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The borderline personality disorder practice guidelines: the good, the bad, and the realistic.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Borderline Personality Disorder (BPD) (2001) are timely with respect to need but early with respect to the state of the evidence. A statement about the treatment of BPD is absolutely necessary, even if incomplete, because BPD is a major psychiatric disorder with profound morbidity and mortality that consumes treatment resources out of proportion with its epidemiology. The compendium delivers a report that accurately reflects the status quo. The relevant existing literature has been gathered, classified, interpreted, and integrated in a fair and understandable fashion. The strengths of the report are its organization and completeness. The weakness is in the state of the evidence itself. The guidelines paradoxically provide evidence of the limited nature of existing empirical knowledge about the treatment of BPD. The entire report is built on only 198 references compared with 581 and 325 for the guidelines for schizophrenia (Practice Guidelines for the Treatment of Patients, with Schizophrenia, 1997) and depression (Practice Guideline for the Treatment of Patients with Major Depressive disorder, 2000), respectively. Furthermore, only 12 citations (6% of the references) account for psychosocial intervention studies conducted with Class A methodologic rigor. Of these, only five concern psychotherapy and these five citations arise from only two laboratories. The number is exceedingly small, yet this collection constitutes the Class A study data base for the Guideline’s recommendation of psychotherapy as the central treatment modality. Pharmacotherapy does somewhat better with 21 citations (11% of the references) of Class A studies. Nevertheless the number is hardly robust when compared with 70 studies of comparable scientific vigor for schizophrenia (Practice Guidelines for the Treatment of Patients, with Schizophrenia, 1997). The sheer limited volume of research renders any statements about treatment efficacy and safety equivocal and incomplete. The limited data on “psychotherapy” is particularly troublesome. Psychoanalytic and psychodynamic therapy is represented but not psychoanalytic or psychodynamic psychotherapy. The former is a treatment embedded in a partial hospital program. The latter, although probably one of the most frequently applied treatments to patients with BPD in America, has no Class A empirical representation in the Guidelines. In fact, psychotherapy appears Journal of Personality Disorders, 16(2), 119-121, 2002 © 2002 The Guilford Press