For the first time since 2001, the American Psychiatric Association (APA) has updated its clinical practice guideline on borderline personality disorder (BPD).
The new guideline is “quite substantial and really serves as a rich textbook of the literature, about borderline personality disorder that any clinician would find very valuable,” John Oldham, MD, MS, member of the guideline writing group, told Medscape Medical News.
“The overall goal is to improve the quality of care and treatment outcomes for patients with BPD,” said Oldham, distinguished emeritus professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine in Houston, Texas.
The updated guideline was published online on November 1 in the American Journal of Psychiatry.
It includes eight evidence-based recommendation statements covering assessment and determination of treatment plan, psychosocial interventions, and pharmacology.
Recommendations denoted by the numeral 1 after the guideline statement indicates confidence that the benefits of the intervention clearly outweigh the harms. A suggestion (denoted by the numeral 2 after the guideline statement) indicates greater uncertainty.
Each guideline statement also has an associated rating for the strength of supporting research evidence — high, moderate, and low, denoted by the letters A, B, and C, respectively.
The APA recommends (1C) that the initial assessment of a patient with possible BPD include the reason the individual is presenting for evaluation; the patient’s goals and preferences for treatment; a review of psychiatric symptoms, including core features of personality disorders and common co-occurring disorders; a psychiatric treatment history; assessment of physical health and psychosocial and cultural factors; a mental status examination; and an assessment of risk of suicide, self-injury, and aggressive behaviors, as outlined in APA Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition.
The APA suggests (2C) that the initial psychiatric evaluation of a patient with BPD include a quantitative measure to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment.
The guideline lists several options, including (but not limited to) the 23-item version of the Borderline Symptom List; the Borderline Evaluation of Severity Over Time; 11-item Borderline Personality Features Scale for Children; and Difficulty in Emotional Regulation Scale.
The APA recommends (1C) that a patient with BPD have a documented, comprehensive, and person-centered treatment plan and be engaged in a collaborative discussion about their diagnosis and treatment, which includes psychoeducation related to the disorder. “This is a new recommendation,” Oldham told Medscape Medical News.
Another new recommendation (1B) advises a structured approach to psychotherapy that has support in the literature and targets the core features of the disorder. These include dialectical behavior therapy and mentalization-based therapy along with other therapies that have demonstrated efficacy in recent studies.
The APA recommends (1C) that a patient with BPD have a review of co-occurring disorders, prior psychotherapies, other nonpharmacological treatments, past medication trials, and current medications before initiating any new medication.
The APA suggests (2C) that that any psychotropic medication treatment of BPD be “time-limited, aimed at addressing a specific measurable target symptom, and adjunctive to psychotherapy.”
“Medication is not a primary treatment but may help diminish symptoms such as affective instability, impulsivity, or psychotic-like symptoms in individual patients, helping them to remain engaged in treatment or reducing short-term risks of self-harm,” said Oldham.
The APA recommends (1C) a review and reconciliation of medications at least every 6 months to assess the effectiveness of treatment and identify medications that warrant tapering or discontinuation.
An Alternative Model of Care
Oldham said it’s important to note that the Alternative DSM-5 Model for Personality Disorders (AMPD) is increasingly being integrated into clinical practice with adolescents and adults.
Unlike the traditional categorical system, which diagnoses personality disorders as distinct and separate conditions, the AMPD views personality disorders along a continuum of severity and impairment.
The AMPD recognizes the variability and overlap in personality disorder symptoms and provides a nuanced, individualized framework for assessment and treatment planning.
Oldham co-chaired the work group that developed the proposal for the alternative model.
“Despite the growing recognition of the importance of the alternative model, our systematic reviews did not identify treatment studies using the alternative model that met our inclusion criteria. Therefore, it is not included in the new guideline,” he said.
Development of the guideline had no commercial funding. Oldham reported no conflicts of interest with his work on the guideline.
Note: This article originally appeared on Medscape.
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