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Highlights of APA’s Newest Practice Guideline

Indeed, in the opinion of John Oldham, M.D., a New York City psychiatrist and chair of the borderline personality disorder practice guideline work group, Sections III and IV should prove especially helpful to clinicians because of the particularly challenging features of the borderline patients. Section III deals with comorbidity; problematic substance use disorders; violent behavior and antisocial traits; chronic self-destructive behavior; trauma, PTSD, and memory considerations; dissociative features; psychosocial stressors; gender; cultural factors; and age. Section IV focuses on general considerations; suicide; anger, impulsivity, and violence; and boundary violations.

Section III D of the guideline, for instance, states: "Some clinicians who are expert in the treatment of borderline personality disorder suggest that the psychotherapist should approach each session with a hierarchy of priorities in mind. In other words, suicidal and self-destructive behavior would be addressed as the highest priorities, with an effort to evaluate the patient’s risk for these behaviors and help the patient find ways to maintain safety. . . ."

Section III I points out cultural factors to consider. For example, "Although inconclusive, some studies have suggested that Asian-American patients may require lower doses of haloperidol and have higher serum levels of haloperidol after oral administration than Caucasian patients."

Section IV R offers this advice: "Monitor patients carefully for suicide risk and document this assessment; be aware that feelings of rejection, fears of abandonment, or a change in the treatment may precipitate suicidal attempts."

Still another guideline inclusion—the declaration that fairly lengthy psychotherapy should constitute the first line of treatment for patients with borderline personality disorder—should also prove of great value to clinicians and patients, Oldham believes. The reason, he explained, is that fairly lengthy psychotherapy may not be easily accessible to borderline patients in today’s managed care world, yet because there is a professional consensus in the field that such therapy is the first line of treatment for patients with the disorder, such a statement may convince managed care companies to pay for sustained psychotherapy for borderline patients.

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