Treatment of outpatients with borderline personality disorder

Outpatient treatment of patients with borderline personality disorder is sometimes more difficult and more challenging than inpatient treatment. Because symptoms are frequently less florid and more variable in the outpatient, diagnostic evaluation must proceed at a slower pace. Diagnostic distinctions among patients with borderline personality disorder are based on whether the predominant symptoms displayed are "affective," "schizotypal," or "impulse-disordered." Outpatient evaluation requires a keen sensitivity to the presenting problems and the ability to assign priorities to treatment issues. Pharmacotherapy can be of advantage in treating outpatients with borderline personality disorder, but care must be taken in selecting appropriate drugs and dosage and in communicating to the patient what can be expected during therapy. Borderline patients with impulse-control disorders, especially substance abuse, cannot be treated effectively with individual psychotherapy alone. Although many creative and articulate psychodynamic formulations of borderline personality disorder have been proposed, an initial "cognitive" approach to psychotherapy combined with pharmacotherapy can be effective in alleviating acute symptoms, and more psychodynamic approaches can be employed when the patient is better equipped to use them.