Updated practice guideline on treatment of borderline personality disorder released by American Psychiatric Association

The American Psychiatric Association(APA) today published an updated Practice Guideline for Treatment of Patients with Borderline Personality Disorder. The guideline provides recommendations on evidence-based assessment, treatment planning, and psychosocial interventions and pharmacotherapy treatments.

Borderline personality disorder is classified among the personality disorders and affects 1.4%-2.7% of the U.S. population. It involves a pattern of instability in personal relationships, intense emotions, poor self-image and impulsivity. It typically begins in adolescence or early adulthood and can persist for many years. However, despite previous understandings of the disorder, it can remit, and symptoms can be reduced and managed.

Despite the lifetime burden and psychosocial impairment associated with borderline personality disorder, evidence-based treatments are often not available, and misperceptions persist. This guideline is intended to improve the quality of care for people with borderline personality disorder by providing clinicians with knowledge and understanding of evidence-based assessment and treatment.

The practice guideline includes eight clinical recommendations or suggestions, depending on the level of scientific evidence.*

Assessment and Determination of Treatment Plan

1. APA recommends (1C) that the initial assessment of a patient with possible borderline personality disorder include the reason the individual is presenting for evaluation; the patient’s goals and preferences for treatment; a review of psychiatric symptoms, including core features of personality disorders and common co-occurring disorders; a psychiatric treatment history; an assessment of physical health; an assessment of psychosocial and cultural factors; a mental status examination; and an assessment of risk of suicide, self-injury, and aggressive behaviors, as outlined in APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition.

2. APA suggests (2C) that the initial psychiatric evaluation of a patient with possible borderline personality disorder include a quantitative measure to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment.

3. APA recommends (1C) that a patient with borderline personality disorder have a documented, comprehensive, and person-centered treatment plan.

4. APA recommends (1C) that a patient with borderline personality disorder be engaged in a collaborative discussion about their diagnosis and treatment, which includes psychoeducation related to the disorder.

Psychosocial Interventions

5. APA recommends (1B) that a patient with borderline personality disorder be treated with a structured approach to psychotherapy that has support in the literature and targets the core features of the disorder.

Pharmacotherapy

6. APA recommends (1C) that a patient with borderline personality disorder have a review of co-occurring disorders, prior psychotherapies, other nonpharmacological treatments, past medication trials, and current medications before initiating any new medication.

7. APA suggests (2C) that any psychotropic medication treatment of borderline personality disorder be time-limited, aimed at addressing a specific measurable target symptom, and adjunctive to psychotherapy.

8. APA recommends (1C) that a patient with borderline personality disorder receive a review and reconciliation of their medications at least every 6 months to assess the effectiveness of treatment and identify medications that warrant tapering or discontinuation.

The guideline was developed by the APA Practice Guideline Writing Group, chaired by George A. Keepers, M.D., using a clearly defined and transparent process consistent with the recommendations of the Institute of Medicine (2011) and the Council of Medical Specialty Societies. A detailed description of the process is included in the guideline.

“Several key findings emerged from the thorough and critical review of the literature conducted to develop this Guideline,” Keepers said. “First, several structured psychotherapies were found to be effective for treatment of borderline personality disorder. No therapy emerged as a ‘gold standard.’ Second, no evidence was found for any pharmacotherapy’s effectiveness in treating the core symptoms of the disorder. This finding led to the recommendations designed to limit polypharmacy and prolonged treatment with medications. We anticipate that many more patients will be able access psychotherapeutic treatment and that clinicians will avoid the risks of ineffective pharmacologic treatment as a result of this guideline.”

Borderline Personality Disorder Guideline Resources

The full Practice Guideline for the Treatment of Borderline Personality Disorder, Executive Summary and Appendices are available free online and as a printed copy for purchase from APA Publishing. APA is also developing related resources to facilitate understanding of the guidelines and their implementation, including training slides, clinician guide, patient/family guide, webinar and case vignettes. All of these materials will be available to practitioners and the public.

*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).

Reference:

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder, Second Edition, https://doi/book/10.1176/appi.books.9780890428009.