing the potential benefits and harms of the statement and then identifying the level of confidence in that determination. This concept of balancing benefits and harms to determine guideline recommendations and strength of recommendations is a hallmark of GRADE (Grading of Recommendations Assessment, Development and Evaluation), which is used by many professional organizations around the world to develop practice guideline recommendations (Guyatt et al. 2013). With the GRADE approach, recommendations are rated by assessing the confidence that the benefits of the statement outweigh its harms and burdens, determining the confidence in estimates of effect as reflected by the quality of evidence, estimating patient values and preferences (including whether they are similar across the patient population), and identifying whether resource expenditures are worth the expected net benefit of following the recommendation (Andrews et al. 2013).

In weighing the balance of benefits and harms for each statement in this guideline, our level of confidence is informed by available evidence, which includes evidence from clinical trials as well as expert opinion and patient values and preferences. Evidence for the benefit of a particular intervention within a specific clinical context is identified through systematic review and is then balanced against the evidence for harms. In this regard, harms are broadly defined and may include serious adverse events, less serious adverse events that affect tolerability, minor adverse events, negative effects of the intervention on quality of life, barriers and inconveniences associated with treatment, direct and indirect costs of the intervention (including opportunity costs), and other negative aspects of the treatment that may influence decision making by the patient, the clinician, or both.

Many topics covered in this guideline have relied on forms of evidence such as consensus opinions of experienced clinicians or indirect findings from observational studies rather than research from randomized trials. It is well recognized that there are guideline topics and clinical circumstances for which high-quality evidence from clinical trials is not possible or is unethical to obtain (Council of Medical Specialty Societies 2017). For example, many questions need to be asked as part of an assessment, and inquiring about a particular symptom or element of the history cannot be separated out for study as a discrete intervention. It would also be impossible to separate changes in outcomes due to assessment from changes in outcomes due to ensuing treatment. Research on psychiatric assessments and some psychiatric interventions can also be complicated by multiple confounding factors such as the interaction between the clinician and the patient or the patient’s unique circumstances and experiences. The GRADE working group and guidelines developed by other professional organizations have noted that a strong recommendation or “good practice statement” may be appropriate even in the absence of research evidence when sensible alternatives do not exist (Andrews et al. 2013; Brito et al. 2013; Djulbegovic et al. 2009; Hazlehurst et al. 2013). For each guideline statement, we have described the type and strength of the available evidence as well as the factors, including patient preferences, that were used in determining the balance of benefits and harms.

The authors of the guideline determined each final rating, as described in the section “Guideline Development Process” (see Table 1). A recommendation (denoted by the numeral 1 after the guideline statement) indicates confidence that the benefits of the intervention clearly outweigh the harms. A suggestion (denoted by the numeral 2 after the guideline statement) indicates greater uncertainty. Although the benefits of the statement are still viewed as outweighing the harms, the balance of benefits and harms is more difficult to judge, or either the benefits or the harms may be less clear. With a suggestion, patient values and preferences may be more variable, and this can influence the clinical decision that is ultimately made. Each guideline statement also has an associated rating for the strength of supporting research evidence. Three ratings are used: high, moderate, and low (denoted by the letters A, B, and C, respectively) and reflect the level of confidence that the evidence for a guideline statement reflects a true effect based on consistency of findings across studies, directness of the effect on a specific health outcome, precision of the estimate of effect, and risk of bias in available studies (Agency for Healthcare Research and Quality 2014; Balshem et al. 2011; Guyatt et al. 2006).

APA Practice Guidelines are assessments of current (as of the date of authorship) scientific and clinical information provided as an educational service. The guidelines 1) do not set a standard of care and are not inclusive of all proper treatments or methods of care; 2) are not continually updated and may not reflect the most recent evidence, as new evidence may emerge between the time information is developed and when the guidelines are published or read; 3) address only the question(s) or issue(s) specifically identified; 4) do not mandate any particular course of medical care; 5) are not intended to substitute for the independent professional judgment of the treating clinician; and 6) do not account for individual variation among patients. As such, it is not possible to draw conclusions about the effects of omitting a particular recommendation, either in general or for a specific patient. Furthermore, adherence to these guidelines will not ensure a successful outcome for every individual, nor should these guidelines be interpreted as including all proper methods of evaluation and care or excluding other acceptable methods of evaluation and care aimed at the same results. The ultimate recommendation regarding a particular assessment, clinical procedure, or treatment plan must be made by the clinician directly involved in the patient’s care in light of the psychiatric evaluation, other clinical data, and the diagnostic and treatment options available. Such recommendations should be made in collaboration with the patient whenever possible and should incorporate the patient’s personal and sociocultural preferences and values in order to enhance the therapeutic alliance, adherence to treatment, and treatment outcomes. For all these reasons, the APA cautions against the use of guidelines in litigation. Use of these guidelines is voluntary. APA provides the guidelines on an “as is” basis and makes no warranty, expressed or implied, regarding them. APA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the guidelines or for any errors or omissions.

The appendixes for this guideline, including evidence tables, literature search results, clinical questions, and more, are available online at https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890428009.