PRACTICE GUIDELINE FOR THE Treatment of Patients With ...

1 1 PRACTICE GUIDELINE FOR THE Treatment of Patients With Borderline Personality DisorderWORK group ON BORDERLINE PERSONALITY DISORDERJohn M. Oldham, , ChairGlen O. Gabbard, K. Goin, , Gunderson, Soloff, Spiegel, Stone, A. Phillips, (Consultant)Originally published in October 2001. This GUIDELINE is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and PRACTICE . In accordance with national standards, including those of the Agency for Healthcare Research and Quality s National GUIDELINE Clearinghouse ( ), this GUIDELINE can no longer be assumed to be current. The March 2005 GUIDELINE Watch associated with this GUIDELINE provides additional information that has become available since publication of the GUIDELINE , but it is not a formal update of the 2010, American Psychiatric Association.

2 APA makes this PRACTICE GUIDELINE freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this GUIDELINE may be reproduced except as permitted under Sections 107 and 108 of Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at PRACTICE GuidelinesAMERICAN PSYCHIATRIC ASSOCIATIONSTEERING COMMITTEE ON PRACTICE GUIDELINESJohn S. McIntyre, ,ChairSara C. Charles, ,Vice-ChairDaniel J. Anzia, A. Cook, T. Finnerty, R. Johnson, E. Nininger, Summergrad, M. Woods, , Yager, AND COMPONENT LIAISONSR obert Pyles, (Area I)C. Deborah Cross, (Area II)Roger Peele, (Area III)Daniel J. Anzia, (Area IV)John P. D. Shemo, (Area V)Lawrence Lurie, (Area VI)R. Dale Walker, (Area VII)Mary Ann Barnovitz, Hafter Gray, Saxena, Tonnu, Kunkle, , Senior Program ManagerAmy B.

3 Albert, , Assistant Project ManagerLaura J. Fochtmann, , Medical EditorClaudia Hart, Director, Department of Quality Improvement and Psychiatric ServicesDarrel A. Regier, , , Director, Division of ResearchCopyright 2010, American Psychiatric Association. APA makes this PRACTICE GUIDELINE freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this GUIDELINE may be reproduced except as permitted under Sections 107 and 108 of Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at of Patients With Borderline Personality Disorder3 CONTENTSS tatement of Intent .. 5 Guide to Using This PRACTICE GUIDELINE .. 6 Introduction .. 7 Development Process .. 8 Part A: Treatment Recommendations for Patients With Borderline Personality Disorder.

4 Summary of Recommendations .. System .. Considerations .. of Recommendations.. and Implementation of a Treatment Plan .. Initial Assessment.. of Psychiatric Management .. of Treatment Selection .. Treatment Strategies for the Clinical Features of Borderline Personality Disorder.. Features Influencing Treatment .. Substance Use .. Behavior and Antisocial Traits .. Self-Destructive Behavior .. Trauma and PTSD .. Features .. Stressors .. Factors .. Management Issues .. Considerations .. , Impulsivity, and Violence .. Violations .. 40 Copyright 2010, American Psychiatric Association. APA makes this PRACTICE GUIDELINE freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this GUIDELINE may be reproduced except as permitted under Sections 107 and 108 of Copyright Act.

5 For permission for reuse, visit APPI Permissions & Licensing Center at PRACTICE GuidelinesPart B: Background Information and Review of Available Evidence.. Definition, Epidemiology, and Natural History .. and Core Clinical Features .. Diagnosis .. History and Course .. and Synthesis of Available Evidence .. in Interpreting the Literature .. of Psychotherapy and Other Psychosocial Treatments .. of Pharmacotherapy and Other Somatic Treatments .. 55 Part C: Future Research Needs.. and Other Somatic Treatments .. 68 Appendixes: Psychopharmacological Treatment Algorithms .. 69 Individuals and Organizations That Submitted Comments .. 72 References .. 73 Copyright 2010, American Psychiatric Association. APA makes this PRACTICE GUIDELINE freely available to promote its dissemination and use; however, copyright protections are enforced in full.

6 No part of this GUIDELINE may be reproduced except as permitted under Sections 107 and 108 of Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at of Patients With Borderline Personality Disorder5 STATEMENT OF INTENTThe American Psychiatric Association (APA) PRACTICE Guidelines are not intended to be con-strued or to serve as a standard of medical care. Standards of medical care are determined onthe basis of all clinical data available for an individual patient and are subject to change as sci-entific knowledge and technology advance and PRACTICE patterns evolve. These parameters ofpractice should be considered guidelines only. Adherence to them will not ensure a successfuloutcome for every individual, nor should they be interpreted as including all proper methodsof care or excluding other acceptable methods of care aimed at the same results.

7 The ultimatejudgment regarding a particular clinical procedure or Treatment plan must be made by the psy-chiatrist in light of the clinical data presented by the patient and the diagnostic and treatmentoptions PRACTICE GUIDELINE has been developed by psychiatrists who are in active clinical prac-tice. In addition, some contributors are primarily involved in research or other academicendeavors. It is possible that through such activities some contributors, including work groupmembers and reviewers, have received income related to treatments discussed in this guide-line. A number of mechanisms are in place to minimize the potential for producing biasedrecommendations due to conflicts of interest. Work group members are selected on the basisof their expertise and integrity. Any work group member or reviewer who has a potential con-flict of interest that may bias (or appear to bias) his or her work is asked to disclose this to theSteering Committee on PRACTICE Guidelines and the work group .

8 Iterative GUIDELINE drafts arereviewed by the Steering Committee, other experts, allied organizations, APA members, andthe APA Assembly and Board of Trustees; substantial revisions address or integrate the com-ments of these multiple reviewers. The development of the APA PRACTICE guidelines is notfinancially supported by any commercial detail about mechanisms in place to minimize bias is provided in a document avail-able from the APA Department of Quality Improvement and Psychiatric Services, APAG uideline Development Process. This PRACTICE GUIDELINE was approved in July 2001 and published in October 2010, American Psychiatric Association. APA makes this PRACTICE GUIDELINE freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this GUIDELINE may be reproduced except as permitted under Sections 107 and 108 of Copyright Act.

9 For permission for reuse, visit APPI Permissions & Licensing Center at PRACTICE GuidelinesGUIDE TO USING THIS PRACTICE GUIDELINEThis PRACTICE GUIDELINE offers Treatment recommendations based on available evidence andclinical consensus to help psychiatrists develop plans for the care of adult Patients with border-line personality disorder. This GUIDELINE contains many sections, not all of which will be equallyuseful for all readers. The following guide is designed to help readers find the sections that willbe most useful to A contains the Treatment recommendations for Patients with borderline personalitydisorder. Section I is the summary of Treatment recommendations, which includes the maintreatment recommendations along with codes that indicate the degree of clinical confidence ineach recommendation. Section II is a guide to the formulation and implementation of a treat-ment plan for the individual patient.

10 This section includes all of the Treatment recommenda-tions. Section III, Special Features Influencing Treatment , discusses a range of clinicalconsiderations that could alter the general recommendations discussed in section II. Section IVaddresses risk management issues that should be considered when treating Patients with bor-derline personality B, Background Information and Review of Available Evidence, presents, in detail, theevidence underlying the Treatment recommendations of Part A. Section V provides an overviewof DSM-IV-TR criteria, prevalence rates for borderline personality disorder, and general infor-mation on its natural history and course. Section VI is a structured review and synthesis of pub-lished literature regarding the available treatments for borderline personality C, Future Research Needs, draws from the previous sections to summarize those areasin which better research data are needed to guide clinical share feedback on this or other published APA PRACTICE guidelines, a form is available 2010, American Psychiatric Association.