Integrating psychotherapy and pharmacotherapy in the treatment of borderline personality disorder

Psychotherapy and pharmacotherapy are each effective in treating borderline personality disorder. In severely symptomatic patients, psychotherapy reduces suicidality and the utilization of inpatient psychiatric care within the first year of treatment, but drop-out rates are high. Pharmacotherapy reduces impulsivity, hostility, suicidality, and psychoticism over five to twelve week periods after which it may not be effective. The combination of both modalities surmounts the limitations of each, but is difficult to achieve because characteristic features of borderline pathology can undermine efforts at integrating the treatments. The meaning of being given medication, the effect of medication on the therapeutic relationship, issues of control, seduction and dependency, the all-or-nothing tendency to 'biologize' or 'psychologize,' and the therapist's counter-reactions to the patient must all be addressed for combined treatment to be possible. Several clinical vignettes illustrate these issues.