Other disorders may be comorbid with borderline personality disorder, such as mood disorders, substance-related disorders, eating disorders (notably, bulimia), PTSD, other anxiety disorders, dissociative identity disorder, and attention-deficit/hyperactivity disorder (ADHD) (see Section V.A.2, "Comorbidity," and refer to relevant APA Practice Guidelines [84–88]). These disorders can complicate the clinical picture and need to be addressed in treatment. Depression, often with atypical features, is particularly common in patients with borderline personality disorder (89, 90). Depressive features may meet criteria for major depressive disorder or dysthymic disorder, or they may be a manifestation of the borderline personality disorder itself. Although this distinction can be difficult to make, depressive features that appear particularly characteristic of borderline personality disorder are emptiness, self-condemnation, abandonment fears, hopelessness, self-destructiveness, and repeated suicidal gestures (91, 92). Depressive features that appear to be due to borderline personality disorder may respond to treatment approaches described in this practice guideline. Depressive features that meet criteria for major depression (especially if prominent neurovegetative symptoms are present) should be treated by using standard treatment approaches for major depression (see the APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder[84; included in this volume]) in combination with treatment targeted at the borderline personality disorder. Available evidence suggests that SSRIs and MAOIs are more effective than tricyclic antidepressants for depressive features in patients with borderline personality disorder (although safety issues must be particularly carefully considered when using MAOIs).

Substance use disorders are common in patients with borderline personality disorder. The presence of substance use has major implications for treatment, since patients with borderline personality disorder who abuse substances generally have a poor outcome and are at greatly higher risk for suicide and for death or injury resulting from accidents. Persons with borderline personality disorder often abuse substances in an impulsive fashion that contributes to lowering the threshold for other self-destructive behavior such as body mutilation, sexual promiscuity, or provocative behavior that incites assault (including homicidal assault).

Patients with borderline personality disorder who abuse substances are seldom candid and forthcoming about the nature and extent of their abuse, especially in the early phases of therapy. For this reason, therapists should inquire specifically about substance abuse at the beginning of treatment and educate patients about the risks involved.

Vigorous treatment of any substance use disorder is essential in working with patients with borderline personality disorder (87). Depending on the severity of the alcohol abuse, if outpatient treatment is ineffective, inpatient treatment may be needed for detoxification and participation in various alcohol-treatment interventions. Participation in Alcoholics Anonymous is often helpful on both an inpatient and an outpatient basis. Clinical experience suggests that the use of disulfiram may occasionally be helpful as adjunctive treatment for patients with borderline personality disorder who use alcohol, but it must be used with caution because of the risk of impulsivity or nonadherence. Other medications effective for the treatment of alcohol abuse or dependence (e.g., naltrexone) may also be considered. Twelve-step programs are also available for persons abusing narcotics or cocaine. Opioid antagonists (e.g., naltrexone) are effective in treating opiate overdoses and are occasionally used in an attempt to decrease opiate abuse. However, they require diligent patient adherence, and there is little empirical support for the effectiveness of this approach for addiction.

Drug counseling may be a useful component of treatment. However, except perhaps for mild marijuana use, psychotherapy alone is generally ineffective for treating substance use disorders.

To the extent that various substances may be abused in order to mask depression, anxiety, and other related states, clinical experience suggests that prescribed medications—antidepressants (especially SSRIs) or nonhabituating anxiolytics such as buspirone—may help to alleviate the underlying symptoms, thus lessening the temptation to resort to the use of alcohol or drugs.

Some patients with borderline personality disorder engage in violent behaviors. Violence may take such forms as hurling objects at family members—or at therapists—during moments of intense anger or frustration. Others may commit physical assaults. Some patients with borderline personality disorder are physically abusive toward their children. Patients with antisocial traits may engage in robbery, burglary, and car theft. Acts of this sort are often associated with an arrest record.

Therapeutic strategies optimal for dealing with antisocial features vary, depending on the severity of these features, and range from minor interventions to broader and more complex strategies suitable for a clinical picture in which antisociality is a major factor.

When antisocial features are mild (e.g., occasional shoplifting at times of severe stress), clinical experience suggests that individual cognitive therapy may be successful (e.g., encouraging the patient to weigh the risks versus the benefits—and the short-term versus the long-term consequences—of various antisocial choices the patient had been contemplating as well as identifying alternative coping strategies). This becomes in effect a psychoeducative approach in which the patient is helped to understand the advantages, in the long term, of socially appropriate alternatives (93).

When more severe antisocial features are present, residential treatment may be indicated. This may take the form of the "therapeutic community" as described by Losel (94) and by Dolan et al. (95). Various forms of group therapy are a mainstay of this approach. When episodic outbursts of violent behavior are present, the use of mood-stabilizing medications or an SSRI may be indicated (59, 96).

When antisocial features are even more severe and become dominant, and when the threat of violence is imminent, psychotherapy of any type may prove ineffective. In this situation hospitalization (involuntary, if necessary) may be required to help the patient regain control and, in cases in which a specific threat has been communicated by the patient, to reduce the risk to the potential victim(s).

Clinicians should be aware that some patients with borderline personality disorder with antisocial comorbidity may not be good candidates for therapy. This is especially true when the clinical picture is dominated by psychopathic traits (as described by Hare [97]) of the intensely narcissistic type: grandiosity, conning, lack of remorse, lying, and manipulativeness. Similarly, when underlying motives of jealousy or of revenge are of extreme intensity, therapy may prove ineffective (93).

A primary feature of borderline personality disorder is impulsive self-destructive behavior, including reckless driving and spending, shoplifting, bingeing and purging, substance abuse, risky sexual behavior, self-mutilation, and suicide attempts. This behavior is thought to reflect the difficulties patients with borderline personality disorder have with modulation and containment of intense emotions or impulses. Some clinicians who are expert in the treatment of borderline personality disorder (4, 17) suggest that the psychotherapist should approach each session with a hierarchy of priorities in mind (as exhibited in Figure 1). In other words, suicidal and self-destructive behaviors would be addressed as the highest priorities, with an effort to evaluate the patient's risk for these behaviors and help the patient find ways to maintain safety. Alternatives to self-mutilation, for example, can be considered (12, 17), and insights might be offered about the meaning of self-defeating behavior. SSRIs might also be prescribed for the self-mutilating patient.

Most experts agree that some type of limit-setting is necessary at times in the treatment of patients with borderline personality disorder. Because patients engage in so many self-destructive and self-defeating behaviors, clinicians may find themselves spending a great deal of the therapy setting limits on the patient's behaviors. The risk in these situations is that therapists may become entrenched in a countertransference posture of policing the patient's behavior to the point that treatment goals are lost and the therapeutic alliance is compromised. Waldinger (18) has suggested that limit-setting should be targeted at a subgroup of behaviors, namely, those that are destructive to the patient, the therapist, or the therapy. Limit-setting is not necessarily an ultimatum involving a threat to discontinue the treatment. Therapists can indicate to the patient that certain conditions are necessary to make treatment viable.

It is also useful for psychiatrists to help the patient think through the consequences of chronic self-destructive behaviors. In this way the behavior may gradually shift from being ego syntonic to ego dystonic (i.e., the behavior becomes more distressing to the patient as he or she becomes more reflective about the adverse consequences). The patient and therapist can then form a stronger therapeutic alliance around strategies to control the behavior.

If self-destructive behaviors are relentless and out of control, and especially if patients are not willing to work on controlling such behaviors, patients may need referral to a more intensive level of care before they are able to resume outpatient treatment. Consultation may also be useful.

Childhood trauma is a common although not universal feature of borderline personality disorder (98–104). Recognizing trauma-related aspects of the patient's affective instability, damaged self-image, relationship problems, fears of abandonment, self-injurious behavior, and impulsiveness is important and can facilitate psychotherapy in a variety of ways.

Recognizing a trauma history, if present, can help the therapist and patient understand current distortions in the patient's view of self and others as an understandable residual of prior life experiences that would produce mistrust. Anger, impulsiveness, and self-defeating behavior in relationships take on different meanings when understood as, in part, displaced responses to abusive early life experiences. Discounting a trauma history has the potential to undermine the therapeutic alliance and the progress of treatment. It can also hamper patients' ability to integrate and come to terms with the trauma. Not integrating traumatic material into the treatment can lead patients to experience the therapy as a form of collusion with the abuser.

Many traumatized patients expect others, including their therapists, to be malevolent, for example, inflicting harm in the guise of providing help, analogous to a parent or other caretaker exploiting and abusing a child. This core transference mistrust may become an ongoing issue to be worked on during psychotherapy.

Decisions about whether and when to focus on trauma, if present, during treatment should be based on the patient's agitation, stability, fragility, evidence of psychotic symptoms, and potential for self-harm or disruption of current vocational, family, or other roles. It is generally thought that working through the residue of trauma is best done at a later phase of treatment, after solidifying the therapeutic alliance, achieving stabilization of symptoms, and establishing an understanding of the patient's history and psychological structures (8).

In the later phase of treatment, one component of effective psychotherapy for patients with a trauma history involves exposure to, managing affect related to, and cognitively restructuring memories of the traumatic experience. This involves grief work (105), acknowledging, bearing, and putting into perspective the residue of traumatic experiences (106). This process helps to reduce the unbidden, intrusive, and alien nature of traumatic memories and differentiates affect associated with the trauma from that elicited by current relationships.

For patients with borderline personality disorder who have experienced trauma, group work can be particularly helpful in providing support and understanding from other trauma survivors as well as a milieu in which they can gain understanding about their self-defeating behaviors and interpersonal relationship patterns. Some patients with borderline personality disorder can be less defensive receiving feedback from peers, and at certain points in therapy this may be the only place they feel understood and safe.

The vulnerability of traumatized patients to revictimization, or their deliberate incurring of risk and reenactment of early trauma, has implications for patient safety and management of the transference. The therapist should address the possibility of current or future harm to the patient.

Even when full criteria for comorbid PTSD are not present, patients with borderline personality disorder may experience PTSD-like symptoms. For example, symptoms such as intrusion, avoidance, and hyperarousal may emerge during psychotherapy. Awareness of the trauma-related nature of these symptoms can facilitate both psychotherapeutic and pharmacological efforts in symptom relief.

Victims of trauma, especially early in life, typically blame themselves inappropriately for traumatic events over which they had no control (107). This may happen because the trauma was experienced during a developmental period when the child was unable to appreciate independent causation and therefore assumed he or she was responsible. Many adults blame themselves so that they avoid reexperiencing the helplessness associated with trauma. It is important in therapy to listen to a patient's guilt and sense of responsibility for past trauma and, when appropriate, to clarify the patient's lack of responsibility for past trauma as well as the importance of taking responsibility for present life circumstances.

Eye movement desensitization and reprocessing (108) has been presented as a treatment for trauma symptoms. It involves having patients discuss a traumatic memory and then move their eyes back and forth rapidly as though they were in rapid eye movement sleep. The specific effect of the eye movements has not been established, and the treatment may mainly involve exposure to and working through trauma-related cognition and affect (109, 110). This therapy is currently under investigation. There is currently no evidence of specific efficacy for this treatment in patients with borderline personality disorder.

Ignoring or discounting a trauma history can undermine the therapeutic alliance by aligning the therapist with individuals in the patient's past who either inflicted harm or ignored it. On the other hand, memories of remote traumatic experiences may contain inaccuracies. Dissociative symptoms may complicate retrieval of traumatic memories in patients with borderline personality disorder (111, 112). The affect may be correct even when the details about events are wrong (113). Furthermore, confrontation of family members regarding possible abusive activity is likely to produce substantial emotional response and family disruption. Thus, the approach to traumatic origins of symptoms should be open-ended, sensitive to both the effects of possible trauma and the fallibility of memory.

There is considerable comorbidity between borderline personality disorder and various dissociative symptoms and disorders (100, 114–117). Transient dissociative symptoms, including depersonalization, derealization, and loss of reality testing, are not uncommon and may contribute to the psychotic-like symptoms that patients with borderline personality disorder may experience. The percentage of patients with borderline personality disorder who also have dissociative identity disorder is unknown, but it is estimated that one-third of patients with dissociative identity disorder also have borderline personality disorder (118). Dissociative symptoms and dissociative identity disorder may appear as or exacerbate other borderline personality disorder characteristics, including identity disturbance, impulsivity, recurrent suicidal behavior, and affective instability. Thus, to manage these symptoms, identification of and attention to comorbid dissociative identity disorder or prominent dissociative symptoms is mandated. This includes the following:

• Exploring the extent of the dissociative symptoms
• Exploring current issues that may lead to dissociative episodes
• Clarifying the nature of dissociative symptoms and distinguishing them from malingering or deception on the one hand and psychotic symptoms on the other
• Teaching the patient how to access and learn to control dissociation, including the possible use of hypnosis in patients with full dissociative disorder
• Working through any possible posttraumatic symptoms associated with the dissociative symptoms
• Facilitating integration of dissociated identities or personality states and integrating amnesic episodes by explaining to patients that the problem is one of fragmentation of personality structure elements; practicing with the patient more fluid transitions among various identities and personality states
• Working through transference issues related to trauma and feelings about controlling dissociative symptoms
• Consolidating and stabilizing gains by providing positive reinforcement for integrated function and consistent response to dissociative components of the personality structure
• Supporting the patient in case of relapse

When borderline personality disorder and dissociative identity disorder coexist, clinical reports suggest that hypnosis may be useful for identifying and controlling dissociative symptoms (119–121). These symptoms can be reconceptualized as uncontrolled hypnotic-like states that can be elicited and modulated with hypnosis, both as a technique in therapy and as a self-hypnotic exercise to be practiced by patients under the therapist's supervision.

A crucial element in working through issues of transference/countertransference and limit-setting is the extent to which the patient is consciously aware and in control of mental states in which impulsive behavior or strong emotions are experienced. Treatment of comorbid dissociative symptoms can help to delineate the areas of available control and expand the patient's repertoire of adaptive symptom-control skills.

In borderline personality disorder, stress may be a contributing factor in the disorder's etiology and a precipitant of symptomatic exacerbation (122). Physical or sexual abuse is not uncommon during childhood for these patients; histories of other forms of trauma, such as verbal abuse or neglect (123) and early parental separation or loss (124), are frequently elicited as well. In addition, most patients with borderline personality disorder are acutely sensitive to psychosocial stressors, particularly interpersonal stressors. Self-esteem is often fragile, and patients seek to shore up their sense of self by "borrowing" a stable, established identity from another (usually idealized) person. Relationships are intense, and everyday distractions or inattention can be interpreted as abandonment, resulting in panic-like anxiety, impulsive self-destructive acts, excessive anger, paranoia, or dissociative episodes. These sensitivities are important in therapy, since regardless of the type of treatment, once a therapeutic relationship has developed, it will take on this overdetermined, intense quality. The psychiatrist should be alert, nimble, flexible, and on the lookout for ways in which the limits of the therapeutic relationship may stimulate anxiety-driven reactions in the patient—reactions that may be confrontational, depressive, or invisible until revealed by self-destructive or impulsive acting out.

Borderline personality disorder is diagnosed predominantly in women, with an estimated gender ratio of 3:1. The disorder may be missed in men, who may instead receive diagnoses of antisocial or narcissistic personality disorder. Men should be as carefully assessed for borderline personality disorder as women. The diagnostic assessment of the patient should include a detailed inquiry regarding reproductive life history, including sexual practices and birth control.

Most treatment studies of borderline personality disorder primarily involve women. There has been little systematic investigation of gender differences in treatment response.

The treatment of pregnant and nursing women raises specific concerns regarding the use of psychotropic medications. The potential risks, which are highest during the first trimester of pregnancy, have been reviewed elsewhere (125). When treating women with borderline personality disorder who are pregnant or nursing, the risks of treatment with medication must be carefully weighed against the potential risks and benefits of alternative treatment (e.g., psychotherapy alone) as well as the risk to the woman if the borderline personality disorder and comorbid conditions are not treated (125, 126). These potential risks and benefits should be discussed with the patient.

Because anticonvulsants are associated with a potential risk of birth defects, and the risk of birth defects from other psychotropic medications is unknown, psychiatrists should encourage careful contraceptive practices for all female patients of childbearing age who are receiving pharmacological treatment. Since carbamazepine can increase the metabolism of birth control pills, the dosage of oral contraceptives may need to be adjusted accordingly. Whenever possible, planned pregnancy should be pursued in consultation with the psychiatrist so that options, including maintenance of pharmacological treatment or discontinuation of these agents, can be thoughtfully pursued. For patients who become pregnant while on a maintenance regimen of psychiatric medications, a consultation for further consideration of the relative risks of continuing or discontinuing medications should also be considered (127, 128).

Gender issues, including psychotropic medication use during pregnancy, that are associated with certain comorbid conditions are discussed in other APA Practice Guidelines (84–86).

Borderline personality disorder has been reported in many cultures around the world (129). The cultural context of a patient's presentation should be considered. Cultural factors may hamper the accurate assessment of borderline personality disorder. An appreciation by the clinician of cultural variables is critical in making an accurate diagnosis. Clinicians should be especially careful to avoid cultural bias when applying the diagnostic criteria and evaluating sexual behavior, expressions of emotion, or impulsiveness, which may have different norms in different cultures.

Ethnic groups may differ in their response to psychotropic medications. Although inconclusive, some studies have suggested that Asian patients may require lower doses of haloperidol and have higher serum levels of haloperidol after oral administration than Caucasian patients (130). Psychiatrists should be aware of this possibility when administering neuroleptic medication to Asian patients. Some studies also suggest that ethnic groups may differ in their response to antidepressant medications (131, 132).

Because the personality of adolescents is still developing, the diagnosis of borderline personality disorder should be made with care in this age group. Borderline personality disorder may be present in the elderly, although later in life a majority of individuals with this disorder attain greater stability in functioning. Virtually no treatment studies have been done in adolescents or elderly persons with borderline personality disorder. Although treatments effective in adults would be expected to be efficacious in these age groups, research that demonstrates this efficacy is needed, especially in adolescents. It should be kept in mind that elderly patients are particularly prone to certain medication side effects (e.g., orthostatic hypotension and anticholinergic effects) and therefore may tolerate certain medications less well than younger adults.