APA to Issue New Practice Guideline on TreatingPatients With Borderline Personality Disorder
The board of trustees of the American Psychiatric Association (APA) has approved a practice guideline for the treatment of borderline personality disorder. The new guideline is the 12th in APA's guideline series and the first to address a personality disorder.
The document is designed to be a practical guide to the management of patients—primarily adults over the age of 18—who have borderline personality disorder. It represents a synthesis of current scientific knowledge and rational clinical practice. As noted in the introduction to the guideline, borderline personality disorder is the most common personality disorder seen in clinical settings, although it is underdiagnosed and often incorrectly diagnosed. The disorder is present in cultures around the world. Its essential feature is a pervasive pattern of instability of interpersonal relationships, affects, and self-image, along with marked impulsivity—characteristics that appear by early adulthood.
The eight-member work group for the development of the new guideline, which consisted of psychiatrists with clinical and research expertise in borderline personality disorder, was formed in 1999 under the leadership of John M. Oldham, M.D. Development followed an iterative process of multiple drafts and widespread review that was established for all APA guidelines by a steering committee chaired by John McIntyre, M.D. As noted in the introduction, the guideline on the treatment of borderline personality disorder strives to be as free as possible of bias toward any theoretical approach to treatment.
The guideline is divided into three parts. Part A presents recommendations for formulating and implementing a treatment plan for patients with borderline personality disorder. It also summarizes special features that influence treatment of these patients and highlights important issues in risk management. The guideline strongly recommends a thorough safety evaluation as part of the initial assessment, because suicide attempts and self-endangering behaviors are common among patients with this disorder. The safety evaluation determines what treatment setting will be used for a more comprehensive assessment.
The guideline notes that the primary treatment for borderline personality disorder is a minimum of one year of psychotherapy complemented by symptom-targeted pharmacotherapy. Two psychotherapeutic approaches have been shown to have efficacy in controlled trials: psychoanalytic-psychodynamic therapies and dialectical behavior therapy. No results are available from direct comparisons of the two approaches to suggest which patients may respond better to which type of treatment. The guideline describes three key elements of both approaches: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation and supervision.
Regardless of the specific type of therapy used, clinical experience summarized in the guideline suggests a number of elements that can help the psychotherapist be more effective. They include building a strong therapeutic alliance, monitoring self-destructive and suicidal behaviors, validating the patient's suffering and experience, and helping the patient take responsibility for his or her actions. Because patients with this disorder may present with a broad array of strengths and weaknesses, flexibility on the part of the clinician is a crucial aspect of effective therapy, according to the guideline. Other components of effective therapy include managing feelings of both the patient and the therapist, promoting reflection rather than impulsive action, diminishing splitting, and setting limits on self-destructive behaviors.
The guideline outlines three areas that may be targeted by pharmacotherapy: affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual symptoms. The guideline strongly recommends selective serotonin reuptake inhibitors as the initial treatment for patients with affective dysregulation and impulsive, disinhibited behavior. Neuroleptics in low dosages are the treatment of choice for cognitive-perceptual symptoms. The guideline includes detailed algorithms for the use of medications.
According to the guideline, special features that influence the treatment of patients with borderline personality disorder include comorbidity with axis I and other axis II disorders, problematic substance use, violent behavior and antisocial traits, chronic self-destructive behavior, trauma and posttraumatic stress disorder, dissociative features, psychosocial stressors, gender, age, and cultural factors. The guideline also emphasizes that the therapist's attention to risk management is critical. Considerations in this area include the need for collaboration and communication with other treating clinicians as well as careful and adequate documentation. Any problems in the transference and countertransference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. The guideline emphasizes the importance of following standard procedures for terminating treatment. Other risk-management issues that require particular consideration, according to the guideline, are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behavior.
Part B of the guideline reviews the evidence on which the treatment recommendations are based, and part C addresses research needs. The guideline's nearly 200 references are coded to indicate the rigor of the evidence supporting clinical recommendations, from the most rigorous—a randomized clinical trial—to the least rigorous, such as case reports and expert opinion.
Practice Guideline for the Treatment of Patients With Borderline Personality Disorder will be published as a supplement to the October issue of the American Journal of Psychiatry. It will also be published as a monograph available for sale from American Psychiatric Publishing, Inc. (www.appi. org).
Bush Administration Takes Next Step in Implementation of New Freedom Initiative
On the 11th anniversary of the Americans With Disabilities Act (ADA) in late July, President Bush announced the start of a nationwide assessment of barriers to community living faced by the 54 million Americans who have physical and psychiatric disabilities. The President charged six cabinet-level agencies with conducting the assessment and delivering a report with recommendations by October 16.
Representatives of the six agencies will form the new Interagency Council on Community Living, which will coordinate federal efforts for people with disabilities. The six agencies are the Departments of Health and Human Services, Education, Labor, Housing and Urban Development, and Justice and the Social Security Administration.
The assessment of barriers to community living will feature a national public comment meeting, a written comment process, and a series of toll-free teleconference sessions. Its purpose is to solicit information and recommendations from people with disabilities, disability experts, state and local program administrators, and the public.
The assessment is the first step in carrying out Executive Order 13217, which was signed by President Bush in June. The order was drafted in response to the 1999 Supreme Court decision in Olmstead v. L.C. and E.W., which supported consumers' rights to care in the community over institutional care. The executive order calls for a broad review of current federal laws, programs, and policies that may interfere with community integration of people with disabilities. It directs federal agencies to assist states in expanding community-based services for this group. The executive order is part of the New Freedom Initiative for Americans With Disabilities announced by President Bush early in his administration. The initiative also proposes the formation of a National Commission on Mental Health (see Psychiatric Services, March 2001, page 398).
Commenting on the formation of the Interagency Council on Community Living, Secretary of Health and Human Services Tommy G. Thompson stated, "We can make real progress only if we first listen to people who know the barriers better than anyone else. I believe our nationwide assessment will bring an outpouring of experience and creative ideas. The new council will bring high-level administration focus to these ideas."
The full text of the New Freedom Initiative can be downloaded from the White House Web site at www. whitehouse.gov.
News Briefs
Results of NMHA depression survey released: The National Mental Health Association has released the results of a nationally representative survey that shows substantial progress in the public's understanding of the nature of depression. Among survey respondents who had never been diagnosed as having depression, 55 percent said that depression is a disease and not "a state of mind that a person can snap out of." A survey in 1991 indicated that only 38 percent of the public recognized depression as an illness. The 2001 survey, conducted for NMHA by Public Opinion Strategies LLC, comprised interviews with 500 adults being treated for depression and 800 members of the general public. Thirty-five percent of the general public believed that a person can be completely cured of depression, compared with only 12 percent of the respondents in treatment. Studies have found that 50 percent of people diagnosed as having depression will experience a subsequent episode. The survey results highlighted a strong correlation between clinical depression and diminished social and economic circumstances for families. Respondents with depression reported higher rates of divorce and unemployment than the general public. For more information, visit the NMHA Web site at www.nmha.org (see News Releases).
Bazelon Center kit explains Medicaid funding for children: The Bazelon Center for Mental Health Law has produced a kit explaining Medicaid definitions of key rehabilitation services for children with serious mental or emotional disorders. The materials are designed to help state policy makers develop appropriate rules covering federally mandated funding of community-based services for Medicaid-eligible children. The kit contains an overview of the federal mandate and a discussion of the issues in Medicaid funding of children's services. Six four-page briefs on specific services address behavioral or therapeutic aides, intensive at-home services, child respite care, after-school programs, therapeutic summer camps, and therapeutic nurseries and preschool programs. Single packets may be ordered for $10 from the bookstore at the center's Web site at www. bazelon.org or by sending payment to the Publications Desk, Bazelon Center, 1101 15th Street, N.W., Suite 1212, Washington, D.C. 20005.
