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Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder

John M. Oldham
DOI: 10.1176/appi.books.9780890423363.148718
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Introduction

Since the 2001 publication of APA's Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSM-IV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

The American Psychiatric Association (APA) practice guidelines are developed by expert work groups using an explicit methodology that includes rigorous review of available evidence, broad peer review of iterative drafts, and formal approval by the APA Assembly and Board of Trustees. APA practice guidelines are intended to assist psychiatrists in clinical decision making. They are not intended to be a standard of care. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. Guideline watches summarize significant developments in practice since publication of an APA practice guideline. Watches may be authored and reviewed by experts associated with the original guideline development effort and are approved for publication by APA's Executive Committee on Practice Guidelines. Thus, watches represent opinion of the authors and approval of the Executive Committee but not policy of the APA. This guideline watch was published in March 2005. Copyright © 2005 American Psychiatric Association. All rights reserved. Suggested citation: Oldham JM: Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Arlington, VA: American Psychiatric Association, 2005. Available online at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm.

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Definition, Diagnostic Stability, and Longitudinal Course

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Definition

With an eye toward DSM-V, careful examination of axis II is occurring. This has, in part, included comparing the relative merits of categorical systems such as DSM-IV-TR and dimensional systems such as the five-factor model (4). This debate is as yet unresolved. However, recent studies have analyzed the nine DSM-IV criteria that define BPD and have concluded that, as defined, BPD appears to reflect a statistically coherent construct (5, 6). Utilization of a polythetic system requiring five out of nine criteria to make a categorical BPD diagnosis inevitably results in extensive heterogeneity within and between BPD populations being treated or studied. Increased attention is being focused on how to set the appropriate diagnostic "cut-off point" (i.e., the minimum number of criteria required to make the diagnosis). Also under discussion is whether some core criteria should be essential or whether all criteria should be weighted equally in establishing a diagnosis. New data also emphasize the importance of evaluating the degree of functional impairment in patients with BPD (7). A dimensional approach can be used to measure overall levels of dysfunction (8). Alternatively, the DSM criteria can be assessed in a dimensional fashion to capture functional impairment (9). However, even with proposed dimensional approaches, a discrete diagnostic threshold would need to be established in terms of illness severity and need for treatment (10).

A number of recent studies have examined the boundaries between BPD and selected axis I conditions. Since some patients with BPD may benefit from mood-stabilizing medications, the overlap between BPD and bipolar II disorder has been of particular interest (11–13). Although some individuals with BPD will also have a co-occurring bipolar disorder, the majority of the evidence to date supports BPD as an independent diagnosis rather than an attenuated form of a mood disorder (14–16). Similarly, though patients with BPD frequently have a history of trauma, the diagnosis is not considered a variant of posttraumatic stress disorder (PTSD) (17, 18). Of continuing interest is the identification of early precursors of BPD, such as a possible association between a history of childhood attention deficit hyperactivity disorder (ADHD) symptoms and diagnosis of BPD in adulthood (19).

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Diagnostic stability and longitudinal course

New prospective longitudinal studies evaluating the long-term stability of BPD have been published. Results of the NIMH Collaborative Longitudinal Personality Disorders Study indicate that at 2 years after BPD diagnosis, only 44% of the patients retain the diagnosis (20). The McLean Hospital group has reported a 6-year follow-up of borderline patients in which 74% of the patients met criteria for remission over the entire follow-up period (21). Longer-term results have been published by Canadian researchers indicating that only 8% of the total borderline patient group still met diagnostic criteria at 27-year follow-up (22, 23). High rates of remission are speculated to relate to a number of factors, such as treatment effectiveness and/or fluctuating severity of comorbid axis I conditions. BPD has been shown to be significantly associated with major depressive disorder (MDD) and PTSD longitudinally (24). Somewhat counterintuitively, however, when BPD and MDD were followed over time, improvement in MDD was not followed by improvement in BPD; instead, improvement in MDD was more often predicted by prior improvement in BPD (25). Thus, the primary determinants of change in patients with BPD may not be related to comorbid axis I psychopathology (26). Other suggested contributions to high rates of remission of BPD over time include diminished impulsivity with increased age (27), social learning, and stress-reducing life adjustments such as avoidance of interpersonal intimacy (22). It should be noted that the concept of remission of BPD reflects dropping below the DSM-IV-TR threshold on the continuum of criteria defining the disorder, yet significant problems relating to the personality structure and organization can continue even if the diagnostic threshold has not been met.

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Epidemiology, Biology, and Etiology

To date, few population-based studies of personality disorders have been carried out. Torgersen (28) tabulated the results of eight epidemiological studies, including the large Norwegian study done by his own group; the mean prevalence of BPD across all studies was 1.2%. In Torgersen et al.'s study of 2,053 individuals in Norway, BPD was found to be equally prevalent among males and females (29). Although it is widely perceived that treatment populations of patients with BPD consist predominantly of females, published studies are in fact contradictory on this point (30). Prevalence of BPD in treatment populations remains much higher than in the general population, and a recent study of a primary care population reported BPD to be fourfold higher than in the general population (31).

New studies are examining the multiple etiologies of BPD, based on the clear relevance of genetic, neurobiological, and psychosocial factors (32, 33). Although the magnitude of the heritability of BPD is thought to be significant (34), genetic risk factors specific to BPD have not been identified. One promising approach may be the study of underlying traits, such as novelty seeking (35) or impulsivity (36). Among the environmental contributions to the etiology of BPD, the role of childhood abuse remains prominent (37), particularly severe abuse (38) and sustained abuse (39).

Deficits in cognitive functioning, such as decision making (40), conflict resolution (41), and "effortful control" (41, 42), are being reported. These deficits are thought to be mediated in the frontal lobe, although not all studies have found frontal lobe impairment in cognitive functioning (43). A number of studies have suggested reduced central nervous system serotonin levels in borderline patients and other patients who demonstrate impulsive-aggressive behavior, but such behavioral disinhibition may reflect dysfunction in multiple monoaminergic systems and may not be specific to BPD (44).

Brain imaging studies of patients with BPD suggest irregularities in both structure and function (44–46). Limbic studies have found reduced volume in the amygdala and hippocampus (47, 48), altered amygdala activation (49, 50), and hippocampal hypometabolism (51). Frontal lobe studies suggest dysfunction of the dorsolateral and medial prefrontal cortex in connection with memories of abandonment (52), of the medial orbital frontal cortex in connection with diminished regulation of impulsive behavior (53), and of the prefrontal cortex under resting conditions (51). In addition, decreased binding of a serotonin precursor has been reported in the medial prefrontal cortex and anterior cingulate cortex in patients with BPD (54). Taken together, these studies suggest abnormalities in prefrontal, corticostriatal, and limbic networks perhaps related to lowered serotonin neurotransmission and behavioral disinhibition (55). Although findings from brain imaging studies are "not ready for prime time" to guide treatment planning for patients with BPD, these techniques may well have relevance in the future for individualized prediction of treatment outcome (46).

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Treatment

Evidence and opinion continue to support the recommendation of the 2001 guideline that psychotherapy represents the primary, or core, treatment for this disorder and that adjunctive, symptom-targeted pharmacotherapy can be helpful. For personality disorders in general, studies of psychotherapy report its effectiveness (56, 57). Persuasive data from randomized, controlled trials (RCTs) of BPD suggest that more than one type of psychotherapy is effective, and additional studies are under way. Dialectical behavior therapy (DBT) has been shown in an RCT to be effective for borderline symptoms in patients with comorbid BPD and substance abuse, though no improvement was shown for the substance abuse itself (58). In another RCT, in patients with BPD and comorbid opiate use, DBT was compared with comprehensive validation therapy (CVT). Both types of treatment were effective. There were fewer dropouts in the CVT group, and the maintenance of gains was greater in the DBT group (59). Studies of DBT by diverse research groups are being published, including a study of female veterans with BPD that compared 6 months of DBT with treatment as usual and reported improvement in the DBT group compared with the control group (60). Another study from the Netherlands that compared 12 months of outpatient DBT with treatment as usual showed better treatment retention, reduced self-mutilation, and reduced self-damaging impulsivity in the DBT group (61). An intriguing inpatient RCT that compared 3 months of inpatient DBT with treatment as usual in the community demonstrated significant gains in the DBT group compared with the control group, including reduced self-injury, dissociation, depression, and anxiety, and improved interpersonal functioning and social adjustment (62).

Promising new psychotherapies for BPD are being piloted in open trials. These include interpersonal therapy (63); cognitive therapy (64); cognitive analytic therapy (CAT), a fusion of cognitive and psychodynamic therapy (65, 66); and systems training for emotional predictability and problem solving (STEPPS), a cognitive-behavioral systems–based form of time-limited group treatment for patients with BPD (67). In an ongoing study comparing transference-focused psychotherapy (TFP) with DBT and supportive psychotherapy, TFP appeared to be beneficial (68), although the comparative analysis of the other two treatments has yet to be completed. The efficacy of TFP is also being assessed in a large multicenter study comparing TFP with schema therapy for patients with BPD (69).

A number of recent studies have focused on the benefits of pharmacotherapy for patients with BPD. An RCT that compared patients receiving fluvoxamine with a control group showed robust, long-lasting reduction in rapid mood shifts only in the treatment group (70). Another RCT that compared olanzapine with placebo in borderline patients showed improvement in global functioning in the medication group compared with the placebo group (71). Another RCT studied three groups of BPD patients—one group receiving fluoxetine, a second group receiving olanzapine, and a third receiving a combination of both; all three interventions led to substantial improvement, though a significantly greater rate of improvement in clinician-rated depression and impulsive aggression was seen in the olanzapine and the combination groups (72). Also, double-blind, placebo-controlled trials demonstrated benefit of divalproex sodium for patients with BPD (73) and for patients with cluster B personality disorders who demonstrate impulsive aggression (74). A number of case reports and noncontrolled medication trials have also been published (75–81).

All in all, the database is growing, and further evidence is accumulating that BPD is a condition that can be effectively treated by a combination of psychotherapy and symptom-targeted pharmacotherapy. Further research is needed to validate the approach taken by the 2001 guideline to select one of three different medication algorithms on the basis of the predominance of cognitive-perceptual symptoms, affective dysregulation symptoms, or impulse dyscontrol symptoms. One retrospective report from the NIMH Collaborative Longitudinal Personality Disorders Study produced mixed results on this question (82).

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1. American Psychiatric Association: Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry 2001; 158:1–52

2. Trull TJ, Stepp SD, Durrett CA: Research on borderline personality disorder: an update. Current Opinion in Psychiatry 2003; 16:77–82

3. Skodol AE: Manifestations, clinical diagnosis, and comorbidity, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 57–87

4. Simonsen E, Widiger TA: Limitations of existing diagnostic categories. Launch Conference on Personality Disorders, Washington, DC, December 2–3, 2004

5. Sanislow CA, Grilo CM, Morey LC, Bender DS, Skodol AE, Gunderson JG, Shea MT, Stout RL, Zanarini MC, McGlashan TH: Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the Collaborative Longitudinal Personality Disorders Study. Am J Psychiatry 2002; 159:284–2901000684
[PubMed]

6. Morey LC, Skodol AE, Grilo CM, Sanislow CA, Zanarini MC, Shea MT, Gunderson JG, McGlashan TH: Temporal coherence of criteria for four personality disorders. J Personal Disord 2004; 18:394–398
[PubMed]

7. Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS, Grilo CM, Shea MT, Zanarini MC, Morey LC, Sanislow CA, Oldham JM: Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry 2002; 159:276–2831000685
[PubMed]

8. Trull TJ, Widiger TA, Lynam DR, Costa PT Jr: Borderline personality disorder from the perspective of general personality functioning. J Abnorm Psychol 2003; 112:193–202
[PubMed]

9. Skodol AE, Oldham JM, Bender DS, Dyck IR, Stout RL, Morey LC, Shea MT, Zanarini MC, Sanislow CA, Grilo CM, McGlashan TH, Gunderson JG: Dimensional representations of DSM-IV personality disorders: relationships to functional impairment. Am J Psychiatry 2005; 162:1919–19251011944
[PubMed]

10. Rothschild L, Cleland C, Haslam N, Zimmerman M: A taxometric study of borderline personality disorder. J Abnorm Psychol 2003; 112:657–666
[PubMed]

11. Deltito J, Martin L, Riefkohl J, Austria B, Kissilenko A, Corless CM: Do patients with borderline personality disorder belong to the bipolar spectrum? J Affect Disord 2001; 67:221–228
[PubMed]

12. Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, Siever LJ: Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res 2001; 35:307–312
[PubMed]

13. Smith DJ, Muir WJ, Blackwood DH: Is borderline personality disorder part of the bipolar spectrum? Harv Rev Psychiatry 2004; 12:133–139
[PubMed]

14. Koenigsberg HW, Harvey PD, Mitropoulou V, Schmeidler J, New AS, Goodman M, Silverman JM, Serby M, Schopick F, Siever LJ: Characterizing affective instability in borderline personality disorder. Am J Psychiatry 2002; 159:784–7881000564
[PubMed]

15. Magill CA: The boundary between borderline personality disorder and bipolar disorder: current concepts and challenges. Can J Psychiatry 2004; 49:551–556
[PubMed]

16. Paris J: Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harv Rev Psychiatry 2004; 12:140–145
[PubMed]

17. Golier JA, Yehuda R, Bierer LM, Mitropoulou V, New AS, Schmeidler J, Silverman JM, Siever LJ: The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. Am J Psychiatry 2003; 160:2018–20241005576
[PubMed]

18. Zlotnick C, Johnson DM, Yen S, Battle CL, Sanislow CA, Skodol AE, Grilo CM, McGlashan TH, Gunderson JG, Bender DS, Zanarini MC, Shea MT: Clinical features and impairment in women with Borderline Personality Disorder (BPD) with Posttraumatic Stress Disorder (PTSD), BPD without PTSD, and other personality disorders with PTSD. J Nerv Ment Dis 2003; 191:706–713
[PubMed]

19. Fossati A, Novella L, Donati D, Donini M, Maffei C: History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality disorder: a controlled study. Compr Psychiatry 2002; 43:369–377
[PubMed]

20. Grilo CM, Shea MT, Sanislow CA, Skodol AE, Gunderson JG, Stout RL, Pagano ME, Yen S: Two-year stability and change of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Consult Clin Psychol (in press)

21. Zanarini MC, Frankenburg FR, Hennen J, Silk KR: The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 2003; 160:274–2831005897
[PubMed]

22. Paris J: Implications of long-term outcome research for the management of patients with borderline personality disorder. Harv Rev Psychiatry 2002; 10:315–323
[PubMed]

23. Paris J, Zweig-Frank H: A 27-year follow-up of patients with borderline personality disorders. Psychiatr Q 2000; 71:291–307

24. Shea MT, Stout RL, Yen S, Pagano ME, Skodol AE, Morey LC, Gunderson JG, McGlashan TH, Grilo CM, Sanislow CA, Bender DS, Zanarini MC: Associations in the course of personality disorders and axis I disorders over time. J Abnorm Psychol 2004; 113:499–508
[PubMed]

25. Gunderson JG, Morey LC, Stout RL, Skodol AE, Shea MT, McGlashan TH, Zanarini MC, Grilo CM, Sanislow CA, Yen S, Daversa MT, Bender DS: Major depressive disorder and borderline personality disorder revisited: longitudinal interactions. J Clin Psychiatry 2004; 65:1049–1056
[PubMed]

26. Warner MB, Morey LC, Finch JF, Gunderson JG, Skodol AE, Sanislow CA, Shea MT, McGlashan TH, Grilo CM: The longitudinal relationship of personality traits and disorders. J Abnorm Psychol 2004; 113:217–227
[PubMed]

27. Stevenson J, Meares R, Comerford A: Diminished impulsivity in older patients with borderline personality disorder. Am J Psychiatry 2003; 160:165–1661000263
[PubMed]

28. Torgersen S: Epidemiology, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 129–141

29. Torgersen S, Kringlen E, Cramer V: The prevalence of personality disorders in a community sample. Arch Gen Psychiatry 2001; 58:590–596
[PubMed]

30. Zlotnick C, Rothschild L, Zimmerman M: The role of gender in the clinical presentation of patients with borderline personality disorder. J Personal Disord 2002; 16:277–282
[PubMed]

31. Gross R, Olfson M, Gameroff M, Shea S, Feder A, Fuentes M, Lantigua R, Weissman MM: Borderline personality disorder in primary care. Arch Intern Med 2002; 162:53–60
[PubMed]

32. Skodol AE, Siever LJ, Livesley WJ, Gunderson JG, Pfohl B, Widiger TA: The borderline diagnosis II: biology, genetics, and clinical course. Biol Psychiatry 2002; 51:951–963
[PubMed]

33. Siever LJ, Torgersen S, Gunderson JG, Livesley WJ, Kendler KS: The borderline diagnosis III: identifying endophenotypes for genetic studies. Biol Psychiatry 2002; 51:964–968
[PubMed]

34. Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J, Tambs K, Kringlen E: A twin study of personality disorders. Compr Psychiatry 2000; 41:416–425
[PubMed]

35. Cloninger CR: Genetics, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 143–154

36. New AS, Siever LJ: Neurobiology and genetics of borderline personality disorder. Psychiatric Annals 2002; 32:329–336

37. Trull TJ: Structural relations between borderline personality disorder features and putative etiological correlates. J Abnorm Psychol 2001; 110:471–481
[PubMed]

38. Zanarini MC, Yong L, Frankenburg FR, Hennen J, Reich DB, Marino MF, Vujanovic AA: Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. J Nerv Ment Dis 2002; 190:381–387
[PubMed]

39. Rinne T, de Kloet ER, Wouters L, Goekoop JG, DeRijk RH, van den BW: Hyperresponsiveness of hypothalamic-pituitary-adrenal axis to combined dexamethasone/corticotropin-releasing hormone challenge in female borderline personality disorder subjects with a history of sustained childhood abuse. Biol Psychiatry 2002; 52:1102–1112
[PubMed]

40. Bazanis E, Rogers RD, Dowson JH, Taylor P, Meux C, Staley C, Nevinson-Andrews D, Taylor C, Robbins TW, Sahakian BJ: Neurocognitive deficits in decision-making and planning of patients with DSM-III-R borderline personality disorder. Psychol Med 2002; 32:1395–1405
[PubMed]

41. Posner MI, Rothbart MK, Vizueta N, Levy KN, Evans DE, Thomas KM, Clarkin JF: Attentional mechanisms of borderline personality disorder. Proc Natl Acad Sci USA 2002; 99:16366–16370
[PubMed]

42. Lenzenweger MF, Clarkin JF, Fertuck EA, Kernberg OF: Executive neurocognitive functioning and neurobehavioral systems indicators in borderline personality disorder: a preliminary study. J Personal Disord 2004; 18:421–438
[PubMed]

43. Kunert HJ, Druecke HW, Sass H, Herpertz SC: Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings. J Personal Disord 2003; 17:497–509
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44. Coccaro EF, Siever LJ: Neurobiology, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 155–169

45. Nahas Z, Molnar C, George MS: Brain imaging, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 623–639

46. Etkin A, Pittenger CJ, Kandel ER: Biology in the service of psychotherapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 669–682

47. Schmahl CG, Vermetten E, Elzinga BM, Douglas BJ: Magnetic resonance imaging of hippocampal and amygdala volume in women with childhood abuse and borderline personality disorder. Psychiatry Res 2003; 122:193–198
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48. Rusch N, van Elst LT, Ludaescher P, Wilke M, Huppertz HJ, Thiel T, Schmahl C, Bohus M, Lieb K, Hesslinger B, Hennig J, Ebert D: A voxel-based morphometric MRI study in female patients with borderline personality disorder. Neuroimage 2003; 20:385–392
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49. Herpertz SC, Dietrich TM, Wenning B, Krings T, Erberich SG, Willmes K, Thron A, Sass H: Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study. Biol Psychiatry 2001; 50:292–298
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50. Donegan NH, Sanislow CA, Blumberg HP, Fulbright RK, Lacadie C, Skudlarski P, Gore JC, Olson IR, McGlashan TH, Wexler BE: Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation. Biol Psychiatry 2003; 54:1284–1293
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51. Juengling FD, Schmahl C, Hesslinger B, Ebert D, Bremner JD, Gostomzyk J, Bohus M, Lieb K: Positron emission tomography in female patients with borderline personality disorder. J Psychiatr Res 2003; 37:109–115
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52. Schmahl CG, Elzinga BM, Vermetten E, Sanislow C, McGlashan TH, Bremner JD: Neural correlates of memories of abandonment in women with and without borderline personality disorder. Biol Psychiatry 2003; 54:142–151
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53. Soloff PH, Meltzer CC, Becker C, Greer PJ, Kelly TM, Constantine D: Impulsivity and prefrontal hypometabolism in borderline personality disorder. Psychiatry Res 2003; 123:153–163
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54. Leyton M, Okazawa H, Diksic M, Paris J, Rosa P, Mzengeza S, Young SN, Blier P, Benkelfat C: Brain regional alpha-[11C]methyl-l-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001; 158:775–7821001070
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55. Johnson PA, Hurley RA, Benkelfat C, Herpertz SC, Taber KH: Understanding emotion regulation in borderline personality disorder: contributions of neuroimaging. J Neuropsychiatry Clin Neurosci 2003; 15:397–4021006009
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56. Leichsenring F, Leibing E: The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry 2003; 160:1223–12321005709
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57. Leichsenring F, Rabung S, Leibing E: The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry 2004; 61:1208–1216
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58. van den Bosch LM, Verheul R, Schippers GM, van den BW: Dialectical behavior therapy of borderline patients with and without substance use problems: implementation and long-term effects. Addict Behav 2002; 27:911–923

59. Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, Heagerty P, Kivlahan DR: Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 2002; 67:13–26
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60. Koons C, Robins CJ, Tweed JL, Lynch TR, Gonzalez AM, Morse JQ, Bishop GK, Butterfield MI, Bastian LA: Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy 2001; 32:371–390

61. Verheul R, van den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, van den BW: Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. Br J Psychiatry 2003; 182:135–140
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62. Bohus M, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C, Lieb K, Linehan MM: Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004; 42:487–499
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63. Markowitz JC: Interpersonal therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 321–334

64. Brown GK, Newman CF, Charlesworth SE, Crits-Christoph P, Beck AT: An open clinical trial of cognitive therapy for borderline personality disorder. J Personal Disord 2004; 18:257–271
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65. Ryle A, Golynkina K: Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome. Br J Med Psychol 2000; 73(Pt 2): 197–210

66. Ryle A: The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. J Personal Disord 2004; 18:3–35
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67. Blum N, Pfohl B, John DS, Monahan P, Black DW: STEPPS: a cognitive-behavioral systems–based group treatment for outpatients with borderline personality disorder—a preliminary report. Compr Psychiatry 2002; 43:301–310
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68. Clarkin JF, Foelsch PA, Levy KN, Hull JW, Delaney JC, Kernberg OF: The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Personal Disord 2001; 15:487–495
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69. Young J, Klosko J: Schema therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 289–306

70. Rinne T, van den BW, Wouters L, van Dyck R: SSRI treatment of borderline personality disorder: a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder. Am J Psychiatry 2002; 159:2048–20541000312
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71. Bogenschutz MP, Nurnberg HG: Olanzapine versus placebo in the treatment of borderline personality disorder. J Clin Psychiatry 2001; 65:104–109

72. Zanarini MC, Frankenburg FR, Parachini EA: A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry 2004; 65:903–907
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73. Hollander E, Allen A, Lopez RP, Bienstock CA, Grossman R, Siever LJ, Merkatz L, Stein DJ: A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001; 62:199–203
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74. Hollander E, Tracy KA, Swann AC, Coccaro EF, McElroy SL, Wozniak P, Sommerville KW, Nemeroff CB: Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology 2003; 28:1186–1197
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75. Cassano P, Lattanzi L, Pini S, Dell'Osso L, Battistini G, Cassano GB: Topiramate for self-mutilation in a patient with borderline personality disorder. Bipolar Disord 2001; 3:161
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76. Hilger E, Barnas C, Kasper S: Quetiapine in the treatment of borderline personality disorder. World J Biol Psychiatry 2003; 4:42–44
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77. Rizvi ST: Lamotrigine and borderline personality disorder. J Child Adolesc Psychopharmacol 2002; 12:365–366
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78. Rocca P, Marchiaro L, Cocuzza E, Bogetto F: Treatment of borderline personality disorder with risperidone. J Clin Psychiatry 2002; 63:241–244
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79. Philipsen A, Richter H, Schmahl C, Peters J, Rusch N, Bohus M, Lieb K: Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder. J Clin Psychiatry 2004; 65:1414–1419
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80. Pascual JC, Oller S, Soler J, Barrachina J, Alvarez E, Perez V: Ziprasidone in the acute treatment of borderline personality disorder in psychiatric emergency services. J Clin Psychiatry 2004; 65:1281–1282
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81. Nickel MK, Nickel C, Mitterlehner FO, Tritt K, Lahmann C, Leiberich PK, Rother WK, Loew TH: Topiramate treatment of aggression in female borderline personality disorder patients: a double-blind, placebo-controlled study. J Clin Psychiatry 2004; 65:1515–1519
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82. Oldham JM, Bender DS, Skodol AE, Dyck IR, Sanislow CA, Yen S, Grilo CM, Shea MT, Zanarini MC, Gunderson EJ, McGlashan TH: Testing an APA practice guideline: symptom-targeted medication utilization for patients with borderline personality disorder. J Psychiatr Pract 2004; 10:156–161
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References

1. American Psychiatric Association: Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry 2001; 158:1–52
 
2. Trull TJ, Stepp SD, Durrett CA: Research on borderline personality disorder: an update. Current Opinion in Psychiatry 2003; 16:77–82
 
3. Skodol AE: Manifestations, clinical diagnosis, and comorbidity, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 57–87
 
4. Simonsen E, Widiger TA: Limitations of existing diagnostic categories. Launch Conference on Personality Disorders, Washington, DC, December 2–3, 2004
 
5. Sanislow CA, Grilo CM, Morey LC, Bender DS, Skodol AE, Gunderson JG, Shea MT, Stout RL, Zanarini MC, McGlashan TH: Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the Collaborative Longitudinal Personality Disorders Study. Am J Psychiatry 2002; 159:284–290
[PubMed]
 
6. Morey LC, Skodol AE, Grilo CM, Sanislow CA, Zanarini MC, Shea MT, Gunderson JG, McGlashan TH: Temporal coherence of criteria for four personality disorders. J Personal Disord 2004; 18:394–398
[PubMed]
 
7. Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS, Grilo CM, Shea MT, Zanarini MC, Morey LC, Sanislow CA, Oldham JM: Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry 2002; 159:276–283
[PubMed]
 
8. Trull TJ, Widiger TA, Lynam DR, Costa PT Jr: Borderline personality disorder from the perspective of general personality functioning. J Abnorm Psychol 2003; 112:193–202
[PubMed]
 
9. Skodol AE, Oldham JM, Bender DS, Dyck IR, Stout RL, Morey LC, Shea MT, Zanarini MC, Sanislow CA, Grilo CM, McGlashan TH, Gunderson JG: Dimensional representations of DSM-IV personality disorders: relationships to functional impairment. Am J Psychiatry 2005; 162:1919–1925
[PubMed]
 
10. Rothschild L, Cleland C, Haslam N, Zimmerman M: A taxometric study of borderline personality disorder. J Abnorm Psychol 2003; 112:657–666
[PubMed]
 
11. Deltito J, Martin L, Riefkohl J, Austria B, Kissilenko A, Corless CM: Do patients with borderline personality disorder belong to the bipolar spectrum? J Affect Disord 2001; 67:221–228
[PubMed]
 
12. Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, Siever LJ: Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res 2001; 35:307–312
[PubMed]
 
13. Smith DJ, Muir WJ, Blackwood DH: Is borderline personality disorder part of the bipolar spectrum? Harv Rev Psychiatry 2004; 12:133–139
[PubMed]
 
14. Koenigsberg HW, Harvey PD, Mitropoulou V, Schmeidler J, New AS, Goodman M, Silverman JM, Serby M, Schopick F, Siever LJ: Characterizing affective instability in borderline personality disorder. Am J Psychiatry 2002; 159:784–788
[PubMed]
 
15. Magill CA: The boundary between borderline personality disorder and bipolar disorder: current concepts and challenges. Can J Psychiatry 2004; 49:551–556
[PubMed]
 
16. Paris J: Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harv Rev Psychiatry 2004; 12:140–145
[PubMed]
 
17. Golier JA, Yehuda R, Bierer LM, Mitropoulou V, New AS, Schmeidler J, Silverman JM, Siever LJ: The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. Am J Psychiatry 2003; 160:2018–2024
[PubMed]
 
18. Zlotnick C, Johnson DM, Yen S, Battle CL, Sanislow CA, Skodol AE, Grilo CM, McGlashan TH, Gunderson JG, Bender DS, Zanarini MC, Shea MT: Clinical features and impairment in women with Borderline Personality Disorder (BPD) with Posttraumatic Stress Disorder (PTSD), BPD without PTSD, and other personality disorders with PTSD. J Nerv Ment Dis 2003; 191:706–713
[PubMed]
 
19. Fossati A, Novella L, Donati D, Donini M, Maffei C: History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality disorder: a controlled study. Compr Psychiatry 2002; 43:369–377
[PubMed]
 
20. Grilo CM, Shea MT, Sanislow CA, Skodol AE, Gunderson JG, Stout RL, Pagano ME, Yen S: Two-year stability and change of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Consult Clin Psychol (in press)
 
21. Zanarini MC, Frankenburg FR, Hennen J, Silk KR: The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 2003; 160:274–283
[PubMed]
 
22. Paris J: Implications of long-term outcome research for the management of patients with borderline personality disorder. Harv Rev Psychiatry 2002; 10:315–323
[PubMed]
 
23. Paris J, Zweig-Frank H: A 27-year follow-up of patients with borderline personality disorders. Psychiatr Q 2000; 71:291–307
 
24. Shea MT, Stout RL, Yen S, Pagano ME, Skodol AE, Morey LC, Gunderson JG, McGlashan TH, Grilo CM, Sanislow CA, Bender DS, Zanarini MC: Associations in the course of personality disorders and axis I disorders over time. J Abnorm Psychol 2004; 113:499–508
[PubMed]
 
25. Gunderson JG, Morey LC, Stout RL, Skodol AE, Shea MT, McGlashan TH, Zanarini MC, Grilo CM, Sanislow CA, Yen S, Daversa MT, Bender DS: Major depressive disorder and borderline personality disorder revisited: longitudinal interactions. J Clin Psychiatry 2004; 65:1049–1056
[PubMed]
 
26. Warner MB, Morey LC, Finch JF, Gunderson JG, Skodol AE, Sanislow CA, Shea MT, McGlashan TH, Grilo CM: The longitudinal relationship of personality traits and disorders. J Abnorm Psychol 2004; 113:217–227
[PubMed]
 
27. Stevenson J, Meares R, Comerford A: Diminished impulsivity in older patients with borderline personality disorder. Am J Psychiatry 2003; 160:165–166
[PubMed]
 
28. Torgersen S: Epidemiology, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 129–141
 
29. Torgersen S, Kringlen E, Cramer V: The prevalence of personality disorders in a community sample. Arch Gen Psychiatry 2001; 58:590–596
[PubMed]
 
30. Zlotnick C, Rothschild L, Zimmerman M: The role of gender in the clinical presentation of patients with borderline personality disorder. J Personal Disord 2002; 16:277–282
[PubMed]
 
31. Gross R, Olfson M, Gameroff M, Shea S, Feder A, Fuentes M, Lantigua R, Weissman MM: Borderline personality disorder in primary care. Arch Intern Med 2002; 162:53–60
[PubMed]
 
32. Skodol AE, Siever LJ, Livesley WJ, Gunderson JG, Pfohl B, Widiger TA: The borderline diagnosis II: biology, genetics, and clinical course. Biol Psychiatry 2002; 51:951–963
[PubMed]
 
33. Siever LJ, Torgersen S, Gunderson JG, Livesley WJ, Kendler KS: The borderline diagnosis III: identifying endophenotypes for genetic studies. Biol Psychiatry 2002; 51:964–968
[PubMed]
 
34. Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J, Tambs K, Kringlen E: A twin study of personality disorders. Compr Psychiatry 2000; 41:416–425
[PubMed]
 
35. Cloninger CR: Genetics, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 143–154
 
36. New AS, Siever LJ: Neurobiology and genetics of borderline personality disorder. Psychiatric Annals 2002; 32:329–336
 
37. Trull TJ: Structural relations between borderline personality disorder features and putative etiological correlates. J Abnorm Psychol 2001; 110:471–481
[PubMed]
 
38. Zanarini MC, Yong L, Frankenburg FR, Hennen J, Reich DB, Marino MF, Vujanovic AA: Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. J Nerv Ment Dis 2002; 190:381–387
[PubMed]
 
39. Rinne T, de Kloet ER, Wouters L, Goekoop JG, DeRijk RH, van den BW: Hyperresponsiveness of hypothalamic-pituitary-adrenal axis to combined dexamethasone/corticotropin-releasing hormone challenge in female borderline personality disorder subjects with a history of sustained childhood abuse. Biol Psychiatry 2002; 52:1102–1112
[PubMed]
 
40. Bazanis E, Rogers RD, Dowson JH, Taylor P, Meux C, Staley C, Nevinson-Andrews D, Taylor C, Robbins TW, Sahakian BJ: Neurocognitive deficits in decision-making and planning of patients with DSM-III-R borderline personality disorder. Psychol Med 2002; 32:1395–1405
[PubMed]
 
41. Posner MI, Rothbart MK, Vizueta N, Levy KN, Evans DE, Thomas KM, Clarkin JF: Attentional mechanisms of borderline personality disorder. Proc Natl Acad Sci USA 2002; 99:16366–16370
[PubMed]
 
42. Lenzenweger MF, Clarkin JF, Fertuck EA, Kernberg OF: Executive neurocognitive functioning and neurobehavioral systems indicators in borderline personality disorder: a preliminary study. J Personal Disord 2004; 18:421–438
[PubMed]
 
43. Kunert HJ, Druecke HW, Sass H, Herpertz SC: Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings. J Personal Disord 2003; 17:497–509
[PubMed]
 
44. Coccaro EF, Siever LJ: Neurobiology, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 155–169
 
45. Nahas Z, Molnar C, George MS: Brain imaging, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 623–639
 
46. Etkin A, Pittenger CJ, Kandel ER: Biology in the service of psychotherapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 669–682
 
47. Schmahl CG, Vermetten E, Elzinga BM, Douglas BJ: Magnetic resonance imaging of hippocampal and amygdala volume in women with childhood abuse and borderline personality disorder. Psychiatry Res 2003; 122:193–198
[PubMed]
 
48. Rusch N, van Elst LT, Ludaescher P, Wilke M, Huppertz HJ, Thiel T, Schmahl C, Bohus M, Lieb K, Hesslinger B, Hennig J, Ebert D: A voxel-based morphometric MRI study in female patients with borderline personality disorder. Neuroimage 2003; 20:385–392
[PubMed]
 
49. Herpertz SC, Dietrich TM, Wenning B, Krings T, Erberich SG, Willmes K, Thron A, Sass H: Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study. Biol Psychiatry 2001; 50:292–298
[PubMed]
 
50. Donegan NH, Sanislow CA, Blumberg HP, Fulbright RK, Lacadie C, Skudlarski P, Gore JC, Olson IR, McGlashan TH, Wexler BE: Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation. Biol Psychiatry 2003; 54:1284–1293
[PubMed]
 
51. Juengling FD, Schmahl C, Hesslinger B, Ebert D, Bremner JD, Gostomzyk J, Bohus M, Lieb K: Positron emission tomography in female patients with borderline personality disorder. J Psychiatr Res 2003; 37:109–115
[PubMed]
 
52. Schmahl CG, Elzinga BM, Vermetten E, Sanislow C, McGlashan TH, Bremner JD: Neural correlates of memories of abandonment in women with and without borderline personality disorder. Biol Psychiatry 2003; 54:142–151
[PubMed]
 
53. Soloff PH, Meltzer CC, Becker C, Greer PJ, Kelly TM, Constantine D: Impulsivity and prefrontal hypometabolism in borderline personality disorder. Psychiatry Res 2003; 123:153–163
[PubMed]
 
54. Leyton M, Okazawa H, Diksic M, Paris J, Rosa P, Mzengeza S, Young SN, Blier P, Benkelfat C: Brain regional alpha-[11C]methyl-l-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001; 158:775–782
[PubMed]
 
55. Johnson PA, Hurley RA, Benkelfat C, Herpertz SC, Taber KH: Understanding emotion regulation in borderline personality disorder: contributions of neuroimaging. J Neuropsychiatry Clin Neurosci 2003; 15:397–402
[PubMed]
 
56. Leichsenring F, Leibing E: The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry 2003; 160:1223–1232
[PubMed]
 
57. Leichsenring F, Rabung S, Leibing E: The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry 2004; 61:1208–1216
[PubMed]
 
58. van den Bosch LM, Verheul R, Schippers GM, van den BW: Dialectical behavior therapy of borderline patients with and without substance use problems: implementation and long-term effects. Addict Behav 2002; 27:911–923
 
59. Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, Heagerty P, Kivlahan DR: Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 2002; 67:13–26
[PubMed]
 
60. Koons C, Robins CJ, Tweed JL, Lynch TR, Gonzalez AM, Morse JQ, Bishop GK, Butterfield MI, Bastian LA: Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy 2001; 32:371–390
 
61. Verheul R, van den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, van den BW: Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. Br J Psychiatry 2003; 182:135–140
[PubMed]
 
62. Bohus M, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C, Lieb K, Linehan MM: Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004; 42:487–499
[PubMed]
 
63. Markowitz JC: Interpersonal therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 321–334
 
64. Brown GK, Newman CF, Charlesworth SE, Crits-Christoph P, Beck AT: An open clinical trial of cognitive therapy for borderline personality disorder. J Personal Disord 2004; 18:257–271
[PubMed]
 
65. Ryle A, Golynkina K: Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome. Br J Med Psychol 2000; 73(Pt 2): 197–210
 
66. Ryle A: The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. J Personal Disord 2004; 18:3–35
[PubMed]
 
67. Blum N, Pfohl B, John DS, Monahan P, Black DW: STEPPS: a cognitive-behavioral systems–based group treatment for outpatients with borderline personality disorder—a preliminary report. Compr Psychiatry 2002; 43:301–310
[PubMed]
 
68. Clarkin JF, Foelsch PA, Levy KN, Hull JW, Delaney JC, Kernberg OF: The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Personal Disord 2001; 15:487–495
[PubMed]
 
69. Young J, Klosko J: Schema therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 289–306
 
70. Rinne T, van den BW, Wouters L, van Dyck R: SSRI treatment of borderline personality disorder: a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder. Am J Psychiatry 2002; 159:2048–2054
[PubMed]
 
71. Bogenschutz MP, Nurnberg HG: Olanzapine versus placebo in the treatment of borderline personality disorder. J Clin Psychiatry 2001; 65:104–109
 
72. Zanarini MC, Frankenburg FR, Parachini EA: A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry 2004; 65:903–907
[PubMed]
 
73. Hollander E, Allen A, Lopez RP, Bienstock CA, Grossman R, Siever LJ, Merkatz L, Stein DJ: A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001; 62:199–203
[PubMed]
 
74. Hollander E, Tracy KA, Swann AC, Coccaro EF, McElroy SL, Wozniak P, Sommerville KW, Nemeroff CB: Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology 2003; 28:1186–1197
[PubMed]
 
75. Cassano P, Lattanzi L, Pini S, Dell'Osso L, Battistini G, Cassano GB: Topiramate for self-mutilation in a patient with borderline personality disorder. Bipolar Disord 2001; 3:161
[PubMed]
 
76. Hilger E, Barnas C, Kasper S: Quetiapine in the treatment of borderline personality disorder. World J Biol Psychiatry 2003; 4:42–44
[PubMed]
 
77. Rizvi ST: Lamotrigine and borderline personality disorder. J Child Adolesc Psychopharmacol 2002; 12:365–366
[PubMed]
 
78. Rocca P, Marchiaro L, Cocuzza E, Bogetto F: Treatment of borderline personality disorder with risperidone. J Clin Psychiatry 2002; 63:241–244
[PubMed]
 
79. Philipsen A, Richter H, Schmahl C, Peters J, Rusch N, Bohus M, Lieb K: Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder. J Clin Psychiatry 2004; 65:1414–1419
[PubMed]
 
80. Pascual JC, Oller S, Soler J, Barrachina J, Alvarez E, Perez V: Ziprasidone in the acute treatment of borderline personality disorder in psychiatric emergency services. J Clin Psychiatry 2004; 65:1281–1282
[PubMed]
 
81. Nickel MK, Nickel C, Mitterlehner FO, Tritt K, Lahmann C, Leiberich PK, Rother WK, Loew TH: Topiramate treatment of aggression in female borderline personality disorder patients: a double-blind, placebo-controlled study. J Clin Psychiatry 2004; 65:1515–1519
[PubMed]
 
82. Oldham JM, Bender DS, Skodol AE, Dyck IR, Sanislow CA, Yen S, Grilo CM, Shea MT, Zanarini MC, Gunderson EJ, McGlashan TH: Testing an APA practice guideline: symptom-targeted medication utilization for patients with borderline personality disorder. J Psychiatr Pract 2004; 10:156–161
[PubMed]
 

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39. Rinne T, de Kloet ER, Wouters L, Goekoop JG, DeRijk RH, van den BW: Hyperresponsiveness of hypothalamic-pituitary-adrenal axis to combined dexamethasone/corticotropin-releasing hormone challenge in female borderline personality disorder subjects with a history of sustained childhood abuse. Biol Psychiatry 2002; 52:1102–1112
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40. Bazanis E, Rogers RD, Dowson JH, Taylor P, Meux C, Staley C, Nevinson-Andrews D, Taylor C, Robbins TW, Sahakian BJ: Neurocognitive deficits in decision-making and planning of patients with DSM-III-R borderline personality disorder. Psychol Med 2002; 32:1395–1405
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41. Posner MI, Rothbart MK, Vizueta N, Levy KN, Evans DE, Thomas KM, Clarkin JF: Attentional mechanisms of borderline personality disorder. Proc Natl Acad Sci USA 2002; 99:16366–16370
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42. Lenzenweger MF, Clarkin JF, Fertuck EA, Kernberg OF: Executive neurocognitive functioning and neurobehavioral systems indicators in borderline personality disorder: a preliminary study. J Personal Disord 2004; 18:421–438
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43. Kunert HJ, Druecke HW, Sass H, Herpertz SC: Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings. J Personal Disord 2003; 17:497–509
[PubMed]

44. Coccaro EF, Siever LJ: Neurobiology, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 155–169

45. Nahas Z, Molnar C, George MS: Brain imaging, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 623–639

46. Etkin A, Pittenger CJ, Kandel ER: Biology in the service of psychotherapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 669–682

47. Schmahl CG, Vermetten E, Elzinga BM, Douglas BJ: Magnetic resonance imaging of hippocampal and amygdala volume in women with childhood abuse and borderline personality disorder. Psychiatry Res 2003; 122:193–198
[PubMed]

48. Rusch N, van Elst LT, Ludaescher P, Wilke M, Huppertz HJ, Thiel T, Schmahl C, Bohus M, Lieb K, Hesslinger B, Hennig J, Ebert D: A voxel-based morphometric MRI study in female patients with borderline personality disorder. Neuroimage 2003; 20:385–392
[PubMed]

49. Herpertz SC, Dietrich TM, Wenning B, Krings T, Erberich SG, Willmes K, Thron A, Sass H: Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study. Biol Psychiatry 2001; 50:292–298
[PubMed]

50. Donegan NH, Sanislow CA, Blumberg HP, Fulbright RK, Lacadie C, Skudlarski P, Gore JC, Olson IR, McGlashan TH, Wexler BE: Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation. Biol Psychiatry 2003; 54:1284–1293
[PubMed]

51. Juengling FD, Schmahl C, Hesslinger B, Ebert D, Bremner JD, Gostomzyk J, Bohus M, Lieb K: Positron emission tomography in female patients with borderline personality disorder. J Psychiatr Res 2003; 37:109–115
[PubMed]

52. Schmahl CG, Elzinga BM, Vermetten E, Sanislow C, McGlashan TH, Bremner JD: Neural correlates of memories of abandonment in women with and without borderline personality disorder. Biol Psychiatry 2003; 54:142–151
[PubMed]

53. Soloff PH, Meltzer CC, Becker C, Greer PJ, Kelly TM, Constantine D: Impulsivity and prefrontal hypometabolism in borderline personality disorder. Psychiatry Res 2003; 123:153–163
[PubMed]

54. Leyton M, Okazawa H, Diksic M, Paris J, Rosa P, Mzengeza S, Young SN, Blier P, Benkelfat C: Brain regional alpha-[11C]methyl-l-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001; 158:775–7821001070
[PubMed]

55. Johnson PA, Hurley RA, Benkelfat C, Herpertz SC, Taber KH: Understanding emotion regulation in borderline personality disorder: contributions of neuroimaging. J Neuropsychiatry Clin Neurosci 2003; 15:397–4021006009
[PubMed]

56. Leichsenring F, Leibing E: The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry 2003; 160:1223–12321005709
[PubMed]

57. Leichsenring F, Rabung S, Leibing E: The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry 2004; 61:1208–1216
[PubMed]

58. van den Bosch LM, Verheul R, Schippers GM, van den BW: Dialectical behavior therapy of borderline patients with and without substance use problems: implementation and long-term effects. Addict Behav 2002; 27:911–923

59. Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, Heagerty P, Kivlahan DR: Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 2002; 67:13–26
[PubMed]

60. Koons C, Robins CJ, Tweed JL, Lynch TR, Gonzalez AM, Morse JQ, Bishop GK, Butterfield MI, Bastian LA: Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy 2001; 32:371–390

61. Verheul R, van den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, van den BW: Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. Br J Psychiatry 2003; 182:135–140
[PubMed]

62. Bohus M, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C, Lieb K, Linehan MM: Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004; 42:487–499
[PubMed]

63. Markowitz JC: Interpersonal therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 321–334

64. Brown GK, Newman CF, Charlesworth SE, Crits-Christoph P, Beck AT: An open clinical trial of cognitive therapy for borderline personality disorder. J Personal Disord 2004; 18:257–271
[PubMed]

65. Ryle A, Golynkina K: Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome. Br J Med Psychol 2000; 73(Pt 2): 197–210

66. Ryle A: The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. J Personal Disord 2004; 18:3–35
[PubMed]

67. Blum N, Pfohl B, John DS, Monahan P, Black DW: STEPPS: a cognitive-behavioral systems–based group treatment for outpatients with borderline personality disorder—a preliminary report. Compr Psychiatry 2002; 43:301–310
[PubMed]

68. Clarkin JF, Foelsch PA, Levy KN, Hull JW, Delaney JC, Kernberg OF: The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Personal Disord 2001; 15:487–495
[PubMed]

69. Young J, Klosko J: Schema therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, pp 289–306

70. Rinne T, van den BW, Wouters L, van Dyck R: SSRI treatment of borderline personality disorder: a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder. Am J Psychiatry 2002; 159:2048–20541000312
[PubMed]

71. Bogenschutz MP, Nurnberg HG: Olanzapine versus placebo in the treatment of borderline personality disorder. J Clin Psychiatry 2001; 65:104–109

72. Zanarini MC, Frankenburg FR, Parachini EA: A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry 2004; 65:903–907
[PubMed]

73. Hollander E, Allen A, Lopez RP, Bienstock CA, Grossman R, Siever LJ, Merkatz L, Stein DJ: A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001; 62:199–203
[PubMed]

74. Hollander E, Tracy KA, Swann AC, Coccaro EF, McElroy SL, Wozniak P, Sommerville KW, Nemeroff CB: Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology 2003; 28:1186–1197
[PubMed]

75. Cassano P, Lattanzi L, Pini S, Dell'Osso L, Battistini G, Cassano GB: Topiramate for self-mutilation in a patient with borderline personality disorder. Bipolar Disord 2001; 3:161
[PubMed]

76. Hilger E, Barnas C, Kasper S: Quetiapine in the treatment of borderline personality disorder. World J Biol Psychiatry 2003; 4:42–44
[PubMed]

77. Rizvi ST: Lamotrigine and borderline personality disorder. J Child Adolesc Psychopharmacol 2002; 12:365–366
[PubMed]

78. Rocca P, Marchiaro L, Cocuzza E, Bogetto F: Treatment of borderline personality disorder with risperidone. J Clin Psychiatry 2002; 63:241–244
[PubMed]

79. Philipsen A, Richter H, Schmahl C, Peters J, Rusch N, Bohus M, Lieb K: Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder. J Clin Psychiatry 2004; 65:1414–1419
[PubMed]

80. Pascual JC, Oller S, Soler J, Barrachina J, Alvarez E, Perez V: Ziprasidone in the acute treatment of borderline personality disorder in psychiatric emergency services. J Clin Psychiatry 2004; 65:1281–1282
[PubMed]

81. Nickel MK, Nickel C, Mitterlehner FO, Tritt K, Lahmann C, Leiberich PK, Rother WK, Loew TH: Topiramate treatment of aggression in female borderline personality disorder patients: a double-blind, placebo-controlled study. J Clin Psychiatry 2004; 65:1515–1519
[PubMed]

82. Oldham JM, Bender DS, Skodol AE, Dyck IR, Sanislow CA, Yen S, Grilo CM, Shea MT, Zanarini MC, Gunderson EJ, McGlashan TH: Testing an APA practice guideline: symptom-targeted medication utilization for patients with borderline personality disorder. J Psychiatr Pract 2004; 10:156–161
[PubMed]

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[Pharmacological treatment for patients with borderline personality disorder: practice and study results]. Fortschr Neurol Psychiatr 2013;81(8):437-43.doi:10.1055/s-0033-1335385.
 
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