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The optimal treatment of patients with borderline personality disorder (BPD) generally involves a combination of medication and psychotherapy. Currently, there are no rigorous empirical studies documenting the efficacy of combined treatment, but a growing number of studies suggest that both psychotherapy and pharmacotherapy independently produce significant changes in a variety of symptoms associated with BPD. In a randomized, controlled trial, dialectical behavior therapy (DBT) during a 12month period reduced the need for hospitalization dramatically and decreased the frequency and severity of parasuicidal behavior.1 Studies of psychodynamic therapy, using a "follow along" or "pre-post" design, have suggested that patients with borderline and other severe personality disorders may benefit from treatments of that nature as well.2'4
A number of psychopharmaeologic agents have been shown to improve specific target symptoms associated with BPD. Because of the protean nature of BPD, much of the research has been directed at specific clusters of target symptoms. These are often divided into symptoms of affective dysregulation, symptoms involving psychotic or cognitive perceptual distortions, and symptoms manifested by impulsivity or loss of control. Selective serotonin reuptake inhibitors (SSRIs), lithium, anti-seizure medications, both typical and atypical antipsychotics, and monoamine oxidase inhibitors have all been shown in controlled studies to be useful in controlling one or more of these symptom areas.5"8 Although the effects are modest, symptomatic improvements resulting from pharmacotherapy may usefully facilitate the patient's capacity to engage in psychotherapy.
There is no consensus regarding which characteristics constitute treatment-resistant status in patients with BPD. Patients in this diagnostic category are generally regarded as rather difficult to treat. In a retrospective chart review of more than 2,000 patients, Howard et al.9 noted that whereas 50% of depressed and anxious patients are improved in 8 to 13 sessions, similar levels of improvement in BPD patients require 26 to 52 sessions. Some do not improve until the second year of treatment. Hence, a fairly significant trial of treatment is required before such patients can be designated as treatment resistant. In the absence of consensually held criteria, I would suggest the following characteristics as possibly emblematic of treatment resistance: (1) little or no improvement after 1 year of competent psychotherapy; (2) no improvement in target symptoms after sufficient trials of two different psychopharmaeologic agents specifically suited for those...