ANRV372-CP05-12 ARI 19 February 2009 11:5

The Treatment of Borderline

Personality Disorder:
Implications of Research
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org

on Diagnosis, Etiology,
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

and Outcome
Joel Paris
McGill University, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec,
H3T 1E4 Canada; email: joel.paris@mcgill.ca

Annu. Rev. Clin. Psychol. 2009. 5:27790 Key Words

First published online as a Review in Advance on
October 31, 2008
The Annual Review of Clinical Psychology is online
at clinpsy.annualreviews.org
This articles doi:
10.1146/annurev.clinpsy.032408.153457
Copyright  c 2009 by Annual Reviews.
All rights reserved
1548-5943/09/0427-0277$20.00
personality disorders, suicidality, long-term outcome, psychotherapy,
pharmacotherapy
Abstract
The treatment of patients with borderline personality disorder (BPD) is
challenging. Making a diagnosis is necessary to plan therapy. But since
we do not know the etiology of BPD, treatment cannot be based on
a well-established theory. Outcome research shows that most patients
recover with time. A series of clinical trials show that a variety of psy-
chotherapies are effective in BPD and that the effects of medication are
unimpressive.

277
 ANRV372-CP05-12 ARI 19 February 2009 11:5
Contents
MAKING THE DIAGNOSIS . . . . . . . .
ETIOLOGICAL MODELS
AND TREATMENT . . . . . . . . . . . . . .
IMPLICATIONS OF OUTCOME
RESEARCH . . . . . . . . . . . . . . . . . . . . . .
EVIDENCE FOR EFFECTIVENESS
OF PSYCHOTHERAPY IN
BORDERLINE PERSONALITY
DISORDER . . . . . . . . . . . . . . . . . . . . . . .
PHARMACOTHERAPY IN
BORDERLINE PERSONALITY
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
DISORDER . . . . . . . . . . . . . . . . . . . . . . .
CONCLUSIONS: THE
TREATMENT OF
BORDERLINE PERSONALITY
DISORDER . . . . . . . . . . . . . . . . . . . . . . .
MAKING THE DIAGNOSIS
To treat patients with borderline personality
disorder (BPD), you have to make the di-
agnosis. If the disorder is underdiagnosed or
missed, patients will receive the wrong treat-
ment. Stern (1938), who published the rst clin-
ical description of these patients, described a
patient population that did not respond to psy-
choanalysis (then considered a standard method
of psychotherapy). Even today, results with
treatment as usual tend to be discouraging
(Bateman & Fonagy 2008, Linehan 1993). An-
ticipating problems so that patients receive
more specic interventions and so that clini-
cians are in a better position to predict clin-
ical course is one of the primary purposes of
diagnosis.
Making a diagnosis need not be difcult.
Borderline
personality disorder The clinician needs to obtain an accurate per-
(BPD): a long-term sonal history and establish that patterns of af-
pattern of emotional fective instability and impulsivity have begun
instability and early in development and are consistent over
impulsivity affecting
time and context.
interpersonal
functioning Epidemiological evidence shows that BPD
can be identied in about 1% of the general
278 Paris
population in the United States (Lenzenweger
et al. 2007, Samuels et al. 2002) as well as in the
United Kingdom (Coid et al. 2006) and Norway
278
(Torgersen et al. 2001). But BPD is much more
common in clinical settings. Zimmerman et al.
279
(2005) found that in a large psychiatric practice,
among 859 patients surveyed, 80 (9.3%) met di-
280
agnostic criteria. The highest prevalence occurs
in emergency room populations, in which BPD
can be identied in about half of all recurrent
suicide attempters (Forman et al. 2004).
281
Even so, BPD often tends to be missed
in practice. Research interviews elicit a much
higher prevalence of BPD in clinical set-
283
tings than does clinical assessment alone
(Zimmerman & Mattia 1999). Practitioners
may prefer to focus on comorbid Axis I con-
ditions (e.g., depression), which they believe to
284
be more easily treatable (Paris 2008a).
However, some of the problems in identify-
ing BPD can be attributed to lack of precision in
diagnostic criteria. As dened in the Diagnostic
and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR; American
Psychiatric Association 2000), BPD is a wide-
ranging syndrome affecting multiple domains,
with symptoms that reect emotional dysreg-
ulation, impulsivity, unstable relationships, and
cognitive dysfunction. It would be helpful to re-
quire problems in all these domains to make a
diagnosis so as to dene a more homogeneous
group (Paris 2007).
Given the prominent affective symptoms
seen in these patients, BPD has sometimes been
seen as a variant of mood disorder (Akiskal et
al. 1985). More recently, the prominence of af-
fective instability has led BPD to be seen as
a form of bipolarity (Akiskal 2002). However,
mood symptoms seen in BPD patients are re-
lated to affective instability, which presents a
very different picture from classical depression
(Gunderson & Phillips 1991) or mania (Paris
et al. 2007). Instead of extended periods of low
or high mood, one sees intense emotions that
escalate rapidly and only slowly return to base-
line (Linehan 1993). Mood changes radically,
even in the course of a day, typically shifting
 ANRV372-CP05-12 ARI 19 February 2009 11:5
from depression to anger (Koenigsberg et al.
2002). Moreover, affective instability in BPD,
unlike bipolar disorder, is mainly driven by re-
actions to life events (Russell et al. 2007).
Corresponding to this difference in phe-
nomenology, BPD patients do not respond to
antidepressants (or mood stabilizers) in the
same way as do patients with mood disor-
ders in the absence of a personality disorder
(Newton-Howes et al. 2006, Paris et al. 2007,
Shea et al. 1990). Instead, as discussed below,
affective instability can be targeted by specic
methods of psychotherapy.
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
Mood symptoms are not the only domain
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
in which BPD patients show prominent symp-
toms: impulsivity is also a central feature (Links
et al. 1999), and the most troubling clin-
ical problems in treatment concern impul-
sive actions such as self-injury and overdoses
(Gunderson 2001). Impulsivity is known to run
in families (Moeller et al. 2001), and the most
frequent disorders seen in rst-degree relatives
of BPD patients are not mood disorders, but
rather are substance abuse and antisocial per-
sonality disorders (White et al. 2003).
Interpersonal problems may be a separate
feature of BPD (Bender & Skodol 2007, Clarkin
et al. 2007a, Zanarini & Frankenburg 2007) or
may be secondary to affective instability and
impulsivity (Siever & Davis 1991). It is not
widely known that BPD patients frequently
develop cognitive symptoms, including brief
psychotic episodes, subdelusional paranoid
thinking, pseudohallucinations, and deper-
sonalization (Zanarini et al. 1990). These
symptoms are transient and can easily be dif-
ferentiated from true psychosis. When BPD
patients hear voices, they almost always know
that these experiences come from their own
mind. All these domains interface with each
other, producing a complex syndrome, and no
single feature denes BPD.
The complexity of BPD has led to the sug-
gestion that it could be better described by
scores on trait dimensions, using the Five-
Factor Model (Costa & Widiger 2002) or
similar schema (Livesley 2003). This proposal
www.annualreviews.org The Treatment of Borderline Personality Disorder
would be appropriate for Axis II categories that
represent exaggerated personality traits, for
example, obsessive-compulsive personality dis-
order. It is less suitable for BPD, which is char-
acterized by a wide range of symptoms that are
not seen in normal people.
For this reason, BPD should logically be
moved to Axis I when the newest version of
the Diagnostic and Statistical Manual (DSM-V) is
published. Diagnosing this condition as an Axis
I disorder would underline its status as a highly
symptomatic mental illness as opposed to a per-
sonality variant. (It should be noted, however,
that BPD would not t neatly into the current
DSM hierarchy because it has features of both
mood and impulsive disorders.)
ETIOLOGICAL MODELS
AND TREATMENT
We do not know what causes BPD. One can
say much the same about all mental disorders.
However, a large body of research has emerged
that attempts to identify biological and psy-
chosocial risk factors.
Biological vulnerability for BPD is sup-
ported by strong but indirect evidence. Per-
sonality disorders are heritable (Reichborn-
Knennerud 2008, Torgersen et al. 2000), as are
their underlying traits (Livesley & Jang 2008,
Livesley et al. 1998). One might expect bi-
ological markers to be associated with these
traits, but they have yet to be discovered. The
most consistent correlates thus far are found
in the relationship between impulsive behaviors
and defects in central serotonergic functioning
(Coccaro et al. 1989, Paris et al. 2004, Rinne
et al. 2002). Moreover, evidence from neu-
ropsychological testing (OLeary & Cowdry
1994) and from imaging studies (Silbersweig
et al. 2007) suggests that BPD patients have pre-
frontal lobe defects associated with problems in
executive function.
As for psychological risks, the majority
of BPD patients describe adverse childhood
experiences (Zanarini 2000), and about half
report some form of childhood sexual abuse
279
 ANRV372-CP05-12
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
ARI 19 February 2009 11:5
(Paris 2003). However, in a meta-analysis of 21
published studies, Fossati et al. (1999) found
only a moderate pooled correlation between
sexual abuse and BPD. Another recent meta-
analysis showed little relationship between
trauma and self-injury (Klonsky & Moyer
2008). Moreover, only about a third of patients
report severe trauma (Paris et al. 1994), i.e., the
forms of abuse found in community studies to
have the most frequent sequelae (Fergusson &
Mullen 1999) and that are known to lead to sig-
nicant psychopathology in adults (Browne &
Finkelhor 1986, Malinovsky-Rummell &
Hansen 1993, Rind et al. 1998). Thus, re-
silience to trauma is common, probably
because childhood experiences have a different
impact depending on cognitive processing and
personality trait proles (Rutter 2006, Rutter
& Rutter 1993).
Social inuences are suggested by the fact
that some of the symptoms associated with
BPD (suicide attempts, self-injury) increased
in prevalence after the Second World War
(Rutter & Smith 1995). BPD can be recognized
in clinical settings around the world (Loranger
et al. 1994), but it is probably less common
in traditional societies (Paris 1996), although
changes in the social environment in the devel-
oping world may be increasing the risk for the
disorder (Millon 1993).
If the etiology of BPD were primarily bio-
logical, we might expect it to remit when phar-
macological agents are prescribed. If the etiol-
ogy of BPD were primarily psychosocial, we
might expect patients with BPD to respond
to psychotherapy in the same way as do pa-
tients with other disorders. Neither of these
expectations corresponds to existing evidence;
thus, understanding the disorder requires a
complex, multidimensional framework using a
stress-diathesis model (Engel 1980, Monroe &
Simons 1991, Paris 2008a).
Our knowledge of etiology is currently in-
sufcient to guide the treatment of BPD. But if
etiological models are multidimensional, then
treatment should also be multidimensional.
BPD patients may need medication to reduce
biological risks, therapy to address psychologi-
280 Paris
cal risks, and practical interventions to deal with
social risks.
IMPLICATIONS OF OUTCOME
RESEARCH
Borderline personality disorder has a unique
course, which has a greater resemblance to that
of substance abuse and other impulsive disor-
ders than to mood or anxiety disorders. Thus,
BPD is a disorder of youth that begins in ado-
lescence, peaks in young adulthood, and tends
to burn out by middle age (Paris 2003).
Although BPD usually begins after puberty
(Zanarini et al. 2001), many clinicians are re-
luctant to make the diagnosis in adolescence.
Reluctance to diagnose may be based on as-
sumptions that symptoms are temporary fea-
tures of adolescent turmoil, since the character-
istic features are virtually identical (Kernberg
et al. 2000), or that a personality disorder has
to be a life-long condition. Actually, although
follow-ups of adolescents with BPD show that
patients do not always retain this diagnosis, ado-
lescent patients usually continue to have serious
symptoms (Bernstein et al. 1993). Yet, as dis-
cussed below, BPD gets better with time.
In the young adult years, BPD has a course
that Schmideberg (1959) once described as sta-
bly unstable. Early follow-up studies had sug-
gested that ve years after initial presentation,
most patients showed little change (Pope et al.
1983). Follow-ups over 15 years (McGlashan
1986, Paris et al. 1987, Plakun et al. 1985, Stone
1990) showed that recovery usually occurs by
age 3040.
In the majority of cases, BPD remits, and
by age 40, 75% of patients no longer met diag-
nostic criteria (Paris et al. 1987). Mean global
assessment of functioning scores (nearly iden-
tical in all studies) are in the mid-sixties, which
can be considered within the range of normal-
ity. A 27-year follow-up of one cohort (Paris &
Zweig-Frank 2001) observed further improve-
ment by a mean age of 50, by which time only
8% still met diagnostic criteria.
Retrospective follow-back studies have
limitations, and prospective research, with
 ANRV372-CP05-12 ARI 19 February 2009 11:5
well-established baseline data, offers important
advantages. The rst prospective study of BPD
outcome (Links et al. 1990) conrmed the nd-
ings of follow-back research, with only a third
of patients being no longer diagnosable as hav-
ing BPD after seven years.
Since then, two large-scale prospective stud-
ies have found that some patients show an even
more rapid recovery. The Collaborative Longi-
tudinal Study of Personality Disorders (Skodol
et al. 2005) found that about half of their BPD
cohort no longer met criteria for diagnosis
within two years of follow-up. It is possible that
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
some of these cases may have been misdiag-
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
nosed on intake (Widiger 2005). Yet even when
DSM criteria were no longer met (largely due
to reductions in impulsivity), functional levels
did not necessarily improve. Another prospec-
tive study (Zanarini et al. 2005) reported similar
results over a 10-year follow-up period: symp-
tomatic improvement with residual functional
limitations.
Also, prospective research can have limited
generalizability in serious mental disorders. In
BPD, samples of patients willing to sign up
for follow-up and who usually attend treatment
regularly do not represent the population seen
by clinicians. Follow-back studies, with all their
aws, include the many noncompliant subjects
who do not follow treatment protocols.
Outcome research shows that BPD is asso-
ciated with suicide completion. Stone (1990),
as well as Paris & Zweig-Frank (2001), found
rates close to 10%. However, in a different sam-
ple, McGlashan (1986) reported suicide rates
of only 3%, whereas Zanarini et al. (2005)
observed that only 4% died by suicide after
10 years. Most of these discrepancies could be
accounted for by sampling and by differences
between follow-back and prospective methods.
Although BPD patients can have dramat-
ically suicidal symptoms when young, in the
longest follow-up study, lasting a mean of
27 years, Paris & Zweig-Frank (2001) observed
that most suicides occurred well after age 30,
usually when patients had failed a series of treat-
ments (and were entirely out of treatment).
Thus, the patients clinicians worry about the
www.annualreviews.org The Treatment of Borderline Personality Disorder
most (young, impulsive, frequent emergency
room visitors) are not necessarily the group at
highest risk (older, hopeless, and isolated).
It is difcult to predict from baseline vari-
ables the patients who will have the best or
the worst outcomes and the patients who will
complete suicide. Demographic factors (such as
education), measures of functional level before
treatment, clinical symptoms, diagnostic cri-
teria, developmental factors (traumatic events
during childhood), and even the number of
attempts are not consistently related to these
outcomes (Paris 2003). The symptom of great-
est negative prognostic importance in BPD is
substance abuse (Links et al. 1990, Stone 1990).
The mechanisms of improvement in BPD
are not known, but one is a decline in im-
pulsivity over time, as seen in other impul-
sive disorders, such as substance abuse (Vaillant
1995) and antisocial personality disorder (Black
et al. 1995). Recovery could reect the ef-
fects of brain maturation and/or social learn-
ing. Also, many patients learn to limit the
intensity of interpersonal relationships, the
domain that gives them the most trouble.
McGlashan (1993), Stone (1990), as well as
Paris & Zweig-Frank (2001) found that BPD
patients are less likely to marry or have chil-
dren than the general population.
In summary, outcome studies point to a
positive prognosis for BPD. Therapists need
to understand mechanisms of improvement to
make this process go faster. Even if short-term
results mainly concern reductions in patient
overdosing and cutting, symptomatic improve-
ment may give therapy a chance to improve
quality of life.
EVIDENCE FOR EFFECTIVENESS
OF PSYCHOTHERAPY IN
BORDERLINE PERSONALITY
DISORDER
We now have strong evidence from clinical
trials of psychotherapy for effective treatment
of BPD (summarized below). However, stan-
dard approaches may not be effective, and
281
 ANRV372-CP05-12 ARI 19 February 2009 11:5
well-structured methods specically designed
for this population are necessary.
Dialectical behavior therapy (DBT) was the
Dialectical behavior
therapy (DBT): a subject of one of the rst randomized con-
treatment method trolled trials of a psychotherapy designed for
based on emotion BPD (Linehan et al. 1991). DBTs efcacy has
regulation been conrmed in comparison to a control
Mentalization-based group of patients treated by community experts
therapy (MBT): a (Linehan et al. 2006) and has been replicated
treatment method
in other settings (e.g., Lynch et al. 2006).
based on observation
of mental states Although we do not know whether treated sam-
ples maintain these gains on long-term follow-
up, Zanarini et al. (2005) found that relapses are
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
uncommon after remission.
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
The generalizability of DBT to practice re-
mains uncertain. The method is resource in-
tensive, expensive, and requires long periods of
therapist and patient time. Linehan (1993) orig-
inally suggested that a full course of treatment
might take several years, but tested only the rst
stage (lasting a year), in which parasuicidal be-
haviors are targeted and brought under control.
However, even this rst stage is not readily ac-
cessible to most patients, given that the treat-
ment cannot be funded easily. To deal with this
problem, DBT can be dismantled and stream-
lined for greater clinical impact. Most of the
effects are apparent within a few months, and
a briefer version (lasting only six months) has
been found to be effective (Stanley et al. 2007).
For a number of years, DBT was the only
therapy that had been subjected to randomized
clinical trials. DBT still has the largest amount
of research behind it. The Cochrane review of
psychotherapy in BPD (Binks et al. 2006a), ap-
plying the highest standards of evidence, con-
cluded that the data are at least promising.
However, now that several other methods have
been tested, we can consider alternatives.
Standard CBT for BPD has been subjected
to clinical trials. Although Becks approach (cor-
recting maladaptive cognitions) has thus far
only been examined in an open uncontrolled
trial (Brown et al. 2004), a randomized con-
trolled trial conducted by Davidson et al. (2006)
found CBT to be superior to treatment as usual.
Moreover, because the average number of ses-
sions in this trial was only 16, the results sug-
282 Paris
gest that therapy can be streamlined. Simi-
larly, Weinberg et al. (2006) found that a 12-
week clinical trial reduced self-harm behavior
in BPD, as compared to treatment as usual. We
need not assume that therapy for BPD must
always take several years.
Schema-focused therapy, developed by
Young (1999), is a hybrid of CBT and psy-
chodynamic therapy that aims to modify mal-
adaptive schema deriving from adverse experi-
ences in childhood. A clinical trial (Giesen-Bloo
et al. 2006) compared schema-focused ther-
apy to transference-focused psychotherapy (see
below), with encouraging results. However,
because the treatment duration is three years,
the clinical application of this method also
remains doubtful.
The Systems Training for Emotional Pre-
dictability and Problem Solving program is a
cognitive method that provides psychoeduca-
tion in a group format and is designed to supple-
ment standard therapy when specialized treat-
ment is not readily available. A clinical trial
of this approach reported encouraging results
(Blum et al. 2008).
Research on psychodynamic methods is
quite recent. Historically, psychoanalysts dom-
inated the treatment of BPD, but patients did
not always do well with that approach. When
offered open-ended psychodynamic therapy,
most dropped out within a few months
(Gunderson et al. 1989).
The rst empirical study of dynamic therapy
for BPD was published by Stevenson & Meares
(1992), who reported improvement in patients
who received two years of a therapy they de-
scribe as a conversational model, with results
that remained stable after ve years (Stevenson
et al. 2005); a replication compared efcacy to
a control group (Korner et al. 2006).
The psychodynamic model that has been
most systematically tested is mentalization-
based therapy (MBT) (Bateman & Fonagy
1999, 2001), but this method also uses many
cognitive techniques. Derived from attachment
theory and theory of mind, MBT is based on
the idea that BPD patients need to taught to
mentalize, i.e., to stand outside their feelings
 ANRV372-CP05-12 ARI 19 February 2009 11:5
and accurately observe emotions in self and
others.
A randomized controlled trial (Bateman &
Fonagy 1999) found MBT to be effective in
BPD, with stable results on 18-month follow-
up (Bateman & Fonagy 2004) and 8 years
after completion of treatment (Bateman &
Fonagy 2008). Because this trial was conducted
in a day hospital, the milieu may have accounted
for some of the improvement. MBT is now be-
ing tested in an outpatient setting.
Transference-focused psychotherapy (TFP)
is a psychodynamic method that aims to cor-
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
rect distortions in the patients perception of
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
signicant others as well of therapists (Clarkin
et al. 2004). The method was evaluated in com-
parison to DBT in a randomized clinical trial
(Clarkin et al. 2007b). Although the results
suggested some advantage for transference-
focused psychotherapy, the two methods were
equivalent on most measures, and there was no
control for allegiance effects.
Although replications are needed, psycho-
dynamic models that are well structured and
that use some of the same interventions as DBT
might do as well as established cognitive ther-
apies. Given the strong evidence for common
factors as the most important elements of all
psychotherapies (Wampold 2001), it should not
be surprising that very different methods, based
on entirely different theories, can be effective.
Some general conclusions are warranted.
All therapies subjected to clinical trials require
active and focused interventions. Therapists
should target affective instability by teaching
patients emotion regulation. They should tar-
get impulsivity by teaching patients to observe
feelings rather than acting on them. And ther-
apists should target problems in relationships
by teaching patients to understand the feel-
ings of other people. All these approaches dif-
fer greatly from classical dynamic therapy, in
which the main focus is on exploring childhood
experiences.
Psychoeducation is another crucial element
of successful therapy for BPD (Huband et al.
2007, Linehan 1993). Therapists can explain
the diagnosis and encourage patients to read
www.annualreviews.org The Treatment of Borderline Personality Disorder
appropriate publications and browse on the In-
ternet to obtain more information. Families of
patients also need to be educated about the dis-
order. As discussed above, BPD is not simply a
response to bad parenting. Instead of blaming
families, we need to make them allies and help
them carry the burden of their childrens psy-
chopathology. Gunderson (2001) developed a
program for psychoeducation for family mem-
bers, paralleling previous work on expressed
emotion in schizophrenia; while Hoffman and
colleagues (2005) have reported data support-
ing a very similar approach.
Another change in outlook, based on re-
search ndings, is that patients with BPD are no
longer seen as suffering from a lifelong illness
that requires lifelong therapy. The encourag-
ing ndings of outcome studies support brief,
focused approaches that can be administered
intermittently rather than continuously (Paris
2008a).
PHARMACOTHERAPY IN
BORDERLINE PERSONALITY
DISORDER
Psychologists and social workers, who treat
many if not most patients with BPD, may feel
that medical backup is necessary if they are to
treat people who are chronically suicidal and
who are in and out of the emergency room.
The problem is that psychiatrists tend to con-
centrate on drug treatment (Paris 2008b).
What is the evidence that drugs make a dif-
ference in the management of BPD? A second
Cochrane report (Binks et al. 2006b) concluded
that data are insufcient to support any phar-
macological treatment. One reason for this con-
clusion was that all research thus far has been
based in small samples. Moreover, large effect
sizes have not been reported, and few patients
actually show remission from BPD as a con-
sequence of pharmacotherapy. The most con-
servative conclusion is that drugs play a role in
symptom control but are not the primary way
to manage BPD.
Let us briey examine the specic phar-
macotherapy options. Low-dose neuroleptics
283
 ANRV372-CP05-12
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
ARI 19 February 2009 11:5
have long been used for this population. Al-
though overdoses of neuroleptics are rarely fa-
tal (Isacsson et al. 1999), these drugs have many
side effects. Soloff et al. (1993) found that pa-
tients tend to stop taking them and that short-
term effects (i.e., reducing impulsivity) are not
maintained on six-month follow-up. Atypical
neuroleptics have now largely replaced typi-
cals, and olanzapine has also been found to
reduce impulsivity in BPD (Bogenschutz &
Nurnberg 2004, Soler et al. 2005, Zanarini &
Frankenburg 2001, Zanarini et al. 2004).
However, atypicals have their own problematic
side effects, particularly obesity and metabolic
syndrome (McEvoy et al. 2005), outcomes
that seriously interfere with therapeutic at-
tempts to improve the quality of life in BPD
patients.
Specic serotonin reuptake inhibitors
(SSRIs) are used to target depressive symptoms
in BPD and, again, have the advantage that
overdoses are not often fatal (McKenzie &
McFarlane 2007). But how effective are they
for the mood symptoms of BPD? Thus far only
one study (Rinne et al. 2002) has suggested
that SSRIs can reduce mood swings, whereas
others (Coccaro & Kavoussi 1997, Salzman
et al. 1995, Zanarini et al. 2004) found that
SSRIs, like neuroleptics, are more effective in
reducing anger and impulsive symptoms. High
doses (e.g., 6080 mg of uoxetine) may reduce
self-injury (Markowitz 1995), but patients have
difculty tolerating such levels.
Although BPD is associated with marked
affective instability, the mood stabilizers used
for bipolar disorders have yielded at best mixed
results. The only controlled study of lithium
in BPD (Links et al. 1990) failed to demon-
strate clinical efcacy, and few would pre-
scribe a drug that is so dangerous on overdose.
Carbamazepine reduces impulsivity (Cowdry
& Gardner 1988), but it is also dangerous
on overdose. Controlled trials of valproate
(Hollander et al. 2005, Kavoussi & Coccaro
1998) have shown only marginal efcacy in
BPD, and results suggested that this drug
is more useful for impulsive aggression than
for affective instability. Better results were
284 Paris
obtained in a small-scale trial of valproate
(Frankenburg & Zanarini 2002), but the sam-
ple was limited to patients who were comorbid
for bipolar II disorder (i.e., patients with clear-
cut hypomanic episodes). Clinical trials of lam-
otrigine (Tritt et al. 2005) and of topiramate
(Loew et al. 2006) have shown effects on anger
and anxiety but not on depression or mood
instability.
In summary, drugs for BPD take the edge off
symptoms but do not lead to remission of the
disorder. In addition, all agents seem to have
similar effects, so there is little reason to pre-
scribe more than one or to combine them in
polypharmacy regimes.
Unfortunately, absence of data has not pre-
vented physicians from prescribing a wide vari-
ety of pharmacological agents for BPD patients,
who are often given four or ve agents (Zanarini
et al. 2001). This use of multiple drugs is not ev-
idence based and probably reects the failure of
any one agent to provide adequate results. Al-
gorithms for drug treatment were supported by
the American Psychiatric Associations guide-
lines for the treatment of BPD (Oldham
et al. 2001), but this document is based on clini-
cal consensus, not on evidence from controlled
trials.
CONCLUSIONS: THE
TREATMENT OF BORDERLINE
PERSONALITY DISORDER
The outlook for patients with BPD today is
much more hopeful than it was in the past. We
can make the diagnosis without worrying that it
implies a hopeless prognosis. We can explain it
to patients and families and encourage them to
read about BPD. We are likely to be stumped
only when asked what causes the disorder.
Recent data on psychotherapy have been
very encouraging. But this form of treatment
either is not readily available or is not practiced
in accordance with research ndings. Some
patients may receive only pharmacological
treatment.
The main reason that evidence-based psy-
chological therapies are not more widely used
 ANRV372-CP05-12 ARI 19 February 2009 11:5

for these patients is their cost and their
long duration. We may eventually be able to
develop a method that makes use of com-
mon factors and enables us to provide psy-
chotherapy in a briefer and more practical way.
The current competition between methods is
counterproductive, distracting us from iden-
tifying factors common to all. Finally, future
treatment research needs to measure long-term
outcome rather than short-term reductions in
symptoms.
Nonetheless, the expansion of research on
the treatment of BPD is heartening and clini-
cally relevant. As more data come in, these trou-
bled and complex patients may recover more
consistently.

SUMMARY POINTS
1. Borderline personality disorder is commonly seen in practice.
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org

2. The diagnosis is not difcult to make, but the criteria can be more specic.
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

3. The etiology of BPD is largely unknown.

4. Outcome research shows that most patients recover with time.
5. Clinical trials demonstrate that several forms of psychotherapy specically developed for
BPD are effective, whereas pharmacotherapy has only mild symptomatic benet.

DISCLOSURE STATEMENT
The author is not aware of any biases that might be perceived as affecting the objectivity of this
review.

LITERATURE CITED
Akiskal HS. 2002. The bipolar spectrum: the shaping of a new paradigm in psychiatry. Curr. Psychiatry Rep.
4:13
Akiskal HS, Chen SE, Davis GC. 1985. Borderline: an adjective in search of a noun. J. Clin. Psychiatry 46:4148
American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC:
Am. Psychiatr. Press. Text rev., 4th ed.
Bateman A, Fonagy P. 1999. Effectiveness of partial hospitalization in the treatment of borderline personality
disorder: a randomized controlled trial. Am. J. Psychiatry 156:156369
Bateman A, Fonagy P. 2001. Treatment of borderline personality disorder with psychoanalytically oriented
partial hospitalization: an 18-month follow up. Am. J. Psychiatry 158:3642
Bateman A, Fonagy P. 2004. Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment.
Oxford, UK: Oxford Univ. Press
Bateman A, Fonagy P. 2008. 8-year follow-up of patients treated for borderline personality disorder
Provides evidence that
with mentalization-based treatment versus treatment as usual. Am. J. Psychiatry 165:63138
MBT has a lasting
Bender DS, Skodol AE. 2007. Borderline personality as a self-other representational disturbance.
effect.
J. Personal. Disord. 21:50017
Bernstein DP, Cohen P, Skodol A, Bezirganian S, Brook JS. 1993. Prevalence and stability of the DSM-III
personality disorders in a community-based survey of adolescents. Am. J. Psychiatry 150:123743
Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. 2006a. Psychological therapies for people
with borderline personality disorder. Cochrane Database Syst. Rev. 1:CD005652
Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. 2006b. Pharmacological interventions for
people with borderline personality disorder. Cochrane Database Syst. Rev. 1:CD005653
Black DW, Baumgard CH, Bell SE. 1995. A 16- to 45-year follow-up of 71 men with antisocial personality
disorder. Compr. Psychiatry 36:13040

www.annualreviews.org The Treatment of Borderline Personality Disorder 285

 ANRV372-CP05-12 ARI 19 February 2009
Describes a clinical trial
of psychoeducation.
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
Describes the first
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.
clinical trial of
transference-focused
psychotherapy.
Reports results of a
clinical trial of standard
CBT.
Describes the first
clinical trial of SFP.
286
11:5
Blum N, St. John D, Pfohl B, Stuart S, McCormick B, et al. 2008. Systems training for emotional
predictability and problem solving (STEPPS) for outpatients with borderline personality disorder:
a randomized controlled trial and 1-year follow-up. Am. J. Psychiatry 165:46878
Bogenschutz MP, Nurnberg GH. 2004. Olanzapine versus placebo in the treatment of borderline personality
disorder. J. Clin. Psychiatry 65:1049
Brown GK, Newman CF, Charlesworth SE, Crits-Cristoph P, Beck A. 2004. An open clinical trial of cognitive
therapy for borderline personality disorder. J. Personal. Disord. 18:25771
Browne A, Finkelhor D. 1986. Impact of child sexual abuse: a review of the literature. Psychol. Bull. 99:6677
Clarkin JF, Lenzenweger MF, Yeomans F, Levey KN, Kernberg OF. 2007a. An object relations model of
borderline pathology. J. Personal. Disord. 21:47499
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. 2004. The Personality Disorders Institute/
Borderline Personality Disorder Research Foundation randomized control trial for borderline personality
disorder: rationale, methods, and patient characteristics. J. Personal. Disord. 18:5272
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. 2007b. Evaluating three treatments for
borderline personality disorder: a multiwave study. Am. J. Psychiatry 164:18
Coccaro EF, Kavoussi RJ. 1997. Fluoxetine and impulsive aggressive behavior in personality-disordered sub-
jects. Arch. Gen. Psychiatry 54:108188
Coccaro EF, Siever LJ, Klar HM, Maurer G, Cochrane K, et al. 1989. Serotonergic studies in patients with
affective and personality disorders. Arch. Gen. Psychiatry 46:58799
Coid J, Yang N, Tyrer P, Roberts S, Ullirch S. 2006. Prevalence and correlates of personality disorder in Great
Britain. Br. J. Psychiatry 188:42331
Costa PT, Widiger TA, eds. 2002. Personality Disorders and the Five Factor Model of Personality. Washington,
DC: Am. Psychol. Assoc. 2nd ed.
Cowdry RW, Gardner DL. 1988. Pharmacotherapy of borderline personality disorder: alprazolam,
carbamazepine, triuoperazine, and tranylcypromine. Arch. Gen. Psychiatry 45:11119
Davidson K, Tyrer P, Gumley A, Tata P, Norrie J, Palmer S. 2006. The effectiveness of cognitive
behavior therapy for borderline personality disorder: results from the borderline personality dis-
order study of cognitive therapy BOSCOT trial. J. Personal. Dis. 20:45065
Engel GL. 1980. The clinical application of the biopsychosocial model. Am. J. Psychiatry 137:53544
Fergusson DM, Mullen PE. 1999. Childhood Sexual Abuse: An Evidence-Based Perspective. Thousand Oaks,
CA: Sage
Forman EM, Berk MS, Henriques GR, Brown GK, Beck AT. 2004. History of multiple suicide attempts as a
behavioral marker of severe psychopathology. Am. J. Psychiatry 161:43743
Fossati A, Madeddu F, Maffei C. 1999. Borderline personality disorder and childhood sexual abuse: a meta-
analytic study. J. Personal. Disord. 13:26880
Frankenburg FR, Zanarini MC. 2002. Divalproex sodium treatment of women with borderline personality
disorder and bipolar II disorder: a double-blind placebo-controlled pilot study. J. Clin. Psychiatry 63:442
46
Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, et al. 2006. Outpatient psy-
chotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs.
transference-focused psychotherapy. Arch. Gen. Psychiatry 63:64958
Gunderson JG. 2001. Borderline Personality Disorder: A Clinical Guide. Washington, DC: Am. Psychiatr. Press
Gunderson JG, Frank AF, Ronningstam EF, Wahter S, Lynch VJ, Wolf PJ. 1989. Early discontinuance of
borderline patients from psychotherapy. J. Nerv. Ment. Disord. 177:3840
Gunderson JG, Phillips KA. 1991. A current view of the interface between borderline personality disorder
and depression. Am. J. Psychiatry 148:96775
Hoffman PD, Fruzetti AE, Buteau E, Neiditch ER, Penney D, et al. 2005. Family connections: a pilot study of
a family program for relatives of persons with borderline personality disorder. Family Process. 44:21725
Hollander E, Swann AC, Coccaro EF, Jiang P, Smith TB. 2005. Impact of trait impulsivity and state aggression
on divalproex versus placebo response in borderline personality disorder. Am. J. Psychiatry 162:62124
Huband N, McMurran M, Evans C, Duggan C. 2007. Social problem-solving plus psychoeducation for adults
with personality disorder: pragmatic randomised controlled trial. Br. J. Psychiatry 190:30713
Paris
 ANRV372-CP05-12 ARI 19 February 2009 11:5

Isacsson G, Holmgren P, Druid H, Bergman U. 1999. Psychotropics and suicide prevention. Implications
from toxicological screening of 5281 suicides in Sweden 19921994. Br. J. Psychiatry 174:25965
Kavoussi RJ, Coccaro EF. 1998. Divalproex sodium for impulsive aggressive behavior in patients with
personality disorder. J. Clin. Psychiatry 59:67680
Kernberg PF, Weiner AS, Bardenstein KK. 2000. Personality Disorders in Children and Adolescents. New York:
Basic
Klonsky ED, Moyer A. 2008. Childhood sexual abuse and nonsuicidal self-injury: meta-analysis.
Br. J. Psychiatry 192:16670
Koenigsberg HW, Harvey PD, Mitropoulou V, Schmeidler J, New AS, et al. 2002. Characterizing affective
instability in borderline personality disorder. Am. J. Psychiatry 159:78488
Korner A, Gerull F, Meares R, Stevenson J. 2006. Borderline personality disorder treated with the conversa-
tional model: a replication study. Compr. Psychiatry 47:40611
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. 2007. DSM-IV personality disorders in the National
Comorbidity Survey Replication. Biol. Psychiatry 62:55364
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org

Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard H. 1991. Cognitive behavioral treatment of
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

chronically parasuicidal borderline patients. Arch. Gen. Psychiatry 48:106064

Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, et al. 2006. Two-year randomized
Describes findings of a
controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal
recent clinical trial of
behaviors and borderline personality disorder. Arch. Gen. Psychiatry 63:75766 DBT.
Linehan MM. 1993. Dialectical Behavioral Therapy of Borderline Personality Disorder. New York: Guilford
Links PS, Heslegrave R, van Reekum R. 1999. Impulsivity, core aspect of borderline personality disorder.
J. Personal. Disord. 13:13139
Links PS, Mitton JE, Steiner M. 1990. Predicting outcome for borderline personality disorder. Compr.
Psychiatry 31:49098
Links PS, Steiner M, Boiago I, Irwin D. 1990. Lithium therapy for borderline patients: preliminary ndings.
J. Personal. Disord. 4:17381
Livesley WJ, Jang KL, Vernon PA. 1998. Phenotypic and genetic structure of traits delineating personality
disorder. Arch. Gen. Psychiatry 55:94148
Livesley WJ, Jang K. 2008. The behavioral genetics of personality disorder. Annu. Rev. Clin. Psychol. 4:24774
Livesley WJ. 2003. The Practical Management of Personality Disorder. New York: Guilford
Loew TH, Nickel MK, Muehlbacher M, Kaplan P, Nickel C, Kettler C. 2006. Topiramate treatment
for women with borderline personality disorder: a double-blind, placebo-controlled study. J. Clin.
Psychopharmacol. 26:6166
Loranger AW, Sartori N, Andreoli A, Berger P, Bucheim P, Channabasavanna SM. 1994. The international
personality disorder examination. Arch. Gen. Psychiatry 51:21524
Lynch TR, Chapman AL, Rosenthal MZ, Kuo JR, Linehan MM. 2006. Mechanisms of change in dialectical
behavior therapy: theoretical and empirical observations. J. Clin. Psychol. 62:45980
Malinovsky-Rummell R, Hansen DJ. 1993. Long-term consequences of physical abuse. Psychol. Bull. 114:6879
Markowitz PJ. 1995. Pharmacotherapy of impulsivity, aggression, and related disorders. In Impulsivity and
Aggression, ed. E Hollander, DJ Stein, pp. 26386. New York: Wiley
McEvoy JP, Meyer J, Goff DC, Nasrallah HA. 2005. Prevalence of the metabolic syndrome in patients
with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness
(CATIE). Schizophr. Res. 80:1932
McGlashan TH. 1986. The Chestnut Lodge follow-up study III: long-term outcome of borderline personal-
ities. Arch. Gen. Psychiatry 43:230
McGlashan TH. 1993. Implications of outcome research for the treatment of borderline personality disorder.
See Paris 1993, pp. 23560
McKenzie MS, McFarland BH. 2007. Trends in antidepressant overdoses. Pharmacoepidemiol. Drug Saf.
16:51323
Millon T. 1993. Borderline personality disorder: a psychosocial epidemic. See Paris 2003, pp. 197210
Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC. 2001. Psychiatric aspects of impulsivity.
Am. J. Psychiatry 158:178393

www.annualreviews.org The Treatment of Borderline Personality Disorder 287

 ANRV372-CP05-12 ARI 19 February 2009 11:5

Monroe SM, Simons AD. 1991. Diathesis-stress theories in the context of life stress research. Psychol. Bull.
110:40625
Newton-Howes G, Tyrer P, Johnson T. 2006. Personality disorder and the outcome of depression: meta-
analysis of published studies. Br. J. Psychiatry 188:1320
Oldham JM, Gabbard GO, Goin MK, Gunderson J, Soloff P, et al. 2001. Practice guideline for the
treatment of borderline personality disorder. Am. J. Psychiatry 158(Suppl.):152
OLeary KM, Cowdry RW. 1994. Neuropsychological testing results with patients with borderline per-
sonality disorder. In Biological and Neurobehavioral Studies of Borderline Personality Disorder, ed. KR Silk,
pp. 12758. Washington, DC: Am. Psychiatr. Press
Paris J, ed. 1993. Borderline Personality Disorder: Etiology and Treatment. Washington, DC: Am. Psychiatr.
Press
Paris J. 1996. Social Factors in the Personality Disorders: A Biopsychosocial Approach to Etiology and Treatment.
London: Cambridge Univ. Press
Paris J. 2003. Personality Disorders Over Time. Washington, DC: Am. Psychiatr. Press
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org

Paris J. 2007. The nature of borderline personality disorder: multiple symptoms, multiple dimensions,
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

but one category. J. Personal. Disord. 21:45773

Paris J. 2008a. The Treatment of Borderline Personality Disorder: An Evidence-Based Guide to Practice. New York:
Guilford
Paris J. 2008b. Prescriptions for the Mind: A Critical View of Contemporary Psychiatry. New York: Oxford Univ.
Press
Paris J, Brown R, Nowlis D. 1987. Long-term outcome of borderline patients in a general hospital.
Compr. Psychiatry 28:53035
Paris J, Gunderson JG, Weinberg I. 2007. The interface between borderline personality disorder and
bipolar spectrum disorder. Compr. Psychiatry 48:14554
Paris J, Zweig-Frank H. 2001. A twenty-seven-year follow-up of borderline patients. Compr. Psychiatry
42:48287
Paris J, Zweig-Frank H, Guzder J. 1994. Psychological risk factors for borderline personality disorder in
female patients. Compr. Psychiatry 35:3015
Paris J, Zweig-Frank H, Ng F, Schwartz G, Steiger H, Nair V. 2004. Neurobiological correlates of
diagnosis and underlying traits in patients with borderline personality disorder compared with normal
controls. Psychiatr. Res. 121:23952
Plakun EM, Burkhardt PE, Muller JP. 1985. 14-year follow-up of borderline and schizotypal personality
disorders. Compr. Psychiatry 27:44855
Pope HG, Jonas JM, Hudson JI. 1983. The validity of DSM-III borderline personality disorder. Arch. Gen.
Psychiatry 40:2330
Reichborn-Kjennerud T. 2008. Genetics of personality disorders. Psychiatr. Clin. North Am. 31:42140
Rind B, Tromovitch P, Bauserman R. 1998. A meta-analytic examination of assumed properties of child
sexual abuse using college samples. Psychol. Bull. 124:2253
Rinne T, Van Den Brink W, Wouters L, van Dyck R. 2002. SSRI treatment of borderline personality disorder:
a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder.
Am. J. Psychiatry 159:204854
Russell J, Moskowitz D, Sookman D, Paris J. 2007. Affective instability in patients with borderline
personality disorder. J. Abnorm. Psychol. 116:57888
Rutter M. 2006. Genes and Behavior: Nature-Nurture Interplay Explained. London: Blackwell Sci.
Rutter M, Rutter M. 1993. Developing Minds: Challenge and Continuity Across the Life Span. New York: Basic
Rutter M, Smith DJ. 1995. Psychosocial Problems in Young People. Cambridge, UK: Cambridge Univ. Press
Salzman C, Wolfson AN, Schatzberg A, Looper J, Henke R, et al. 1995. Effect of uoxetine on anger
in symptomatic volunteers with borderline personality disorder. J. Clin. Psychopharmacol. 15:2329
Samuels J, Eaton WW, Bienvenu J, Clayton P, Brown H, et al. 2002. Prevalence and correlates of
personality disorders in a community sample. Br. J. Psychiatry 180:53654
Schmideberg M. 1959. The borderline patient. In The American Handbook of Psychiatry, ed. S Arieti,
Vol. I, pp. 398416. New York: Basic

288 Paris
 ANRV372-CP05-12 ARI 19 February 2009 11:5

Shea MT, Pilkonis PA, Beckham E, Collins JF, Elikin E, et al. 1990. Personality disorders and treatment
outcome in the NIMH Treatment of Depression Collaborative Research Program. Am. J. Psychiatry
147:71118
Siever LJ, Davis KL. 1991. A psychobiological perspective on the personality disorders. Am. J. Psychiatry
148:164758
Silbersweig D, Clarkin JF, Goldstein M, Kernberg OF, Tuescher K, Levy KN. 2007. Failure of frontolimbic
inhibitory function in the context of negative emotion in borderline personality disorder. Am. J. Psychiatry
164:183241
Skodol AE, Gunderson JG, Shea MT, McGlashan TH, Morey LC, et al. 2005. The collaborative
Summarizes a large-
longitudinal personality disorders study CLPS: overview and implications. J. Personal. Disord.
scale prospective
19:487504 follow-up.
Soler J, Pascual JC, Campins J, Barrachina J, Puigdemont D, et al. 2005. Double-blind, placebo-controlled
study of dialectical behavior therapy plus olanzapine for borderline personality disorder. Am. J. Psychiatry
162:122124
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org

Soloff PH, Cornelius J, George A, Nathan S, Perel JM, et al. 1993. Efcacy of phenelzine and haloperidol
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

in borderline personality disorder. Arch. Gen. Psychiatry 50:37785

Stanley B, Brodsky B, Nelson J, Dulit R. 2007. Brief dialectical behavior therapy for suicidality and self-
injurious behaviors. Arch. Suicide Res. 11:33741
Stern A. 1938. Psychoanalytic investigation of and therapy in the borderline group of neuroses. Psychoanal. Q.
7:46789
Stevenson J, Meares R. 1992. An outcome study of psychotherapy for patients with borderline personality
disorder. Am. J. Psychiatry 149:35862
Stevenson J, Meares R, DAngelo R. 2005. Five-year outcome of outpatient psychotherapy with borderline
patients. Psychol. Med. 35:7987
Stone MH. 1990. The Fate of Borderline Patients. New York: Guilford
Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, et al. 2000. A twin study of personality disorders. Compr.
Psychiatry 41:41625
Torgersen S, Kringlen E, Cramer V. 2001. The prevalence of personality disorders in a community sample.
Arch. Gen. Psychiatry 58:59096
Tritt K, Nickel C, Lahmann C, Leiberich PK, Rother WK, et al. 2005. Lamotrigine treatment of aggression
in female borderline-patients: a randomized, double-blind, placebo-controlled study. J. Psychopharmacol.
19:28791
Vaillant GE. 1995. The Natural History of Alcoholism Revisited. Cambridge, MA: Harvard Univ. Press
Wampold BE. 2001. The Great Psychotherapy Debate: Models, Methods, and Findings. Mahwah, NJ: Erlbaum
Weinberg I, Gunderson JG, Hennen J, Cutter CJ Jr. 2006. Manual assisted cognitive treatment for deliberate
self-harm in borderline personality disorder patients. J. Personal. Disord. 20:48292
White CN, Gunderson JG, Zanarini MC, Hudson JI. 2003. Family studies of borderline personality disorder:
a review. Harvard Rev. Psychiatry 12:11819
Widiger TA. 2005. CIC, CLPS, and MSAD. J. Personal. Disord. 19:58693
Young JE. 1999. Cognitive Therapy for Personality Disorders: A Schema-Focused Approach. Sarasota, FL: Prof.
Resource Press. 3rd ed.
Zanarini MC. 2000. Childhood experiences associated with the development of borderline personality disor-
der. Psychiatr. Clin. North Am. 23:89101
Zanarini MC, Frankenburg FR. 2001. Olanzapine treatment of female borderline personality disorder patients:
a double-blind, placebo-controlled pilot study. J. Clin. Psychiatry 62:84954
Zanarini MC, Frankenburg FR. 2007. The essential nature of borderline psychopathology. J. Personal. Disord.
21:51835
Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. 2005. The McLean Study of Adult
Summarizes a major
Development (MSAD): overview and implications of the first six years of prospective follow-up.
follow-up study.
J. Personal. Disord. 19:50523
Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J. 2001. Treatment histories of borderline inpatients.
Compr. Psychiatry 42:14450

www.annualreviews.org The Treatment of Borderline Personality Disorder 289

 ANRV372-CP05-12 ARI 19 February 2009 11:5

Zanarini MC, Frankenburg FR, Parachini EA. 2004. A preliminary, randomized trial of uoxetine, olanzap-
ine, and the olanzapine-uoxetine combination in women with borderline personality disorder. J. Clin.
Psychiatry 65:9037
Zanarini MC, Gunderson JG, Frankenburg FR. 1990. Cognitive features of borderline personality disorder.
Am. J. Psychiatry 147:5763
A study showing how Zimmerman M, Mattia JL. 1999. Differences between clinical and research practices in diagnosing
common BPD is in borderline personality disorder. Am. J. Psychiatry 156:157074
practice. Zimmerman M, Rothschild L, Chelminski I. 2005. The prevalence of DSM-IV personality disorders
in psychiatric outpatients. Am. J. Psychiatry 162:191118
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

290 Paris
 AR372-FM ARI 6 March 2009 17:50

Annual Review of
Clinical Psychology

Contents Volume 5, 2009

Construct Validity: Advances in Theory and Methodology

Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org

Milton E. Strauss and Gregory T. Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

Item Response Theory and Clinical Measurement

Steven P. Reise and Niels G. Waller p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p27
Methodological Issues in Molecular Genetic Studies
of Mental Disorders
Carrie E. Bearden, Anna J. Jasinska, and Nelson B. Freimer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p49
Statistical Methods for Risk-Outcome Research: Being Sensitive
to Longitudinal Structure
David A. Cole and Scott E. Maxwell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p71
Psychological Treatment of Anxiety: The Evolution of Behavior
Therapy and Cognitive-Behavior Therapy
S. Rachman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p97
Computer-Aided Psychological Treatments: Evolving Issues
Isaac Marks and Kate Cavanagh p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 121
The Past, Present, and Future of HIV Prevention: Integrating
Behavioral, Biomedical, and Structural Intervention Strategies
for the Next Generation of HIV Prevention
Mary Jane Rotheram-Borus, Dallas Swendeman, and Gary Chovnick p p p p p p p p p p p p p p p p p p 143
Evolving Prosocial and Sustainable Neighborhoods and Communities
Anthony Biglan and Erika Hinds p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 169
Five-Factor Model of Personality Disorder: A Proposal for DSM-V
Thomas A. Widiger and Stephanie N. Mullins-Sweatt p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 197
Differentiating the Mood and Anxiety Disorders: A Quadripartite
Model
David Watson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 221
When Doors of Perception Close: Bottom-Up Models of Disrupted
Cognition in Schizophrenia
Daniel C. Javitt p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 249

vii
 AR372-FM ARI 6 March 2009 17:50

The Treatment of Borderline Personality Disorder: Implications

of Research on Diagnosis, Etiology, and Outcome
Joel Paris p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 277
Development and Etiology of Disruptive and Delinquent Behavior
Rolf Loeber, Jeffrey D. Burke, and Dustin A. Pardini p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 291
Anxiety Disorders During Childhood and Adolescence:
Origins and Treatment
Ronald M. Rapee, Carolyn A. Schniering, and Jennifer L. Hudson p p p p p p p p p p p p p p p p p p p p p p 311
APOE-4 Genotype and Neurophysiological Vulnerability
to Alzheimers and Cognitive Aging
Annu. Rev. Clin. Psychol. 2009.5:277-290. Downloaded from www.annualreviews.org
by Universitat Zurich- Hauptbibliothek Irchel on 09/04/13. For personal use only.

Susan Bookheimer and Alison Burggren p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 343

Depression in Older Adults
Amy Fiske, Julie Loebach Wetherell, and Margaret Gatz p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 363
Pedophilia
Michael C. Seto p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 391
Treatment of Smokers with Co-occurring Disorders: Emphasis on
Integration in Mental Health and Addiction Treatment Settings
Sharon M. Hall and Judith J. Prochaska p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 409
Environmental Inuences on Tobacco Use: Evidence from Societal
and Community Inuences on Tobacco Use and Dependence
K. Michael Cummings, Geoffrey T. Fong, and Ron Borland p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 433
Adolescent Development and Juvenile Justice
Laurence Steinberg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 459

Indexes

Cumulative Index of Contributing Authors, Volumes 15 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 487

Cumulative Index of Chapter Titles, Volumes 15 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 489

Errata

An online log of corrections to Annual Review of Clinical Psychology articles may be

found at http://clinpsy.annualreviews.org

viii Contents