APA updates borderline personality disorder treatment guidelines

Key takeaways:

• The guidelines prioritize psychotherapy over “ineffective pharmacologic treatment,” an author said.
• Clinicians should review medications at least every 6 months to identify those that can be tapered or discontinued.

Updated guidelines from the American Psychiatric Association highlight psychotherapy as “the core of treatment” for borderline personality disorder in adolescents and adults.

George A. Keepers, MD, chair of the APA Practice Guideline Writing Group, said in a press release that he and his colleagues identified several important updates since the APA first published practice guidelines on borderline personality disorder (BPD) in 2001.

“First, several structured psychotherapies were found to be effective for treatment of BPD. No therapy emerged as a ‘gold standard’,” he said. “Second, no evidence was found for any pharmacotherapy’s effectiveness in treating the core symptoms of the disorder. This finding led to the recommendations designed to limit polypharmacy and prolonged treatment with medications.”

According to the authors, BPD affects up to 2.7% of the United States population, typically beginning in adolescence or early adulthood.

The updated guidance includes eight recommendations and suggestions:

Treatment plan

• The initial examination should include the reason for evaluation; the patient’s treatment goals and preferences; an examination of psychiatric symptoms and treatment history; physical and mental health assessments; examination of psychosocial and cultural factors; and risk assessment of suicide, self-injury and aggression. (Recommendation, low level of confidence)
• The initial psychiatric evaluation should include a quantitative measure to determine symptom severity and functioning impairments that can be targeted with treatment. (Suggestion, low level of confidence)
• Patients should have a comprehensive, person-centered treatment plan. (Recommendation, low level of confidence)
• Patients should be involved in discussions about their diagnosis and treatment, including psychoeducation. (Recommendation, low level of confidence)

Psychosocial interventions

• Treatment should include a structured psychotherapy approach that targets core BPD features. (Recommendation, moderate level of confidence)

Pharmacotherapy

• Before starting patients on a new medication, clinicians should review co-occurring conditions, past psychotherapy and medication trials, other nonpharmacological therapies and current medications. (Recommendation, low level of confidence)
• Limit psychotropic medication treatment durations and ensure these treatments address measurable symptoms and are adjunctive to psychotherapy. (Suggestion, low level of confidence)
• Review and reconcile patients’ medications at least every 6 months to assess their effectiveness and identify those that can be tapered or discontinued. (Recommendation, low level of confidence)

“We anticipate that many more patients will be able to access psychotherapeutic treatment and that clinicians will avoid the risks of ineffective pharmacologic treatment as a result of this guideline,” Keepers said.

Reference:

• American Psychiatric Association publishes updated practice guideline on the treatment of borderline personality disorder. https://www.psychiatry.org/news-room/news-releases/updated-borderline-personality-disorder-guideline. Published Dec. 10, 2024. Accessed Dec. 12, 2024.