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A recent study found that throughout childhood, all BPD patients evaluated14 had suffered chronic, severe, and pervasive psychological abuse, with or without a physical/sexual component, to the extent that the developing self was invalidated in the extreme. There was also evidence that three fourths of these patients had a talent for perceiving the feelings and motivations of others, which may have made them vulnerable as children to pathologic aspects of caretakers' personalities.

TREATMENT

In light of our current understanding, it now seems that these chronically disturbed individuals have a mental illness created by environmental events rather than biologic causes. Therefore, treating BPD is fundamentally different from treating a psychotic illness. Suicide prevention is a major concern, particularly early in treatment.15 Rather than treating only disturbing symptoms and behaviors, therapy focuses on helping patients understand and deal with what has happened to them.6,16,17 These patients can be difficult to treat, even for experienced therapists, largely because of the strong emotional responses (countertransference) they evoke.2,5

Medication: Although there is no specific drug therapy for BPD, pharmacotherapy is frequently necessary. The comorbid disorders that are usually seen with BPD—mood, anxiety, phobic, posttraumatic, substance-abuse, eating, and panic disorders4—provide guidelines to appropriate drugs.

Depression is so common in BPD that a trial of antidepressants is usually warranted.2 Selective serotonin reuptake inhibitors (ie, fluoxetine, sertraline, paroxetine) are usually the drugs of choice, often helping to calm patients and reduce their depression, anger, impulsivity, and vulnerability to stressful events. If drug-induced sexual dysfunction becomes a problem, bupropion can be tried.

Monoamine oxidase inhibitors can be effective but require a strict dietary regimen. Heterocyclic anti-depressants are not well tolerated, perhaps because of the sensitivity of BPD patients to side effects. Mood stabilizers (eg, lithium) are sometimes effective. Low-dose dopamine antagonists and anxiolytics can be helpful in selected cases, although I many patients have a negative response.

PROGNOSIS

Clinicians have generally considered BPD patients unreliable and often unresponsive to treatment, creating crises and suicidal emergencies. However, long-term follow-up studies have demonstrated the striking and unexpected finding that after 15 years, two thirds of the patients studied were no longer "borderline" and were functioning normally or with only minimal symptoms.8,15

         
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©2004 Lee Crandall Park, M.D.