APA practice guideline for the treatment of patients with Borderline Personality Disorder.pdf

Practice

Guideline

for the

Treatment of Patients

With Borderline

Personality Disorder

American Psychiatric Association

Originally published in October 2001.

A guideline watch, summarizing significant developments in

the scientific literature since publication of this guideline,

may be available in the Psychiatric Practice section

of the APA web site at www.psych.org.

American Psychiatric Association

1000 Wilson Boulevard

Arlington, VA 22209-3901

www.psych.org

WORK GROUP ON BORDERLINE PERSONALITY DISORDER

John M. Oldham, M.D., Chair

Katharine A. Phillips, M.D., Consultant

Glen O. Gabbard, M.D.

Marcia K. Goin, M.D., Ph.D.

John Gunderson, M.D.

Paul Soloff, M.D.

David Spiegel, M.D.

Michael Stone, M.D.

STEERING COMMITTEE ON PRACTICE GUIDELINES

John S. McIntyre, M.D., Chair

Sara C. Charles, M.D., Vice-Chair

Kenneth Altshuler, M.D.

C. Deborah Cross, M.D.

Helen Egger, M.D.

Barry J. Landau, M.D.

Louis Alan Moench, M.D.

Allan Tasman, M.D.

Stuart W. Twemlow, M.D.

Sherwyn Woods, M.D., Ph.D.

Joel Yager, M.D.

CONSULTANTS AND LIAISONS

Paula Clayton, M.D. (Consultant)

Amarendra Das, M.D., Ph.D. (Liaison)

Marcia K. Goin, M.D., Ph.D. (Liaison)

Marion Goldstein, M.D. (Liaison)

Sheila Hafter Gray, M.D. (Consultant)

Margaret T. Lin, M.D. (Liaison)

Herbert Meltzer, M.D. (Consultant)

Grayson Norquist, M.D. (Consultant)

Susan Stabinsky, M.D. (Consultant)

Robert Johnston, M.D. (Area I)

James Nininger, M.D. (Area II)

Roger Peele, M.D. (Area III)

Anthony D’Agostino, M.D. (Area IV)

R. Scott Benson, M.D. (Area V)

Lawrence Lurie, M.D. (Area VI)

R. Dale Walker, M.D. (Area VII)

Michael B. First, M.D., Medical Editor, Quick Reference Guides

STAFF

Rebecca M. Thaler, M.P.H., C.H.E.S., Senior Project Manager

Robert Kunkle, M.A., Project Manager

Althea Simpson, Project Coordinator

Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services

Lloyd I. Sederer, M.D., Director, Division of Clinical Services

For Continuing Medical Education credit for APA Practice Guidelines,

visit www.psych.org/cme

To order the 2004 Compendium of Quick Reference Guides to the

APA Practice Guidelines,

visit www.appi.org or call 800-368-5777.

The American Board of Psychiatry and Neurology (ABPN)

has reviewed the APA Practice Guidelines CME Program

and has approved this product as part of a comprehensive

lifelong learning program, which is mandated by the

American Board of Medical Specialties as a necessary

component of maintenance of certification.

ABPN approval is time limited to 3 years for each

individual Practice Guideline CME course.

Refer to APA’s CME web site for ABPN approval status of each course.

CONTENTS

STATEMENT OF INTENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

GUIDE TO USING THIS PRACTICE GUIDELINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

OVERVIEW OF GUIDELINE DEVELOPMENT PROCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

PART A: TREATMENT RECOMMENDATIONS FOR PATIENTS WITH

BORDERLINE PERSONALITY DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

I. EXECUTIVE SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

A. Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

B. General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

C. Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

II. FORMULATION AND IMPLEMENTATION OF A TREATMENT PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . 6

A. The Initial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

B. Principles of Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

C. Principles of Treatment Selection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

D. Specific Treatment Strategies for the Clinical Features of Borderline Personality Disorder. . . . . . . . . . . . 14

III. SPECIAL FEATURES INFLUENCING TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

A. Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

B. Problematic Substance Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

C. Violent Behavior and Antisocial Traits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

D. Chronic Self-Destructive Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

E. Childhood Trauma and PTSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

F. Dissociative Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

G. Psychosocial Stressors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

H. Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

I. Cultural Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

J. Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

IV. RISK MANAGEMENT ISSUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

A. General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

B. Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

C. Anger, Impulsivity, and Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

D. Boundary Violations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

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