Robert J. Gregory, MD

Patients with borderline personality disorder (BPD) can present with multiple crises and minor incidents of self-harm or threats, but determining when the actions are true cause for concern can be a challenge. Assessing the patient’s current state of being, recent stressors, alcohol misuse, and support system can inform the health care provider about immediate risk. Similarly, below are suggested strategies that psychiatrists in various roles can employ to help reduce the risk of suicide. This Tipsheet is for quick reference only and not a replacement for the psychiatrist's experience and training, which are at the heart of what determines the severity of a psychiatric patient's condition. For further information, see 

Managing Suicide Risk in Borderline Personality Disorder Distinguishing Real Risk From Attention Seeking

TIPSHEET: Management Strategies To Minimize Suicide Risk in BPD

• Look for triggers of suicidal ideation or behavior, especially abuse, separation, or loss; are these time-limited or on-going? Ask yourself what has changed between the time of the overdose and the present to lower the risk of suicide? Consider hospitalization if there have been no changes.

• When eliciting the history, look to see whether the patient is placing blame for current difficulties onto self or onto others: the first is strongly suggestive of the guilty perpetrator state and higher suicide risk; the second is suggestive of the angry victim state and lower suicide risk.

• Treat the patient with care and respect; sarcastic comments or a dismissive attitude can increase the risk for suicide or for aggressive behavior.

• Ultimately, the consultant may face a dilemma: discharge may be perceived as abandonment, whereas admission may lead to regression; either action can potentially increase suicide risk.

 It is usually helpful to convey this dilemma to the patient-he or she is more likely to assume an adult, responsible role if included in the decision-making process.

• Hospital stays should be kept short to minimize regression, generally a few days to a week.

• The goals of inpatient stays are brief stabilization, preparation for outpatient treatment, and consultation with the outpatient therapist. Ask the patient about patient-therapist boundaries and the nature of the relationships outside of therapy, especially issues of abuse, rejection, loss, and separation. Use motivational interviewing to build autonomous motivation for inpatient and outpatient treatment; a family meeting can help clarify possible precipitating factors for the admission.

• Excessive focus on co-occurring Axis I disorders and pharmacotherapy may worsen regression by fostering a passive sick role. Patients with Axis I disorders tend to respond poorly to usual treatment strategies when co-occurring borderline personality disorder (BPD) is present.

• Avoid benzodiazepines to manage patient anxiety. Patients tend to like benzodiazepines and often describe them as the only medications that are helpful; however, benzodiazepines have been shown to worsen behaviors and mood dysregulation.

• Patients provoke strong urges in health care providers to either adopt a nurturing role or be dismissive and scornful (the patient is just attention-seeking). Often, inpatient health care providers become split into opposing camps

; educate team members about this dynamic and about the causes of suicidal behaviors in this population.

• Manual-based treatments, such as dialectical behavior therapy,

 are often much more effective than relying on clinical intuition and judgment in an eclectic, unstructured model.

• The most effective treatments for BPD strongly emphasize the importance of clear boundaries between patient and therapist and frequent case consultation with other therapists. Staying within the treatment frame can be extremely challenging with patients who have BPD, since they tend to evoke strong reactions in health care providers, both positive and negative.

• Encourage patients to take responsibility for maintaining their own safety and making a commitment to work toward recovery; this can be instituted as part of reviewing written treatment goals and expectations early in treatment.

• The single most effective technique to improve dissociation and core symptoms of BPD is to get patients to verbalize recent upsetting interpersonal experiences, create sequential narratives of these experiences, and label associated emotions.

 Paris J. Is hospitalization useful for  suicidal patients with borderline personality disorder? 

 Skodol AE, Grilo CM, Keyes KM, et al. Relationship of personality  disorders to the course of major depressive disorder in a nationally  representative sample. 

 Cowdry RW, Gardner DL. Pharmacotherapy of borderline personality  disorder. Alprazolam, carba-mazepine, trifluoperazine, and tranylcypromine. 

 Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized  controlled trial and follow-up of dialectical behavior therapy vs therapy by  experts for suicidal behaviors and borderline personality dis-order [published  correction appears in 

 Gregory RJ, DeLucia-Deranja E, Mogle JA. Dynamic deconstructive  psychotherapy versus optimized community care for borderline personality  disorder co-occurring with alcohol use disorders: 30-month follow-up. 

 Bateman A, Fonagy P. Randomized controlled trial of outpatient  mentalization-based treatment versus structured clinical management for  borderline personality disorder. 

 Doering S, HÃ¶rz S, Rentrop M, et al. Transference-focused  psychotherapy v. treatment by community psychotherapists for borderline  personality disorder: randomised controlled trial. 

Articles

Patients with borderline personality disorder can present with multiple crises and minor incidents of self-harm or threats, but determining when the actions are true cause for concern can be a challenge.

Management Strategies To Minimize Suicide Risk in Borderline Patients

Patients with borderline personality disorder (BPD) are often high users of health care and may present with multiple crises and minor incidents of self-harm or threats.

 As with the boy who cried wolf, inpatient consultants and health care providers may end up feeling manipulated and may not take suicide risk very seriously.

Ms A, a 22-year-old, was brought to the emergency department (ED) by ambulance; she had overdosed on zolpidem. After detoxification in the ED, a psychiatric consultation was requested. Ms A told the consultant that she had had a bad day and simply took 5 extra zolpidem tablets to “go to sleep” and that “it was just a stupid thing to do.” While obtaining the history, the consultant noted that Ms A’s therapist had left for vacation 2 days earlier.

The consultant informed Ms A that her overdose was just a reaction to her therapist’s vacation, that she did not have a major mental disorder, and that she was going to be discharged. In response, Ms A became irate, “No one cares about me; I just tried to kill myself and you just want to get rid of me! If you don’t admit me, I’m going to walk in front of the next bus!”

Feeling manipulated but with no other options, the consultant admitted Ms A to the inpatient psychiatric unit. Once there, the staff noted that Ms A seemed cheerful, childlike, and cooperative. In the morning, however, Ms A angrily demanded to be discharged when she was refused a smoking pass. The inpatient psychiatrist questioned Ms A about the recent overdose and suicide threats; she stated that she never intended to carry out her threats but was just trying to get attention.

Although health care providers may not take the threat of suicide seriously in patients who have BPD, these patients are often serious about suicide. Long-term studies indicate that compared with controls, patients with BPD have an 8% to 10% increased risk of completed suicide, which is comparable to that of patients who have MDD and schizophrenia.

 Moreover, minor overdoses frequently represent ambivalent suicide intent, and episodes of non-suicidal self-injury are markers for suicide risk and predict future suicide attempts.

Conscious “attention-seeking” behavior is rare, although both patients and health care providers may attempt to frame suicidal behavior that way. As with Ms A, patients may minimize the seriousness of their intent, stating it was just “attention-seeking,” or “I was just trying to sleep,” making it easy for health care providers to question the validity of their patients’ actions.

On the other hand, not every gesture or threat is an indication for a prolonged inpatient hospital stay. Patients may threaten suicide as a way of obtaining or extending hospital stays. A study by Gregory and Jindal

 of 100 consecutive inpatient admissions showed that factitious production of suicide ideation, gestures, and threats was common among women with BPD at the time of discharge. Suicide threats and behavior served as a means of justifying the seriousness of their condition to providers, and to themselves. Given this information, is the underlying message that we should take suicidal ideation and behavior seriously, but not too seriously? How can we understand suicide risk in BPD?

What is already known about suicide risk in patients with borderline personality disorder (BPD)? 
? Patients with BPD are at significant risk for completed suicide; episodes of non­suicidal self-injury predict future suicide attempts.

What new information does this article provide? 
? The article provides a model for understanding suicide risk and behavior in patients with BPD and how that affects clinician-patient interactions.

What are the implications for psychiatrists? 
? Minor overdoses or superficial cutting behaviors are not merely attention-seeking, even if the patient says they are. Are patients placing blame on themselves or on others for recent interpersonal difficulties? If you find yourself in conflict with the patient, realize that the patient likely has an internal conflict over the same issue. A good therapeutic alliance includes clear expectations and boundaries, helping patients build autonomous motivation, and helping patients verbalize experiences and emotions.

Understanding the causes of suicide in BPD

The affect, mood, and behavior of patients with BPD can suddenly switch and appear contradictory, causing bewilderment and frustration for their health care providers. Patients can appear very depressed and suicidal at one moment and appear angry and entitled the next. Indeed, affective instability is the feature of BPD most closely associated with attempted suicide.

Many clinicians have found the states of being model of dynamic deconstructive psychotherapy helpful for understanding affective instability in BPD and how it increases suicide risk.

 According to this model, patients with BPD can be triggered to switch between different states of being, or pseudo-personalities. In a matter of days, hours, or even minutes, patients can alternately appear helpless and childlike (

). These states are not methods of manipulation, but rather represent different sets of polarized and poorly integrated attributions of self and others.

When in the angry victim state, patients see themselves as heroic victims. They accept no responsibility for failures and instead blame others for their difficulties. They can become angry, manipulative, or violent in this state, since they perceive their actions as totally justified. This state is a defense against feelings of shame or humiliation and is triggered by situations that provoke such feelings. For example, Ms A reacted with rage when the consultant questioned the seriousness of her condition and the legitimacy of her suicide attempt. Patients are at low risk for suicide while in this state because they see the source of their difficulties as outside of themselves.

On the other hand, when in the guilty perpetrator state, patients with BPD are at significantly increased risk for suicide, especially when there are other risk factors, such as poor social supports, co-occurring alcohol misuse, or poor physical health.

 When in the guilty perpetrator state, patients take on total responsibility for every bad thing that has ever happened to them. They see their lives as a series of failures and bad decisions; they feel ugly, worthless, and evil-a pest that deserves to be exterminated.

In the guilty perpetrator state, the patient preserves an idealized image of others by taking all the badness onto himself or herself. This state is usually triggered by perceived rejection, abandonment, or separation anxiety, but it can also be triggered by any situation that causes the patient to become ambivalent toward major attachment figures. For example, Ms A’s initial presentation of having had a “bad day” was triggered by her therapist’s vacation. Instead of being able to acknowledge anger toward her therapist for abandoning her, Ms A maintained a positive image of her therapist by devaluing herself instead. During that day, Ms A’s self-image was the unlovable and difficult patient who was beyond help and who deserved to be “abandoned.” Despite Ms A’s later protestations, her overdose most likely included some suicide intent, in addi-tion to self-directed anger.

The states of being and rapidity of switching can be exacerbated by circumstances that intensify attachment wishes and fears, such as abusive relationships, prolonged hospital stays, or poor patient-therapist boundaries (physical touching, multiple contacts per week, extended sessions, etc). Patients can regress and become moody and childlike under these conditions: they react strongly to minor provocations and alternate rapidly between different states of being; their risk of suicide varies as well. The childlike qualities and sudden fluctuations in states contribute to health care providers’ confusion and skepticism.

The first step in managing suicide risk in patients with BPD is to correctly identify the disorder. After multiple encounters that end in feeling manipulated or duped, physicians often come to assign the diagnosis of BPD only to patients whom they dislike or view as attention-seeking. Despite the importance of this diagnosis, physicians do not usually screen for BPD because making an accurate diagnosis can be time-consuming; they often come to believe that they can magically sense whether or not BPD is present.

Underdiagnosis of BPD is common, as is a misdiagnosis of bipolar disorder.

 Some indicators for systematic diagnostic screening for BPD include meeting criteria for multiple Axis I conditions; taking 3 or more psychiatric medications; or having evidence of behavioral dyscontrol, such as an eating disorder, substance use disorder, or recurrent incidents of self-harm. Routine use of brief self-rating scales, such as the McLean Screening Instrument for Borderline Personality Disorder

 and the patient questionnaire portion of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II),

 can also greatly enhance diagnostic accuracy.

The conflict within health care providers over whether their patient’s suicidal behavior and threats are legitimate mirrors a similar conflict within patients with BPD over whether their illness is legitimate, or whether they are totally to blame for their problems, attention-seeking, and needing to get their act together. Patients can rapidly switch states as they take one side of the conflict or the other, switching blame from self to others. Assessing the patient’s current state of being, recent stressors, alcohol misuse, and support system informs the health care provider about immediate risk. The 

 provides some management strategies to minimize risk of suicide.

Table: Management strategies to minimize suicide risk in BPD 



• Look for triggers of suicidal ideation or behavior, especially abuse, separation, or loss; are these time-limited or on-going? Ask yourself what has changed between the time of the overdose and the present to lower the risk of suicide? Consider hospitalization if there have been no changes.

• When eliciting the history, look to see whether the patient is placing blame for current difficulties onto self or onto others: the first is strongly suggestive of the guilty perpetrator state and higher suicide risk; the second is suggestive of the angry victim state and lower suicide risk.

• Treat the patient with care and respect; sarcastic comments or a dismissive attitude can increase the risk for suicide or for aggressive behavior.

• Ultimately, the consultant may face a dilemma: discharge may be perceived as abandonment, whereas admission may lead to regression; either action can potentially increase suicide risk.

 It is usually helpful to convey this dilemma to the patient-he or she is more likely to assume an adult, responsible role if included in the decision-making process.





 • Hospital stays should be kept short to minimize regression, generally a few days to a week.

 • The goals of inpatient stays are brief stabilization, preparation for outpatient treatment, and consultation with the outpatient therapist. Ask the patient about patient-therapist boundaries and the nature of the relationships outside of therapy, especially issues of abuse, rejection, loss, and separation. Use motivational interviewing to build autonomous motivation for inpatient and outpatient treatment; a family meeting can help clarify possible precipitating factors for the admission.

 • Excessive focus on co-occurring Axis I disorders and pharmacotherapy may worsen regression by fostering a passive sick role. Patients with Axis I disorders tend to respond poorly to usual treatment strategies when co-occurring borderline personality disorder (BPD) is present.



 • Avoid benzodiazepines to manage patient anxiety. Patients tend to like benzodiazepines and often describe them as the only medications that are helpful; however, benzodiazepines have been shown to worsen behaviors and mood dysregulation.



 • Patients provoke strong urges in health care providers to either adopt a nurturing role or be dismissive and scornful (the patient is just attention-seeking). Often, inpatient health care providers become split into opposing camps

; educate team members about this dynamic and about the causes of suicidal behaviors in this population.





 • Manual-based treatments, such as dialectical behavior therapy,

 are often much more effective than relying on clinical intuition and judgment in an eclectic, unstructured model.

 • The most effective treatments for BPD strongly emphasize the importance of clear boundaries between patient and therapist and frequent case consultation with other therapists. Staying within the treatment frame can be extremely challenging with patients who have BPD, since they tend to evoke strong reactions in health care providers, both positive and negative.

 • Encourage patients to take responsibility for maintaining their own safety and making a commitment to work toward recovery; this can be instituted as part of reviewing written treatment goals and expectations early in treatment.

 • The single most effective technique to improve dissociation and core symptoms of BPD is to get patients to verbalize recent upsetting interpersonal experiences, create sequential narratives of these experiences, and label associated emotions.

Staying empathic and keeping the conflict within the patient instead of between the patient and health care provider, is a key to successful management. Other keys include maintaining clear expectations and boundaries, building autonomous motivation, and helping patients verbalize experiences and emotions.

 Ansell EB, Sanislow CA, McGlashan TH, Grilo CM. Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group. 

 Washington, DC: American Psychiatric Press; 2003.


 Cooper J, Kapur N, Webb R, et al. Suicide after deliberate self-harm: a 4-year cohort study. 

 Soloff PH, Lis JA, Kelly T, et al. Self-mutilation and suicidal behavior in borderline personality disorder. 

 Gregory RJ, Jindal S. Factitious disorder on an inpatient psychiatry ward. 

 Yen S, Shea MT, Sanislow CA, et al. Borderline personality disorder criteria associated with prospectively observed suicidal behavior. 

 Ruggero CJ, Zimmerman M, Chelminski I, Young D. Borderline personality disorder and the misdiagnosis of bipolar disorder. 

 Staying empathic and keeping the conflict within the patient instead of between the patient and health care provider, is a key to successful management. 

Managing Suicide Risk in Borderline Personality Disorder

Borderline personality disorder (BPD) is a serious illness involving multiple symptoms and mal adaptive behaviors. According to DSM-IV, "the essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects" (p. 650). This pervasive pattern of instability also applies to behaviors that are impulsive and potentially damaging, including excessive spending, sexual promiscuity, reckless driving, binge eating, and substance misuse.

Substance misuse associated with BPD is often frequent and severe enough to warrant a separate diagnosis. As the Figure illustrates, about 50% to 70% of psychiatric in patients with BPD also have a substance use disorder (SUD), especially alcohol abuse or dependence but often in combination with other drugs.

Depending on the sample, structured diagnostic interviews have found a variable prevalence of BPD among patients being treated for drug or alcohol dependence. The reported prevalence of BPD has ranged from 18% to 34% in patients receiving treatment for cocaine dependence.

 In large samples of patients treated for opiate dependence, rates of co-occurring BPD have varied from 5% to 45%.

 Among persons in treatment for alcohol use disorders, the prevalence of BPD appears similar to that for those in treatment for drug dependence, ranging from 16% to 22%.


There is evidence that co-occurring BPD worsens the outcome of alcohol and drug rehabilitation. In the study by Marlowe and colleagues

 of persons dependent on cocaine, BPD was the only Axis II disorder diagnosis that was consistently associated with a negative outcome, including measures of both treatment compliance and abstinence, and this relationship was in dependent of measures of anxiety, depression, or initial severity of drug dependence. Cacciola and colleagues6 examined 7-month outcomes of 197 men admitted to a methadone clinic. In that study, BPD had no significant effect on drug use, but it was associated with negative outcomes on other measures, including alcohol use, medical and psychiatric symptoms, and social relationships.

There is also evidence that BPD worsens the severity or course of alcohol use disorders. In a retrospective study by Martinez-Raga and colleagues,

 patients at a detoxification program who had BPD or antisocial personality disorder were significantly more likely to have an unplanned discharge from the facility than those who did not have those personality disorder diagnoses. In the previously cited study by Morgenstern and colleagues,

 co-occurring BPD predicted lifetime severity of alcohol dependence, psychological problems re lated to drinking, earlier age at onset of drinking, worse adaptive coping, and suicidal ideation, even after controlling for the effects of gender and concurrent Axis I disorders.

Likewise, studies examining patient populations in treatment for BPD have demonstrated that co-occurring SUD adversely affects outcome on measures of psychopathology. According to Miller and colleagues,

 BPD complicated by an alcohol use disorder is associated with unemployment, poor school performance, and promiscuity, com pared with BPD without a co-occurring alcohol use disorder. In their 2001 study, van den Bosch and coauthors

 compared 29 patients who had BPD with 35 patients who had co-occurring BPD and SUD. The latter group was found to have greater levels of anxiety, antisocial behavior, and suicide attempts.In a large psychological autopsy study of substance-related suicides, female victims were noted to have had high rates of BPD.

 reported that cognitive analytic therapy for BPD was less effective for those patients with co-occurring alcohol abuse. However, a post hoc analysis of a randomized trial of dialectical behavior therapy (DBT) indicated that the presence of a co-occurring SUD was not a significant determinant of improvement in psychopathology.

In a large prospective study of 290 subjects with diagnosed BPD who had been hospitalized at McLean Hospital in Belmont, Mass, Zanarini and associates2 reported that co-occurring SUD strongly and negatively correlated with remission from BPD at 6-year follow-up. The presence of SUD had a greater effect on outcome than did the presence of any other co-occurring Axis I disorder, including posttraumatic stress disorder, bipolar disorder, eating dis orders, or major depressive disorder. In their discussion, the authors stressed the need for the development of treatments that specifically target persons who have co-occurring BPD and SUD.


It is not clear why so many patients with BPD also have SUD and why this combination is so detrimental. Do patients with BPD misuse substances simply because they are impulsive? Indeed, research studies have demonstrated a correlation between substance use and measures of impulsivity and affective lability in this population.

 However, patients sometimes describe their substance use as a mal adaptive coping mechanism. In the words of one patient, "You feel like a big shot when you're on cocaine, like you're important and in control and nothing else matters." Other patients note a calming effect from substances: "I feel like drinking after our sessions because we touch on a lot of things I've been trying to cover up, or hide, or not feel. So when I leave here, I have all kinds of feelings going on that I'm now going through. The drinking calms me down or lets me focus on something else."

Some intriguing neurobiologic research suggests that substance use in some persons can serve as a substitute for unmet attachment needs. In large prospective studies in Denmark, early weaning from breast-feeding has been associated with the development of alcoholism in adulthood.

 These findings are similar to findings in animal studies. Barr and colleagues

 found that macaque monkeys separated from their mothers developed higher levels of ethanol preference. In addition, Moles and coinvestigators

 reported that mice that were lacking the µ-opioid receptor gene displayed both reduced reward dependence to nonopioid drugs of abuse and reduced attachment be haviors to ward their mothers. Satisfaction of unmet attachment needs may make substances particularly attractive to patients with BPD, who may otherwise exhibit pathologic interpersonal dependency.


Almost every major class of psychotropic medication has been tried in controlled treatment trials of BPD. Although a variety of medications, including SSRIs, mood stabilizers, and antipsychotic agents, may be helpful in some patients, a recent Cochrane review suggests that their efficacy compared with placebo has generally been very modest,

 and thus medications are not considered the primary treatment for BPD.

 There is evidence from one controlled study that although patients often prefer benzodiazepines to other classes of medications, benzodiazepines may actually worsen the course of the disorder, possibly through disinhibition.

Unfortunately, many pharmacotherapy protocols have excluded the large number of patients with co-occurring BPD/SUD from their trials. It is unclear whether medications are helpful at all in this subgroup, and benzodiazepines may be even more problematic in persons with active SUD because of their addictive potential.

Another important class of medications consists of those specifically de veloped and approved for use in sub stance dependence, such as nal trexone or acamprosate. Unfortunately, these also have not been examined in the large and refractory group of patients with co-occurring BPD and SUD.


Various psychotherapy modalities have been developed for the treatment of BPD that can be effective for both symptom management and core features of the disorder. Of these, DBT, a form of cognitive-behavioral therapy, has been the most studied in randomized controlled trials, and it appears to be especially effective for parasuicidal behavior.26 DBT is a complex and sophisticated treatment that integrates aspects of cognitive-behavioral and meditative practices.

A modified form of DBT has been developed for patients with co-occurring BPD/SUD; it has been used in combination with drug replacement therapy and tested for efficacy in 2 small trials.

 The results of both studies indicated improvement in recreational drug use with combined treatment. However, there was little improvement in parasuicidal behavior, and dropout rates were 36% to 45%. The high dropout rates in these 2 studies highlight the difficulties in engaging this co-occurring subgroup in a meaningful therapeutic relationship.

Schema therapy is another form of cognitive-behavioral therapy that has shown promise in a recent randomized controlled trial.

 This treatment identifies maladaptive schemas and modes of interaction and provides a combination of psychoeducation, coping strategies, and limited reparenting. This treatment has also been modified for persons who have co-occurring personality disorders and SUD.

Another treatment modality shown to be effective for BPD has been psy chodynamic psychotherapy. Bateman and Fonagy

 compared the effects of a psychodynamically oriented partial hospital program to usual care in the community. Compared with patients receiving usual care, those who had received psychodynamic treatment continued to improve on measures of self-injurious behavior, depression, anxiety, interpersonal functioning, and inpatient utilization for 2 years following discharge from the partial hospital program.

 Although the results were very positive, the study protocol excluded subjects with co-occurring SUD.

A manual-based form of psychodynamic psychotherapy, labeled transference-focused psychotherapy (TFP) is also being evaluated.

 In a 3-year randomized trial comparing TFP with schema therapy for patients with BPD, both treatments were effective in reducing core symptoms of BPD, but overall better results were obtained in the latter group.

 In this study, some of the patients had co-occurring SUD.

A study that more directly addresses the efficacy of psychodynamic psycho therapy for the co-occurring subgroup is presently in progress. A manual-based form of psychodynamic therapy labeled dynamic deconstructive therapy (DDT), specifically for those pa tients with BPD who are most difficult to engage in a therapeutic process, in cluding those who have a co-occurring SUD, has been developed.

 DDT posits that persons with co-occurring BPD and substance dependence feel very vulnerable in relationships and have a fear of close attachments. The treatment recognizes the patient's need for autonomy and encourages the therapist to maintain a nonjudgmental and nondirective stance toward maladaptive behaviors. Results of a study by Karno and Longa baugh

 indicate that the outcome of alcoholic patients with moderate or high reactance is strongly and negatively related to the degree of therapist directiveness.

An ongoing 30-month study is as sessing the effectiveness of DDT com pared with high-intensity community care for patients with co-occurring BPD and alcohol use disorders. Initial findings suggest that DDT is effective in reducing parasuicidal behavior, alcohol misuse, and institutional care and is associated with far better treatment retention than community care.


Persons with co-occurring BPD and SUD represent a large subgroup of both the BPD and substance using pa tient populations. This subgroup ap pears to be especially impaired and dif ficult to engage in treatment. Although there is evidence that a variety of treatments may be effective for BPD, treatments for the co-occurring subgroup are much less well established. Initial studies of modified forms of cognitive-behavioral and psychodynamic therapies hold promise for the development of effective treatments in this very challenging population, but further research is necessary.

Dr Gregory is associate professor of psychiatry in the department of psychiatry at the State University of New York Upstate Medical Uni versity in Syracuse. He reports that he has no conflicts of interest concerning the subject matter of this article.

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Borderline personality disorder (BPD) is a serious illness involving multiple symptoms and mal adaptive behaviors. According to DSM-IV, “the essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects” (p. 650). This pervasive pattern of instability also applies to behaviors that are impulsive and potentially damaging, including excessive spending, sexual promiscuity, reckless driving, binge eating, and substance misuse.

Robert J. Gregory, MD

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