Guideline Statements and Implementation

The importance of the psychiatric evaluation cannot be underestimated because it serves as the initial basis for a therapeutic relationship with the patient and provides information that is crucial to differential diagnosis and shared decision-making about treatment. The initial evaluation can also provide an opportunity for educating patients, family members, friends, or others involved in the patient’s care about such factors as BPD features, treatments, course, and prognosis. APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition (American Psychiatric Association 2016a), describes recommended and suggested elements of assessment for any individual who presents with psychiatric symptoms (Table 2). These elements are by no means comprehensive, and additional areas of inquiry will become apparent as the evaluation unfolds, depending on the responses to initial questions, the presenting concerns, the observations of the clinician during the assessment, the complexity and urgency of clinical decision-making, and other aspects of the clinical context. In many circumstances, aspects of the evaluation will extend across multiple visits (American Psychiatric Association 2016a).

The specific approach to the interview will depend on many factors, including the patient’s ability to communicate, degree of cooperation, level of insight, illness severity, and ability to recall historical details (American Psychiatric Association 2016a). Such factors as the patient’s health literacy (Clausen et al. 2016) and cultural background (Lewis-Fernández et al. 2016) can also influence their understanding or interpretation of questions. Typically, a psychiatric evaluation involves a direct interview between the patient and the clinician (American Psychiatric Association 2016a). The use of open-ended, empathic questions about the patient’s current life circumstances and reasons for evaluation can provide an initial picture of the person and serve as a way of establishing rapport. Such questions can be followed up with additional structured inquiry about history, symptoms, or observations made during the assessment.

A respectful and empathic approach to the interview is important because patients may have had prior experiences with stigma or bias in health care settings or may have self-stigmatizing views (Denning et al. 2022; Goldhammer et al. 2019; Klein et al. 2022a; Masland et al. 2023; McKenzie et al. 2022; Olbert et al. 2018; Rodriguez-Seijas et al. 2023; Schwartz and Blankenship 2014; Stiles et al. 2023; Zimmerman et al. 2022). These biases, stigma, and self-stigma can also influence assessment and diagnosis related to BPD (Klein et al. 2022a; Masland et al. 2023; McKenzie et al. 2022; Stiles et al. 2023). In addition, disparities in assessment and diagnosis based on race or gender identity are common (Denning et al. 2022; Goldhammer et al. 2019; Masland et al. 2023; Olbert et al. 2018; Rodriguez-Seijas et al. 2021; Schwartz and Blankenship 2014; Zimmerman et al. 2022).

Many individuals with BPD will also have had traumatic experiences during their lifetime, such as childhood maltreatment, sexual trauma, or violent victimization (de Aquino Ferreira et al. 2018; Hailes et al. 2019; Porter et al. 2020; Tate et al. 2022). Sensitivity to the impact of these experiences, including use of trauma-informed approaches, can aid in establishing a supportive environment that is conducive to rapport (Burns et al. 2023; Center for Substance Abuse Treatment 2014; Huo et al. 2023; Menschner and Maul 2016; National Council for Mental Wellbeing 2019; Raja et al. 2015; Rudolph 2021; Saunders et al. 2023; Substance Abuse and Mental Health Services Administration 2014). Depending on the circumstances of the initial evaluation, it may be preferable to defer discussion of prior traumatic experiences until a therapeutic relationship is established or until the setting is more conducive to obtaining detailed information.

Throughout the assessment process, it is important to gain an understanding of the patient’s goals, view of the illness, and preferences for treatment. This information will serve as a starting point for person-centered care and shared decision-making with the patient, family, friends, and others involved in the patient’s care (Dixon et al. 2016; Hamann and Heres 2019). It will also provide a framework for recovery, which has been defined as “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential” (Substance Abuse and Mental Health Services Administration 2012, p. 3). Consequently, discussions of goals should be focused beyond symptom relief and may include goals related to schooling, employment, living situation, relationships, leisure activities, and other aspects of functioning and quality of life. Family context and educational factors are particularly crucial to identify when assessing adolescents and emerging adults. Questions about the patient’s views may help determine whether the patient is aware of having an illness and assist in understanding the patient’s explanations for or experience of their symptoms or distress (Saks 2009). Based on prior treatment experiences, patients may have specific views about such topics as medications, other treatment approaches, mechanical restraints, or involuntary treatment. It is also important to inquire about the patient’s strengths and protective factors. For example, they may be able to delineate strategies that have been helpful for them in coping with or managing their symptoms in the past (Cohen et al. 2017). Some patients will have completed a psychiatric advance directive (Murray and Wortzel 2019) and, if so, it will be important to review that with them.

In addition to direct interview, patients may be asked to complete electronic or paper-based forms that ask about psychiatric symptoms or key aspects of the history (American Psychiatric Association 2016a). When available, prior medical records, electronic prescription databases, and input from other treating clinicians can add further details to the history or corroborate information obtained in the interview (American Psychiatric Association 2016a).

People with BPD have heterogeneous relationships with family members, friends, and other individuals. Often, family members, friends, or others in the patient’s support network can be an important part of the care team. Such individuals can also serve as valuable sources of collateral information about the reason for evaluation, the patient’s past history, and their current symptoms and behavior (American Psychiatric Association 2016a). Input from and engagement of parents, guardians, or other caregivers is particularly important when assessing and treating adolescents and emerging adults.

In other circumstances, a patient may not want a specific family member or other individual to be involved in their care. For example, a patient may wish to avoid burdening a loved one or may have experienced abuse by a particular family member in the past. A patient may also have felt unsupported by family members or others in terms of issues such as their life goals, their gender identity, coping with their BPD symptoms, or other aspects of their lives. For these reasons, the patient’s permission is typically obtained before outreach to family, friends, and others in the support network, except in emergent situations to prevent or lessen a serious and imminent threat to the health or safety of the patient or others (American Psychiatric Association 2013b, 2016a; Office for Civil Rights 2017). In addition, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA; Office for Civil Rights 2017), a clinician may listen to information provided by a family member or other involved person, as long as confidential information about the patient is not provided to that individual (American Psychiatric Association 2016a).

The initial evaluation typically begins with the reason the individual is presenting for evaluation. Common concerns in individuals with BPD include anxiety, depression, mood instability, irritability, difficulties with anger, hopelessness, low self-esteem, unstable self-image or sense of self, unstable and intense interpersonal relationships, concerns about real or feared abandonment, suicidal thoughts or attempts, NSSI, other impulsive or self-harming behaviors (e.g., substance use, reckless driving, risky sexual behavior), or harm to others.

As part of the initial evaluation, it is useful to ask about the onset, course, and duration of symptoms. Features common in BPD that can aid in establishing a diagnosis include extreme responses to real or imagined abandonment, sudden shifts in the person’s views of others, intense dysphoria, prominent mood reactivity, chronic feelings of emptiness, or intense anger (American Psychiatric Association 2022a). Other illness-driven behaviors, such as self-injurious behavior, may also be present. Specific questions may be needed to identify whether the patient has had transient dissociative experiences, hallucinations, ideas of reference, or persecutory ideas, particularly in periods of stress (American Psychiatric Association 2022a). It is also helpful to determine whether impairments are present in self-functioning (i.e., identity and self-direction) and in interpersonal functioning (i.e., empathy and intimacy) (American Psychiatric Association 2022a).

If the patient has received treatment previously, it is important to ask about a broad range of treatments and other approaches used to address the patient’s symptoms and functioning and to specifically ask about the full range of treatment settings (e.g., outpatient, partial hospitalization, inpatient) and approaches or aspects of the therapeutic relationships that the patient has found helpful or problematic (American Psychiatric Association 2016a; Bachelor 2013; Barnicot et al. 2022; de Freixo Ferreira et al. 2023; Woodbridge et al. 2023). For example, prompting may be needed to learn information about the patient’s experiences with psychotherapies (e.g., dialectical behavior therapy [DBT], cognitive-behavioral therapy [CBT], mentalization-based treatment [MBT], transference-focused psychotherapy [TFP], schema-focused therapy [SFT], dynamic deconstructive psychotherapy [DDP], other psychodynamic therapies, couples or family therapy, supportive therapy) as well as their formats, frequencies, and durations. A patient may believe that they have not responded to a specific type of psychotherapy, but the fidelity to key treatment principles (as described in the “Implementation” section of Statement 5) may have been limited or the treatment intensity or duration may have been insufficient. The formats and focus of the different psychotherapies may be a good fit for some individuals but not for others; for example, some but not all patients do well with the structure of homework assignments, some prefer individual treatment to groups, and some prefer insight-oriented approaches to skills-based approaches (Woodbridge et al. 2023). With medications, information about the specific medication, duration of treatment, formulation, route, and dosage are important to obtain. Specific questions may be needed on long-acting injectable (LAI) medications (e.g., antipsychotics, naltrexone, buprenorphine) or implants (e.g., buprenorphine, contraceptive agents), over-the-counter medications, herbal products, or nutritional supplements because these medications may be overlooked by patients and are less likely to be included in pharmacy databases and patients’ lists of active medications. Experimental treatments such as psilocybin and ketamine are increasingly available. Other interventions can include substance use treatments, neuromodulatory therapies (e.g., electroconvulsive therapy [ECT], transcranial magnetic stimulation [TMS]), court-ordered treatment, treatment while incarcerated, 12-step programs, self-help groups, culture-based approaches, spiritual healers, and complementary or alternative treatment approaches. For each specific type of intervention that the patient has received, it is important to learn more about their response (including tolerability, changes in quality of life, level of functioning, symptom response/remission, and persistence of improvement) as well as their engagement in therapy and degree of adherence.

A thorough history is also important for identifying the presence of co-occurring psychiatric conditions or physical disorders that need to be addressed in treatment planning (American Psychiatric Association 2016a; Firth et al. 2019). Substance use and SUDs are common in individuals with BPD (Grant et al. 2008; Trull et al. 2018), and some individuals with BPD may use substances to cope with their emotional distress or help regulate their emotions. Therefore, a substance use history will be valuable in determining whether the individual uses tobacco, marijuana, or other substances such as alcohol, caffeine, nicotine, cocaine, opioids, sedative-hypnotic agents, stimulants, 3,4-methylenedioxymethamphetamine (MDMA), solvents, androgenic steroids, hallucinogens, ketamine, or synthetic substances (e.g., “bath salts,” K2, Spice). The route by which substances are used (e.g., ingestion, smoking, vaping, intranasal, intravenous) and the frequency and circumstances of use are also important to document.

In addition to SUDs, other common co-occurring psychiatric conditions in individuals with BPD include MDD, bipolar disorder, PTSD, anxiety disorders, eating disorders, ADHD, 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). Individuals with BPD may also have physical health conditions, sleep disturbances, or chronic pain that need to be considered in assessing functioning and developing a plan of treatment (Doering 2019; El-Gabalawy et al. 2010; Heath et al. 2018b; Kalira et al. 2013; Sansone and Sansone 2012; Vanek et al. 2021; Winsper et al. 2017). Prior head trauma or other brain abnormalities (e.g., due to anoxic injury) can contribute to impulsivity or emotional dysregulation (McHugo et al. 2017).

The psychosocial history reviews the stages of the patient’s life and may include attention to perinatal events, delays in developmental milestones, disruptive behavioral disorders in childhood, childhood maltreatment (including neglect or emotional, physical, or sexual abuse), academic history and performance (including a history of being bullied, learning difficulties, special education interventions, or disciplinary actions), occupational history (including military history), legal history, and identification of major life events (e.g., adoption or foster care, family separation, parental loss, divorce, migration history, sexual trauma, other traumatic experiences) and psychosocial stressors (e.g., financial, housing, legal, school/occupational, or interpersonal/relationship problems; childcare or other caregiving responsibilities; lack of social support; trauma related to racial/ethnic discrimination; discrimination or trauma related to LGBTQ+ identity; painful, disfiguring, or terminal medical illness; other social determinants of health) (American Psychiatric Association 2016a; Barnhill 2014; MacKinnon et al. 2016; Smith et al. 2019). Information on the patient’s gender identity and pronouns are also important to elicit.

Individuals may have received disability-related income support, supported employment, or accommodations related to disability in academic, workplace, or other settings. Such accommodations are important to be aware of because they can help promote functioning and enhance integration into the community. If patients are eligible for disability-related income support, supported employment, or disability-related accommodations but have not received them, this will also be relevant to treatment planning. Furthermore, inquiring into an individual’s accommodation history can serve as a starting point for discussion around accessibility needs during treatment and ensuring that these are met.

The patient’s history of interpersonal relationships, including family and intimate relationships, is particularly essential to obtain. Such relationships can be supportive and helpful, or they can be unstable or intense in individuals with BPD. The patient’s current and prior degree of interpersonal functioning (including in academic, occupational, social, and family roles, such as parenting) is similarly vital to the history and subsequent treatment planning. Assessment of interpersonal functioning should take developmental considerations into account, particularly in adolescents and emerging adults. Information about the patient’s family constellation and other persons who provide support serves as a foundation for working collaboratively with the patient and their support network. A family health history is also important in identifying family members who have a history of personality disorder, particularly BPD or BPD traits, as well as the presence of SUDs, other psychiatric disorders, or suicidal behaviors in the family.

The patient’s cultural history is similarly integral to understanding them and developing an effective plan of treatment. In addition to emphasizing relationships, both familial and nonfamilial, it also delineates the role of important cultural, spiritual, and religious beliefs and practices in the patient’s life (Aggarwal and Lewis-Fernández 2015; American Psychiatric Association 2022b; Lewis-Fernández et al. 2016). The Cultural Formulation Interview (American Psychiatric Association 2022b) provides a framework for obtaining this information as part of the evaluation. Clinicians should be especially careful to avoid cultural bias when applying the diagnostic criteria and evaluating sexual behavior, expressions of emotion, suspiciousness, or impulsiveness, which may have different norms in different cultures or subcultures. Individuals from different cultures or with different spiritual or religious beliefs may also have different views of roles among family members and intimate partners as well as different views of and knowledge about health and mental health, including diagnoses, treatments, attitudes, and beliefs toward the patient’s health and mental health issues.

The mental status examination is an essential part of the initial assessment. A full delineation of the mental status examination is beyond the scope of this document, and detailed information on conducting the examination is available elsewhere (American Psychiatric Association 2016a; Barnhill 2014; MacKinnon et al. 2016; Smith et al. 2019; Strub and Black 2000). In addition, for individuals with possible BPD, risk assessment is particularly important. It is crucial to identify past and current risks to self (e.g., suicidal ideas, methods, plans, and intent; NSSI; suicide attempts, including interrupted and aborted suicide attempts) and risks to others (e.g., aggressive or homicidal thoughts, statements, or behaviors). Information gathered and synthesized as part of the history and mental status examination will help identify modifiable risk factors for suicidal or aggressive behaviors that can serve as targets of intervention when constructing a plan of treatment. Inquiring about the patient’s degree of insight and judgment, as discussed earlier, also provides information relevant to risk assessment, treatment outcomes, and adherence (Mintz et al. 2003; Mohamed et al. 2009).

Several rating scales are available that have been used to identify and determine the severity of symptoms of BPD. Although rating scales have primarily been used in research contexts, they can also be used clinically to complement other aspects of the screening and assessment process (American Psychiatric Association 2016a).

Use of rating scales can aid treatment planning in several ways. Such measures provide a structured, replicable way to document the patient’s baseline symptoms. They also can help to determine which symptoms should be the target of intervention on the basis of factors such as frequency of occurrence, magnitude, or impact on the patient’s functioning, well-being, and quality of life. As treatment proceeds, use of quantitative measures allows more precise tracking of whether psychotherapies or other treatments are having their intended effect or whether a shift in the treatment plan is needed (Lewis et al. 2019). The exact frequency of measures depends on clinical circumstances. Nevertheless, it is preferable to use a consistent approach to quantitative measurement for a given patient because each rating scale defines and measures symptoms differently. In addition, patients’ ratings can be compared with family members’ impressions of treatment effects to clarify the longitudinal course of the patient’s illness.

When rating scales are used, they should always be implemented in a way that supports developing and maintaining the therapeutic relationship with the patient. Often, patient-rated scales are less time-consuming to administer than clinician-rated scales or structured or semistructured interviews. The use of anchored, self-rated scales with criteria to assess the severity and frequency of symptoms can also help patients become more informed self-observers. In addition, they provide important insights into the patient’s experience that support person-centered care. Reviewing scale results with the patient can help foster a collaborative dialogue about progress toward symptom improvement, functioning gains, and recovery goals. Such a review may help clinicians, patients, families, and other support persons recognize that improvement is occurring or, conversely, identify issues that need further attention.

If more than one quantitative measure is being used, it is important to minimize duplication of questions and avoid overwhelming the patient with an excessive number of scales to complete. Optimal scale properties (e.g., sensitivity, specificity) differ depending on the desired purpose(s) for using the scale in a given patient. In addition, when choosing among available quantitative measures, the psychometric properties (e.g., scale validity, reliability)1 and the objectives for using the scale (e.g., screening, documenting baseline symptoms, ongoing monitoring) should be considered. Assessments of scale properties are typically conducted cross-sectionally, however; therefore, less information may be available about longitudinal use.

A number of factors can affect the interpretation of quantitative measures. For example, some scales ask the patient to rate symptoms over several weeks, which can reduce their ability to detect changes in symptoms. This can be particularly problematic in acute care settings, where treatment adjustments and symptom improvement can occur quickly. Other symptom-based quantitative measures focus either on symptom frequency over the observation period or on symptom severity. Although these features often increase or decrease in parallel, that is not invariably the case. Quantitative measures that ask the patient to consider both symptom frequency and severity can also make the findings difficult to interpret.

It is also possible for rating scales to introduce biases into the assessment process. Factors such as comorbid illnesses, age, language, race, ethnicity, sex/gender, cultural background, literacy, and health literacy are often inadequately addressed during rating scale development. These factors and others can affect patients’ interpretation of questions. Thus, the answers to questions and the summative scores on quantitative measures need to be interpreted in the context of the rating scale’s properties and the patient’s clinical presentation.

The type and extent of quantitative measures used will also be determined by the clinical setting, the time available for evaluation, the urgency of the situation, the availability of validated rating scales in the patient’s primary language, and the patient’s age. In adolescents, for example, self-report scales and ratings from parents/guardians and teachers can provide helpful information (De Los Reyes et al. 2015). In some clinical contexts, such as a planned outpatient assessment, patients may be asked to complete electronic- or paper-based quantitative measures, either prior to the visit or on arrival at the office (Allen et al. 2009; Harding et al. 2011). Between or prior to visits, electronic approaches (e.g., mobile phone applications, clinical registries, patient portal sites in electronic health records) may also facilitate obtaining quantitative measurements (Lewis et al. 2019; Palmier-Claus et al. 2012; Wang et al. 2018). In other clinical contexts, such as acute inpatient settings, electronic modes of data capture may be more challenging. As an alternative, printed versions of scales may be completed by the patient (or a proxy) or administered by the clinician. In emergency settings, use of a quantitative rating scale may need to be postponed until the acute crisis has subsided or until the patient’s clinical status permits a detailed examination. Furthermore, some patients may have difficulty completing self-report instruments due to severe symptoms, co-occurring psychiatric conditions, low health literacy, reading difficulties, or cognitive impairment (Harding et al. 2011; Narrow et al. 2013; Valenstein et al. 2009; Zimmerman et al. 2011).

Although recommending a particular measure is outside the scope of this practice guideline, a number of objective, quantitative rating scales are available for monitoring the symptoms and features of BPD. The 23-item version of the Borderline Symptom List (BSL-23), which is condensed from the 93-item version (Bohus et al. 2007; Central Institute of Mental Health 2020), is a freely available self-report scale that assesses 23 feelings and experiences typically reported by BPD patients (Kleindienst et al. 2020). Individuals are asked to describe the extent to which they experienced a particular item in the past week based on a scale from 0 (not at all) to 4 (very strong) (Kleindienst et al. 2020). The BSL-23, similar to the BSL-93, was found to have high internal consistency, good sensitivity to the effects of treatment, and an ability to discriminate BPD from other psychiatric diagnoses (Bohus et al. 2009). In addition, symptom severity as measured by the BSL-23 appears to correlate with treatment seeking, as well as with the presence of a BPD diagnosis (Kleindienst et al. 2020).

The Borderline Evaluation of Severity Over Time (BEST) is another freely available self-report scale that focuses on the degree to which a symptom interfered with life in the past week and on idealization/devaluation shifts in relationships (Pfohl et al. 2009). In addition, the BEST includes two anger-related items, two abandonment-related items, one item for other BPD criteria, and an item for suicidal ideation (Pfohl et al. 2009). It is reported to have high internal consistency and moderate test-retest reliability (Pfohl et al. 2009).

For adolescents, the 11-item Borderline Personality Features Scale for Children includes self-report and parent-report versions (Sharp et al. 2011, 2014; Vanwoerden et al. 2019; Wall et al. 2019).

The self-report version of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD; Zanarini et al. 2015) is developed from and organized and scored similarly to the interview-based version of the ZAN-BPD (Zanarini et al. 2003). Both versions of the scale require the author’s permission for use, are based on the nine items in the DSM-IV criteria for BPD, and include anchored ratings on a five-point scale from 0 (no symptoms) to 4 (severe symptoms). The scores for each item can be summed to yield a total score, or scores can be calculated for four symptom domains: affective, cognitive, impulsive, and interpersonal (Zanarini et al. 1990). Alternatively, the self-report version of the rating scale can be formatted with Yes/No answers to questions for use as a screening measure. Both versions of the ZAN-BPD showed adequate sensitivity to change at 7–10 days (Zanarini et al. 2015). In addition, scores of the self-report version of the ZAN-BPD showed high convergent validity with scores based on the interview version of the scale as well as good internal consistency and excellent same day test-retest reliability (Zanarini et al. 2015).

The Difficulty in Emotional Regulation Scale (DERS; Gratz and Roemer 2004) is another self-report scale that has been used clinically and in research studies of individuals with BPD. It is freely available and consists of 36 items rated from 1 (almost never) to 5 (almost always) that address six domains: nonacceptance of negative emotions, inability to engage in goal-directed behaviors when distressed, difficulties controlling impulsive behaviors when distressed, limited access to emotion regulation strategies perceived as effective, lack of emotional awareness, and lack of emotional clarity. The psychometric properties of the DERS have been noted to be improved by removing the scale items related to awareness (Hallion et al. 2018; Lee et al. 2016). However, in other respects, the DERS scores generally have good internal consistency and construct validity in adolescents as well as adults (Fowler et al. 2014; Gratz and Roemer 2004; Neumann et al. 2010; Ritschel et al. 2015). In addition, it shows changes with treatment (Gratz et al. 2014; McCauley et al. 2018). Several shortened versions of the DERS are available: the DERS-18 (Victor and Klonsky 2016), the DERS-16 (Bjureberg et al. 2016), the DERS-8 (Penner et al. 2022), and the DERS-SF (Kaufman et al. 2016). Results of the shortened versions correlated with findings on the full 36-item scale. Two studies that compared the original 36-item DERS with the DERS-18, DERS-16, and DERS-SF did not find any of these shortened versions to be superior to the others (Hallion et al. 2018; Skutch et al. 2019).

Self-harm, including suicide attempts and NSSI, is common among individuals with BPD (Grilo and Udo 2021; Yen et al. 2021; Zanarini et al. 2008). Although many of the rating scales for BPD symptoms include items related to self-harm, multiple scales exist that provide more detailed information about self-harming behaviors (Latimer et al. 2012; Sansone and Sansone 2010). One example of such a scale is the Deliberate Self-Harm Inventory (DSHI; Gratz 2001), which is a freely available 17-item self-report tool with good test-retest reliability and construct validity (Fliege et al. 2006; Gratz 2001). In addition to noting which self-harming behaviors are present and their frequency, information from the scale can be transformed into a continuous variable by summing the frequency scores for each item (Gratz and Gunderson 2006). Another scale, the Inventory of Statements About Self-injury, is aimed at assessing the patient’s perspective on interpersonal and intrapersonal functions of non-suicidal self-injurious behaviors (Klonsky and Glenn 2009).

The Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF) is aimed at assessing personality function more broadly, consistent with the AMPD (Hutsebaut et al. 2016; Weekers et al. 2019). It is freely available and consists of 12 statements rated as “very false or often false,” “sometimes or somewhat false,” “sometimes or somewhat true,” or “very true or often true.” Factor analysis suggested that the LPFS-BF evaluates two domains: self-functioning and interpersonal functioning (Weekers et al. 2019). In addition, there was high sensitivity to change at 3 months of treatment, adding to the evidence that LPFS-BF scores are indicative of personality functioning (Le Corff et al. 2022; Weekers et al. 2019).

Other self-report rating scales of relevance to individuals with a personality disorder have been reviewed in detail by the International Consortium for Health Outcomes Measurement (ICHOM), a multidisciplinary international working group that conducted a systematic review and subsequent Delphi process to develop a standard set of outcome measures for individuals with personality disorders (Prevolnik Rupel et al. 2021).

Because reductions in symptoms can occur despite significant impairments in quality of life or functioning (Gunderson et al. 2011; Niesten et al. 2016), rating scales that assess these latter domains can also provide helpful information. One example of a scale that can be utilized to assess quality of life is the WHOQOL-BREF scale (Skevington et al. 2004; WHOQOL Group 1998; http://depts.washington.edu/seaqol/WHOQOL-BREF), developed by the World Health Organization. For assessing functioning difficulties due to health and mental health conditions, DSM-5 (American Psychiatric Association 2013a) includes the 36-item self- and proxy-administered versions of the World Health Organization Disability Schedule 2.0 (WHODAS 2.0; American Psychiatric Association 2013c; Üstün et al. 2010). Other options for assessing functioning include the Social and Occupational Functioning Assessment Scale (SOFAS; American Psychiatric Association 2000) and the Personal and Social Performance scale (Morosini et al. 2000). Several versions of Patient-Reported Outcomes Measurement Information System (PROMIS) scales, which address social roles and functioning, are also available (www.healthmeasures.net/explore-measurement-systems/promis).

Once a diagnosis of BPD has been established, it is important to discuss the diagnosis with the patient in a collaborative fashion that allows them to ask questions and share their experiences and perspectives. When treating an adolescent, parents or other involved caregivers should also be engaged in the discussion of the diagnostic impression. Clinicians are sometimes reluctant to document a diagnosis of BPD or to share the diagnosis with patients out of concern for upsetting the patient, disrupting the therapeutic relationship, or contributing to discrimination toward the patient because of stigma against individuals with BPD or those with psychiatric conditions more generally (Lequesne and Hersh 2004; Proctor et al. 2021; Sims et al. 2022; Sisti et al. 2016; Sulzer et al. 2016). However, disclosure and discussion of a BPD diagnosis is preferred by patients (Proctor et al. 2021; Sulzer et al. 2016), does not adversely affect patient satisfaction (Zimmerman et al. 2018), is crucial on ethical grounds (American Medical Association Code of Medical Ethics 2023b), and is part of good clinical practice. In addition, with the passing of the 21st Century Cures Act (Office of the National Coordinator for Health Information Technology 2020), clinical notes are required to be shared with patients except under very limited circumstances, and proactively disclosing and discussing the diagnosis of BPD will aid patients in understanding these notes. For many patients, having access to notes and understanding the information that they contain fosters greater engagement in their own care (DesRoches et al. 2020).

Disclosing a diagnosis of BPD is also an initial step in discussing treatment options as well as in providing psychoeducation about BPD to patients. When psychoeducation is provided in a compassionate, nonjudgmental fashion, it can provide context and validation for the patient’s experiences (e.g., in relationships, sense of self, emotional response). It is also important to ask about and understand the patient’s beliefs about BPD and its features because patients may have internalized stigma or received misinformation related to the diagnosis (Koivisto et al. 2022; Masland et al. 2023). Typically, topics reviewed as part of psychoeducation include symptoms and behaviors that are often a part of the disorder and the expected types and courses of treatment (American Psychiatric Association 2016a). For patients with BPD, it is particularly important to emphasize that treatment is effective (Ng et al. 2016, 2019a, 2019b). Many patients with BPD benefit from ongoing education about self-care (e.g., safe sex, potential legal problems, balanced diet) as well as education about crisis or safety plans. For patients who also have other concomitant disorders, these can be discussed in terms of their features and treatments in the context of BPD. In addition to psychoeducation provided by the clinician, it can be helpful to share criteria from DSM-5-TR (American Psychiatric Association 2022a), internet resources (Emotions Matter 2023a; Gunderson and Berkowitz 1991; National Education Alliance for Borderline Personality Disorder 2023c; National Institute of Mental Health 2023; New York Presbyterian Hospital 2023), or books on personality traits (Oldham and Morris 1995) or BPD (National Education Alliance for Borderline Personality Disorder 2023a) written for laypersons. More extensive psychoeducational intervention, consisting of workshops, lectures, seminars, or web-based programs may also be helpful.

Family members and other caregivers will often be a key part of the patient’s support network and care team, and this is particularly true when treating an adolescent. For this reason, family members and others in the support network will often benefit from receiving educational materials about BPD or being directed to organizations that offer education and support (Emotions Matter 2023a; Mental Health America 2023; National Alliance on Mental Illness 2023; National Education Alliance for Borderline Personality Disorder 2023b; New York Presbyterian Hospital 2023). In addition to providing emotional support, such individuals may also be providing material support such as housing, financial assistance, insurance, transportation, childcare, or other assistance. They may be able to share observations about the patient’s symptoms or behaviors, help the patient develop a safety plan, provide opinions about specific treatment approaches, or identify practical barriers to the patient’s ability to participate in treatment, such as limitations on insight, geographical issues, lack of transportation, childcare or caregiving responsibilities, financial or insurance coverage constraints, insufficient access to recommended treatment, or other systemic barriers to care. Psychoeducation for families should be distinguished from family therapy, which is sometimes a desirable part of the treatment plan and sometimes not, depending on the patient’s history and status of current relationships.

Psychotherapy is at the core of treatment for BPD for adolescents and adults. A structured approach that has support in the literature is recommended. The specific psychotherapeutic approach selected should target the core features of the disorder.

With all psychotherapeutic modalities, it is important to foster a positive, trusting therapeutic alliance, convey a validating and nonjudgmental attitude, and balance active support with an impetus to change and develop self-efficacy. Setting a framework for treatment is also crucial (see the “Implementation” section for Statement 3), although aspects of the therapeutic framework will depend on the type of structured psychotherapy for BPD being used. Teaching of skills and development of crisis plans are elements of treatment that are shared by many psychotherapies for BPD, whereas other psychotherapies have a basis in psychodynamic principles and focus on helping patients use the therapeutic relationship to address problematic defensive patterns and understand their own and others’ mental states (Bohus et al. 2021; Leichsenring et al. 2023). In adolescents and young adults, psychotherapy will typically need to address developmental issues (Sharp and Wall 2018) and to incorporate family members or other caregivers as part of psychotherapy. For adults, family members and others in the patient’s support network may also be involved in treatment. Developmental tasks may also warrant exploration at other points in the individual’s life.

Multiple structured approaches to psychotherapy are available and have been studied in patients with BPD (see Appendix C, Statement 5, and Appendix D); characteristics of these approaches are summarized in Table 3. Structured psychotherapies for BPD have an associated manual or protocol and typically incorporate ongoing supervision. These factors build on initial training and supervision in the use of a specific psychotherapy and help support delivery of treatment with a high degree of fidelity.

Although a number of structured approaches to psychotherapy that target BPD are superior to treatment-as-usual or wait-list control conditions, there is no clear evidence that any specific structured approaches to psychotherapy of BPD have significantly superior outcomes to other BPD-focused structured psychotherapeutic modalities in either adults or adolescents (Storebø et al. 2020; see Statement 5 in Appendix C). In addition, limited information is available on treatment of men, gender minorities, or non-White individuals or those with Hispanic ethnicity (Storebø et al. 2020; see Statement 5 in Appendix C). In most studies that compare two active treatments, both types of psychotherapy are associated with clinical improvement, even when the outcomes of the therapies do not differ with respect to one another (see Appendices C and D). As such, selection of a treatment approach will depend on factors such as patient preferences for treatment, the availability of specific treatments, and the resource requirements of a treatment (Bohus et al. 2021; Choi-Kain et al. 2016, 2017). Under some circumstances, a patient may be unable or prefer not to access a structured form of psychotherapy for BPD (e.g., due to availability, insurance coverage, affordability of a specific psychotherapy, other reasons related to logistics or patient preference). In this situation, less structured supportive psychotherapy may still produce clinical improvements via ongoing treatment engagement, including building a therapeutic alliance and providing psychoeducation (see Statement 3).

In terms of the optimal duration of psychotherapy for BPD, evidence is also limited in terms of the time needed to resolve interpersonal problems and to attain and maintain lasting improvements in personality-related dysfunction and overall functioning. Most studies of structured psychotherapies for BPD have ranged in duration from 6 months to 18 months (Storebø et al. 2020; see Appendix D). In one longitudinal study, a majority of patients continued in some form of outpatient treatment for much of a 6-year period of follow-up (Zanarini et al. 2004b). Although other treatment trials have been of shorter duration, study participants often continue to receive other treatment, including psychotherapy for BPD, after completion of the research trials. In addition, a significant number of patients with BPD do not fully respond to initial treatment (Woodbridge et al. 2022) and may require longer periods of treatment. It is also unclear whether the optimal treatment duration varies with specific BPD features, overall severity, or with treatment intensity. For example, in an inpatient sample of individuals with BPD, many with co-occurring disorders, an intensive multimodal therapeutic approach that incorporated a mentalization-based therapeutic model was associated with a significant degree of benefit on multiple outcomes with an average length of stay of 6 weeks (Fowler et al. 2018).

DBT is a multicomponent approach that has efficacy in treating adolescents and adults with BPD but may also be useful in treating patients with other diagnoses who are at significant risk for suicide (Linehan 1993a, 1993b; Linehan et al. 2015). A key focus of DBT is to help patients develop a proactive problem-solving approach and to learn to tolerate stress, regulate emotions, improve interpersonal effectiveness, and develop mindfulness (i.e., an ability to focus awareness on the present moment) as a way to address emotional dysregulation. At the core of the therapy is a philosophical dialectic between self-acceptance and strategies aimed at change. Skills worksheets and a specific protocol for addressing suicidal thoughts and behaviors are incorporated in the therapy. DBT is administered by a team of clinicians and is time intensive for clinical teams as well as for patients. It typically includes 6–12 months of treatment with 1 hour of individual therapy and 90 minutes of group skills training weekly. Treatment team members are also available by cellphone for skills coaching between sessions. Weekly therapist consultation is an integral part of the treatment.

DBT skills training has also been studied as a standalone treatment and showed comparable effects to the full multicomponent approach to DBT when individual therapy was replaced with a case management intervention (Linehan et al. 2015). As a less intensive intervention, DBT skills training may be more accessible than multicomponent DBT. Manual-assisted CBT, a 10-session intervention, can also be considered as a less intensive approach in the treatment of individuals with BPD (Davidson et al. 2014; Tyrer et al. 2004; Weinberg et al. 2006).

As the name implies, MBT focuses on mentalization, the ability to reflect on one’s thoughts and feelings as well as those of others. Without such an ability, it is challenging to have a realistic emotional perspective on interpersonal events, particularly under stress. In MBT, the therapist guides the patient in learning to assess the emotional aspects of stressful interpersonal situations, such as those related to attachment, and then adopt a more realistic behavioral response (Bateman and Fonagy 2004, 2009; Jørgensen et al. 2013). The therapeutic relationship can also provide examples for working through these steps, although transference interpretations are not used. MBT typically includes 12–18 months of treatment with 50 minutes of weekly individual therapy and 75–90 minutes of group therapy. In adolescents, family therapy is incorporated in the treatment instead of group therapy. A weekly team meeting is also part of the treatment protocol.

TFP is a manualized, psychodynamically oriented psychotherapy that uses the transference relationship to help address intense emotional states and difficulties in interpersonal relationships (Caligor et al. 2018; Clarkin et al. 2007; Doering et al. 2010; Giesen-Bloo et al. 2006; Yeomans et al. 2015). A core principle of TFP is the belief that internal images of the self in relation to others, based on developmental experiences, exist in the mind of all people. These mental images of self in relation to others are connected by strong emotions. In BPD, the internal mental images are extreme, intense, and polarized due to biological and developmental influences. Transference is the activation of these internal images in interactions with people. In the structured setting of therapy, this activation of the internal images of the self in relation to others can be observed and understood as they are experienced in relation to the therapist. This treatment model engages reflection on the emotions being experienced in the moment, along with reflection on the reasons that the images are extreme and polarized. This joint reflection on internal states helps the patient to modulate affects better and to experience both the self and relations with others in a more complex and realistic way. TFP typically includes 12–18 months of individual therapy delivered for 50 minutes twice weekly. TFP concepts and techniques can also be incorporated into other settings (Hersh et al. 2017). Supervision is recommended for clinicians who treat patients with TFP.

DDP is a manualized individual psychotherapy (Gregory 2022; Gregory and Remen 2008), derived from psychodynamic psychotherapy, that uses the philosophical concept of deconstruction as a framework for treatment. Links to neurobiology and object relations are also part of the theoretical foundation of DDP. Therapeutic interventions focus on approaches such as alliance building, reflective listening, describing affect-laden experiences as simple narratives, recognizing and addressing polarized attributions, learning to assess oneself from an external perspective, and facilitating mourning of the limitations of oneself and others (Gregory 2022). Recent interpersonal experiences serve as primary examples for discussion, although dream exploration, artwork, or creative writing can also be used. DDP typically includes 12–18 months of treatment delivered weekly in 45- to 50-minute sessions. Other interventions such as interpersonally focused group therapy, art therapy, or 12-step programs can supplement DDP.

SFT is based on the concept that individuals view themselves and others in terms of cognitive “schemas” that are an outgrowth of developmental experiences and that manifest themselves in persistent patterns of thinking, feeling, and behaving, although they are often outside of conscious awareness (Arntz and van Genderen 2021; Farrell et al. 2009; Giesen-Bloo et al. 2006; Young et al. 2003). In BPD, dysfunctional “schema modes” are seen as strongly held and controlling a person’s life through recurring and rapidly shifting constellations of intense emotions, thoughts, feelings, and behaviors. These dysfunctional schema modes are addressed by fostering attachment between the patient and therapist as well as by applying behavioral, cognitive, and experiential techniques (including homework assignments). SFT also incorporates emotional awareness training and psychoeducation and employs individualized plans for managing distress. In clinical trials, SFT has been delivered in individual 50-minute twice weekly sessions for 3 years (Giesen-Bloo et al. 2006) or in weekly 90-minute group sessions for 8 months (Farrell et al. 2009).

STEPPS is designed as a supplement to other treatment approaches and is delivered in a seminar format using detailed lesson plans (Bartels and Crotty 1992; Blum et al. 2008; STEPPS 2022). STEPPS consists of weekly 2-hour groups for 20 weeks as well as a single 2-hour session for families. It incorporates psychoeducation and skills training in emotional and behavioral management, viewed from the context of social and family systems. Participants are asked to monitor their thoughts, feelings, and behaviors over the course of the program to increase their awareness and identify improvements.

GPM uses a multimodal case management model in which BPD is understood as a reflection of interpersonal hypersensitivity (Gunderson et al. 2018; Links 2014; McMain et al. 2009). As originally studied (McMain et al. 2009), GPM was developed using psychodynamic principles. Treatment uses a generalist model that emphasizes improvements in vocational and social functioning and incorporates psychoeducation about BPD, as well as psychopharmacological management when clinically appropriate (Gunderson et al. 2018; Links 2014). The therapy uses a here-and-now approach in which the therapist shows interest in the patient’s experiences and the interpersonal context and thoughts that precede their feelings and behaviors. It also focuses on the therapeutic alliance, including attention to signs that a negative transference may be developing. GPM is typically delivered in once-weekly sessions with weekly therapist supervision. An advantage of GPM is that it is relatively easy for clinicians to learn and apply (Bernanke and McCommon 2018; Hong 2016; Links et al. 2015). It has also been adapted for use with adolescents (Ilagan and Choi-Kain 2021). In addition, training in GPM may improve clinician attitudes about treating patients with BPD (Keuroghlian et al. 2016; Klein et al. 2022b; Masland et al. 2018).

Psychotherapy is the primary modality recommended for use in the treatment of BPD. As such, it is important to learn about a patient’s past and current psychotherapies, including the types, the clinician’s fidelity to treatment principles, the treatment intensity and duration, and the patient’s experience with therapy if this information was not already obtained as part of the initial evaluations (see Statement 1). Such information is helpful in determining whether a current psychotherapy can be optimized before adding medication or whether a change in the psychotherapeutic approach may be needed.

Similarly, it is important to obtain information about prior medication trials, including the dosages, durations, effectiveness, and associated adverse effects if this information was not already obtained as part of the initial evaluations (see Statement 1). A review of current medications is also important to determine whether the patient has been able to obtain, adhere to, and tolerate the medication. If the medication has been ineffective or if the response has been insufficient, it may be possible to increase the dosage of the medication in an effort to achieve therapeutic benefit. Alternatively, if response has been minimal, it may be preferable to discontinue the medication and reassess the need for pharmacotherapy.

Half or more of BPD patients receive polypharmacy (Bridler et al. 2015; Gartlehner et al. 2021; Paris 2015; Romanowicz et al. 2020; Shapiro-Thompson and Fineberg 2022; Soler et al. 2022; Starcevic and Janca 2018), and drug-drug interactions may affect efficacy and tolerability by increasing or decreasing serum medication levels. Consequently, the medication regimen should be examined as a whole, rather than only assessing the value of single medications as a part of the treatment plan.

In addition to reviewing past and current treatments, including other nonpharmacological treatments (e.g., ECT, TMS, light therapy), it is important to determine whether the patient has co-occurring psychiatric symptoms or disorders that warrant medication treatment (see the subsection “Addressing Co-occurring Psychiatric Disorders” in Statement 3). Although patients with BPD often have co-occurring psychiatric disorders, such as mood disorders, PTSD, anxiety disorders, eating disorders, ADHD, 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; Santo et al. 2022; Tate et al. 2022; Trull et al. 2018; Zanarini et al. 2004a, 2010, 2019; Zimmerman et al. 2017), they also may exhibit symptoms such as impulsivity or mood dysregulation that are a reflection of BPD and not indicative of a co-occurring disorder. A careful history, including a family history of psychiatric illness and a longitudinal history of psychiatric symptoms or episodes, will facilitate appropriate diagnosis of co-occurring conditions when they are present without overdiagnosing (and overtreating) co-occurring conditions when they are not present.

Despite the lack of evidence in support of medication treatment from clinical trials (see Appendix C, Statement 7, and Appendix D; Gartlehner et al. 2021; Stoffers-Winterling et al. 2022), there may be circumstances in which treatment with a medication may be considered on clinical grounds. For example, medication to address co-occurring disorders will generally be appropriate to use (see the subsection “Addressing Co-occurring Psychiatric Disorders” in Statement 3). In other circumstances, pharmacotherapy may be used on a time-limited basis as an adjunct to psychotherapy for BPD and may help diminish symptoms such as affective instability, impulsivity, or psychotic-like symptoms in individual patients, helping them to remain engaged in treatment or reducing short-term risks of self-harm.

Selection of a medication, if one appears to be appropriate, will depend on the BPD symptom or symptoms being targeted or on the typical recommended treatments for a co-occurring condition. For example, in a patient with co-occurring MDD or OCD, SSRIs may be appropriate to use. A low dosage of a second-generation antipsychotic medication may be used for treatment of BPD symptoms in patients with psychosis, high levels of impulsivity, or agitation (Bohus et al. 2021). For extremely ill hospitalized patients with BPD (with or without psychotic symptoms), clozapine may be considered based on case reports, naturalistic data, and a small clinical trial (Chengappa et al. 1999; Crawford et al. 2022; Rohde et al. 2018). Anticonvulsant mood-stabilizing medications are sometimes used but have limited evidence of efficacy in individuals with BPD without co-occurring mood disorders (Gartlehner et al. 2021; Crawford et al. 2018). Use of benzodiazepines is not generally recommended because of the potential for greater impulsivity or disinhibition as well as the potential for misuse or the development of dependence (Leichsenring et al. 2023; Lieslehto et al. 2023; Pascual et al. 2023). Decisions about medication should also consider potential risks of toxicity in overdose or potential for misuse, particularly in individuals with a co-occurring SUD. In addition, before treating a co-occurring disorder, a thorough assessment is needed to establish the diagnosis and to determine the target symptoms for ongoing monitoring.

Prior to prescribing a medication, it is important to educate patients about the adjunctive nature of the medication in treating BPD symptoms and its potential benefits and adverse effects. In particular, medications would not be expected to affect the core features of BPD. Also, the response of co-occurring conditions to medications may be less in individuals who also have BPD. Overreliance on medication can send the erroneous message that emotional responses can be addressed by pharmacotherapy. Frequent dosage escalation or medication changes in response to crises or transient mood states are also problematic and rarely effective. Potential adverse effects of specific medications should be reviewed prior to treatment initiation. Examples include risk of metabolic syndrome, weight gain, extrapyramidal side effects, or tardive dyskinesia with antipsychotic agents; risk of neural tube defects with divalproex use early in pregnancy; risk of polycystic ovary disease with divalproex in individuals with ovaries; risk of Stevens-Johnson syndrome with lamotrigine; and cognitive effects with topiramate. In adolescents, clinical trials of medications to treat BPD have not been conducted, and side effects of medications may be more problematic.

If a medication is started, the duration of treatment should be time limited, with tapering and discontinuation of the medication, if possible, once symptoms have stabilized. While treatment is occurring, however, patients should receive any monitoring that is necessary for the specific medication (e.g., serum levels for some anticonvulsants, metabolic monitoring for antipsychotics).

Communication with other members of the treatment team is an essential aspect of decision-making about medications. Treatment team members and other collateral sources of information (e.g., family members) can provide ongoing observations about symptom response, in addition to direct observation and feedback from the patient. It is also important to communicate with other health professionals, such as primary care clinicians, who may be unaware of the complexities of prescribing medications to individuals with BPD and may inadvertently prescribe unwarranted medications.

Appropriate use of pharmacotherapy for BPD includes prescribing as few medications as possible, using medication as an adjunct to treatment with psychotherapy, and selecting medications based on their ability to target specific and prominent symptom clusters (Gartlehner et al. 2021; Yadav 2020). Continuous review and reconciliation of medications is critical for avoiding or mitigating prolonged and unnecessary exposure to pharmacotherapy as well as inappropriate polypharmacy (Bridler et al. 2015; Gartlehner et al. 2021; Paris 2015; Romanowicz et al. 2020; Shapiro-Thompson and Fineberg 2022; Soler et al. 2022; Starcevic and Janca 2018). Medication reconciliation is a recommended best practice in hospital as well as outpatient settings (Institute for Safe Medication Practice 2023; The Joint Commission 2022).

Medication review has been suggested as an important part of optimizing therapeutic benefit for patients with BPD and should involve a structured, critical assessment of all medications prescribed, including among patients also participating in psychotherapy (Kadra-Scalzo et al. 2021). It is especially useful following stabilization of an acute crisis because this is often a precipitating event that prompts medication initiation, and once resolved, might preclude the need for continued pharmacotherapy (Starcevic and Janca 2018). Medication monitoring and review is an important strategy for early identification of drug-drug interactions and adverse reactions, the latter of which could lead to symptom exacerbation (e.g., use of benzodiazepines to reduce anxiety may exacerbate disinhibition and cognitive deficits) (Fineberg et al. 2019). Medication review is also necessary given the natural course of BPD, wherein symptoms fluctuate in intensity and frequency and may remit rapidly (Fineberg et al. 2019; Videler et al. 2019). In addition, patients may improve with psychotherapy and no longer require the same medications or medication dosages. Thus, patients taking medication need to be monitored carefully and routinely to determine treatment response and taper or discontinue as needed (Fineberg et al. 2019). Ongoing reevaluation of the risks and benefits of a patient’s current medication should continue throughout treatment, especially given that some symptoms may resolve spontaneously (Ripoll 2013).

Appropriate use of pharmacotherapy for patients with BPD should also include a plan for deprescribing, such as tapering strategies and ongoing monitoring for changes in clinical presentation and adverse reactions (Fineberg et al. 2019; Shapiro-Thompson and Fineberg 2022). An effective plan for deprescribing includes making a list of medications—such as dosage, route of administration, duration, expected benefits, adverse reactions, and potential for withdrawal symptoms with discontinuation—and working collaboratively with the patient to weigh the risks and benefits of tapering or discontinuing the medication (Chanen and Thompson 2016; Fineberg et al. 2019).