Practice Assessment Tool for the Care of Patients With Borderline Personality Disorder

Abstract

Borderline personality disorder (BPD) is characterized by a long-term pattern of instability of interpersonal relationships, unstable self-image, marked impulsivity, and/or affective instability. In addition, these features can be evidenced by efforts to avoid real or feared abandonment, chronic feelings of emptiness, mood reactivity, recurrent self-injurious or suicidal behavior, other impulsive behaviors with potential for self-damaging effects, intense anger or difficulty with anger control, and transient paranoid ideation or stress-related dissociative symptoms. BPD is associated with substantial lifetime burdens and psychosocial impairments, including high rates of co-occurring psychiatric disorders; disruptions in interpersonal relationships, school, work, and housing; and suicide attempts and nonsuicidal self-injury. Consequently, early identification and treatment of BPD are crucial. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder aims to enhance knowledge and increase the appropriate use of interventions for BPD, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with BPD. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and ABPN Continuing Certification, Improvement in Medical Practice.

Borderline personality disorder (BPD) is characterized in Section II of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM-5-TR) (1) by a long-term pattern of instability of interpersonal relationships, unstable self-image, marked impulsivity, and/or affective instability (Box 1). In addition, these features can be evidenced by efforts to avoid real or feared abandonment, chronic feelings of emptiness, mood reactivity, recurrent self-injurious or suicidal behavior, other impulsive behaviors with potential for self-damaging effects, intense anger or difficulty with anger control, and transient paranoid ideation or stress-related dissociative symptoms (1).

BOX 1. DSM-5-TR criteria for borderline personality disorder^a .

Criteria for borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• 1.Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
• 2.A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
• 3.Identity disturbance: markedly and persistently unstable self-image or sense of self.
• 4.Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
• 5.Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
• 6.Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
• 7.Chronic feelings of emptiness.
• 8.Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
• 9.Transient, stress-related paranoid ideation or severe dissociative symptoms.

^aReprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (1). Used with permission.

The lifetime prevalence of BPD in the United States is approximately 1.4%–2.7%, although estimates can vary depending on the study location, sample demographic characteristics, case findings, and diagnostic approaches (2–8). Among primary care patients, the lifetime prevalence of BPD is about four times as high as in the general population (9), whereas, in psychiatric populations, up to one-quarter of patients will have a diagnosis of BPD (2, 7, 9–13). In clinical populations, women are more frequently diagnosed as having BPD and tend to seek treatment more often than men; however, nonclinical samples suggest that the prevalence of BPD is likely to be comparable in men and women (5, 14, 15). Other psychiatric disorders commonly co-occur with BPD (5, 13, 16–33) and often add to the severity of symptoms and difficulty in achieving remission (18, 20, 21, 34, 35).

BPD typically has an onset in adolescence or early adulthood and can persist for many years (1, 10, 22, 36). Consequently, the lifetime burden and psychosocial impairment associated with BPD can be substantial due to disruptions in relationships, schooling, employment, and housing (37–40); financial instability (40–42); and increases in health care costs (41). Self-harm, including suicide attempts and nonsuicidal self-injury, is common among individuals with BPD (43–45). In longitudinal studies, BPD is associated with increases in deaths by suicide as well as with increases in all-cause mortality (46–49). Furthermore, the lived experience of BPD can be associated with significant emotional pain and a diminished quality of life (38, 39, 50, 51).

The Performance in Practice (PIP) Practice Assessment Tool for the Care of Patients With Borderline Personality Disorder was developed to assist psychiatrists in optimizing patient care and meeting Continuing Certification, Improvement in Medical Practice, requirements of the American Board of Psychiatry and Neurology and the American Board of Medical Specialties. Continuing Medical Education information and directions for completing the activity are presented in Box 2.

BOX 2. Continuing Medical Education information and directions for completing the activity.

Completion of Steps A, B, and C in sequence is designated by the American Psychiatric Association (APA) for 20 AMA Physician’s Recognition Award (AMA PRA) Category 1 Credits™. Begin date: September 1, 2025 – End Date: September 1, 2028

The American Board of Psychiatry and Neurology (ABPN) has reviewed the Performance in Practice (PIP): Practice Assessment Tool for the Care of Patients with Borderline Personality Disorder and has approved this program as a Performance in Practice Clinical Module (Continuing Certification), which is mandated by the American Board of Medical Specialties as a necessary component of Continuing Certification.

APA reports continuing certification completion data on behalf of our members directly to ABPN. However, diplomates are still required by ABPN to log on to their ABPN Physician Portal at least once per calendar year to attest to completion of their Continuing Certification activities.

The course is completed online at education.psychiatry.org. APA members log in with their APA username and password. Nonmember Focus subscribers can e-mail apacme@psych.org to be enrolled in the online course.

Completion of three steps (A, chart review; B, improvement plan; and C, second chart review), evaluation of each step, and credit claim for each step of the PIP takes place in the online course in the APA Education Portal, education.psychiatry.org.

The tool presented here is used to complete steps A and C and is available for download in the online course. Chart review data are for the use of the participant only and are not submitted to APA.

Three steps are involved in each PIP unit:

• Step A: Chart review

  • The physician compares their current practice (through a review of chart documentation) with guidelines and measures provided for the topic area.

  • No patient/chart data are submitted (5 credits).

• Step B: Improvement plan

  • Based on the results from chart reviews, the physician then selects an area in which improvement is needed and documents their strategy for improvement.

  • This improvement plan is for the personal use of the physician and is not submitted to APA.

  • Educational resources are suggested that can assist with the improvement plan; however, any educational activities relevant to the improvement plan can be used.

  • During Step B, the physician implements the educational and improvement plan for a recommended period of at least 30 days or as long as the doctor deems necessary (5 credits).

Suggested intervention: For a more thorough presentation of specific clinical and psychosocial issues relating to the treatment of patients with borderline personality disorder (BPD), physicians and others interested in strengthening the quality of care provided to their patients with BPD are strongly encouraged to carefully review the American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder, 2nd ed. (52) (http://psychiatryonline.org/guidelines.aspx).

• Focus: The Journal of Lifelong Learning in Psychiatry, special issue on borderline and other personality disorders (Volume 20, Issue 4, October 2022): review original articles and influential publications on BPD published in this issue.

• Emotions Matter (https://emotionsmatterbpd.org): Aims to connect and empower those impacted by BPD and includes resources and educational materials for individuals affected by BPD and their families, as well as professional resources.

• Step C: Reassessment/second chart review

  • The physician reassesses their performance with review of five patient charts and determines the results of their performance improvement effort.

  • These can be the same five patients assessed in Step A, or a new group of patients seen since beginning the PIP activities.

  • Again, the physician retains all patient/chart data (5 credits).

In support of improving patient care, this activity has been planned and implemented by the American Psychiatric Association (APA) and American Professional Agency, Inc. APA is jointly accredited by the American Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

The American Psychiatric Association designates this enduring activity for a maximum of 20 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The PIP tool draws on the structure and content of the American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (52). This evidence-based guideline was developed through a systematic review of relevant literature and critical evaluation of scientific research by experts in the assessment and treatment of BPD. The guideline highlights critical issues related to evidence-based assessment and treatment and notes the importance of formulating a person-centered plan that incorporates psychiatric and psychological expertise, providing structured psychotherapy that is supported by the literature and targets the core features of BPD, and using time-limited adjunctive pharmacotherapy aimed at addressing specific measurable target symptoms. Careful review of the full guideline is recommended to obtain additional details on assessment and treatment of individuals with BPD.

In addition to providing key evidence-based recommendations that relate to the assessment and treatment of BPD, the PIP tool is also intended to provide a simple retrospective chart review tool for physicians to determine whether their own assessment and treatment practices are consistent with the latest evidence-based recommendations. Furthermore, the PIP tool offers valuable clinical resources related to assessment and treatment interventions, including possible ways to improve the clinical care of individuals with BPD. In addition to its value as a self-assessment tool, this tool could also be used for peer review initiatives or broader systematic efforts by organizations and health care delivery systems to improve the assessment and treatment of patients with BPD, such as ensuring the initial psychiatric evaluation includes the recommended and suggested elements of assessment for any individual who presents with psychiatric symptoms (Box 3) and offering structured psychotherapy with support in the literature (Table 1).

BOX 3. Recommended aspects of psychiatric evaluation^a .

History of present illness

Reason the patient is presenting for evaluation, including current symptoms, behaviors, and precipitating factors

Current psychiatric diagnoses and psychiatric review of systems

Psychiatric history

Hospitalization and emergency department visits for psychiatric issues, including substance use disorders

Psychiatric treatments (type, duration, and, where applicable, doses)

Response and adherence to psychiatric treatments, including psychosocial treatments, pharmacotherapy, and other interventions such as electroconvulsive therapy or transcranial magnetic stimulation

Prior psychiatric diagnoses and symptoms, including

• Hallucinations (including command hallucinations), delusions, and negative symptoms

• Aggressive ideas or behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts)

• Impulsivity

• Suicidal ideas, suicide plans, and suicide attempts, including details of each attempt (e.g., context, method, damage, potential lethality, intent) and attempts that were aborted or interrupted

• Intentional self-injury in which there was no suicide intent

Substance use history

Use of tobacco, alcohol, and other substances (e.g., vaping, marijuana, cocaine, heroin, hallucinogens) and any misuse of prescribed or over-the-counter medications or supplements

Current or recent substance use disorder or change in use of alcohol or other substances

Medical history

Whether or not the patient has an ongoing relationship with a primary care health professional

Allergies or drug sensitivities

All medications patient is currently taking or has recently taken and side effects of these medications (i.e., both prescribed and nonprescribed medications, herbal and nutritional supplements, and vitamins)

Past or current medical illnesses and related hospitalizations

Relevant past or current treatments, including surgeries, other procedures, or complementary and alternative medical treatments

Sexual and reproductive history

Cardiopulmonary status

Past or current neurological or neurocognitive disorders or symptoms

Past physical trauma, including head injuries

Past or current endocrinological disease

Past or current infectious disease, including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infectious diseases such as Lyme disease

Past or current sleep abnormalities, including sleep apnea

Past or current symptoms or conditions associated with significant pain and discomfort

Additional review of systems, as indicated

Family history

Including history of suicidal behaviors or aggressive behaviors in biological relatives

Personal and social history

Preferred language and need for an interpreter

Personal/cultural beliefs, sociocultural environment, and cultural explanations of psychiatric illness

Presence of psychosocial stressors (e.g., financial, housing, legal, school/occupational, or interpersonal/relationship problems; lack of social support; painful, disfiguring, or terminal medical illness)

Exposure to physical, sexual, or emotional trauma

Exposure to violence or aggressive behavior, including combat exposure or childhood abuse

Legal or disciplinary consequences of past aggressive behaviors

Examination, including mental status examination

General appearance and nutritional status

Height, weight, and body mass index (BMI)

Vital signs

Skin, including any stigmata of trauma, self-injury, or drug use

Coordination and gait

Involuntary movements or abnormalities of motor tone

Sight and hearing

Speech, including fluency and articulation

Mood, degree of hopelessness, and level of anxiety

Thought content, process, and perceptions, including current hallucinations, delusions, negative symptoms, and insight

Cognition

Current suicidal ideas, suicide plans, and suicide intent, including active or passive thoughts of suicide or death

If current suicidal ideas are present, assess patient’s intended course of action if current symptoms worsen; access to suicide methods including firearms; possible motivations for suicide (e.g., attention or reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations); reasons for living (e.g., sense of responsibility to children or others, religious beliefs); and quality and strength of the therapeutic alliance

Current aggressive ideas, including thoughts of physical or sexual aggression or homicide

If current aggressive ideas are present, assess specific individuals or groups toward whom patient’s homicidal or aggressive ideas or behaviors have been directed in the past or at present; impulsivity, including anger management issues and access to firearms

^aAdapted from (64).

TABLE 1. .

Comparison of characteristics of psychotherapies for borderline personality disorder

Characteristic	Dialectical behavior therapy (DBT)	Dynamic deconstructive psychotherapy (DDP)	Mentalization-based treatment (MBT)	Schema-focused therapy (SFT)	Systems Training for Emotional Predictability and Problem Solving (STEPPS)	Transference-focused psychotherapy (TFP)	Good psychiatric management (GPM)
Typical treatment duration	6 – 12 months	12 – 18 months	12 – 18 months	Depends on format	20 weeks	12 – 18 months	12 months
Individual therapy	1 hour/week	1 hour/week	1 hour/week	2 hours/week for 3 years	Not part of treatment	Two 45- to 50-minute sessions/week	Once weekly as needed
Group therapy	1.5 hour s /week	Not part of treatment	75 – 90 minutes/week	90 minutes/week for 8 months	2 hours/week	Used as indicated	Encouraged
Family therapy/involvement	Multifamily group for adolescents	Not part of the treatment	MBT-Family	Not part of treatment	1 - hour session	Used as indicated	Family psychoeducation
	Family groups for adults		MBT-Family Group Therapy
Crisis management	Minimize emergency department (ED) use	Exploration in session	On-call mentalizing team or ED after hours	Individualized plans	Use skills in group with referral to ED or individual therapist, as needed	Minimize ED use, and use only when absolutely necessary	Crisis plan or algorithm regarding inter-session contact
	Focus on use of skills and skills coaching
	Between-session availability
Manual available for treatment in adolescents	Yes	No	Yes	No	No	Yes	Yes
Comments	DBT skills training can be used independently from other DBT components			Delivered in an individual or group format but not both	Supplements other treatment

This PIP clinical tool has been designed to be relevant across different clinical settings, is straightforward to complete, and can be used in a pen-and-paper format to aid adoption. The PIP tool includes sections related to patient assessment (Table 2 ) and general treatment approaches (Table 3 ). Each section highlights aspects of care that have significant health implications or for which gaps in guideline adherence are common, as described earlier.

TABLE 2. .

Practice Assessment Tool for the Care of Patients With Borderline Personality Disorder, part 1: assessment of patients meeting diagnostic criteria for borderline personality disorder (BPD) ^a

I. Assessment of borderline personality disorder. Did the initial evaluation or your initial visit with the patient assess the following?	Patient					Number of patients with check mark in row b	Recommendations and clinical resources
	#1	#2	#3	#4	#5
1. Did the initial evaluation include the reason the individual was presenting for evaluation and a review of common symptoms and concerns in individuals with BPD?	□	□	□	□	□	__/5	The initial evaluation can take several visits to complete and should address the recommendations of the American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd ed. (64). It typically begins with the reason the individual is presenting for evaluation. Determining the patient’s symptoms, behaviors, and mental status are crucial in making a diagnosis of BPD (Box 3). Common concerns in individuals with BPD include anxiety, depression, mood instability, irritability, difficulties with anger, hopelessness, low self-esteem, unstable self-image or sense of self, unstable and intense interpersonal relationships, concerns about real or feared abandonment, suicidal thoughts or attempts, nonsuicidal self-injury, other impulsive or self-harming behaviors (e.g., substance use, reckless driving, risky sexual behavior), or harm to others. When such symptoms or behaviors are present, it is important to ask about their onset, course, and duration.
2. Did the evaluation of the patient include the patient’s goals, view of the illness, and preferences for treatment?	□	□	□	□	□	__/5	Throughout the assessment process, it is important to gain an understanding of the patient’s goals, view of the illness, and preferences for treatment. This information will serve as a starting point for person-centered care and shared decision-making with the patient, family, friends, and others involved in the patient’s care (65, 66).
							It is also important to inquire about the patient’s strengths and protective factors. For example, they may be able to delineate strategies that have been helpful for them in coping with or managing their symptoms in the past (67).
3. Did the evaluation of the patient include identification of prior treatment and response to treatment?	□	□	□	□	□	__/5	If the patient has received treatment previously, it is important to ask about a broad range of treatments and other approaches that have been used to address BPD or co-occurring psychiatric conditions, including substance use disorders.
							It is useful to specifically ask about the full range of treatment settings (e.g., outpatient, partial hospitalization, inpatient) as well as approaches or aspects of the therapeutic relationships that the patient has found helpful or problematic in addressing their symptoms and functioning (64, 68–71). For example, prompting may be needed to learn information about the patient’s experiences with psychotherapies (e.g., dialectical behavior therapy [DBT], cognitive-behavioral therapy [CBT], mentalization-based treatment [MBT], transference-focused psychotherapy [TFP], schema-focused therapy [SFT], dynamic deconstructive psychotherapy [DDP], other psychodynamic therapies, couples or family therapy, supportive therapy) as well as their formats, frequencies, and durations.
							With medications, information about the specific medication, duration of treatment, formulation, route, and dosage are important to obtain.
4. Was the patient assessed for co-occurring psychiatric disorders and other co-occurring health conditions?	□	□	□	□	□	__/5	Substance use and substance use disorders are common in individuals with BPD (3, 30), and some individuals with BPD may use substances to cope with their emotional distress or help regulate their emotions. In addition to substance use disorders, other common co-occurring psychiatric conditions in individuals with BPD include major depressive disorder, bipolar disorder, posttraumatic stress disorder, anxiety disorders, eating disorders, attention-deficit/hyperactivity disorder, and other personality disorders (5, 13, 16–23).
							Individuals with BPD may also have physical health conditions, sleep disturbances, or chronic pain that need to be considered in assessing functioning and developing a plan of treatment (10, 72–77). Prior head trauma or other brain abnormalities (e.g., due to anoxic injury) are important to identify because they can contribute to impulsivity or emotional dysregulation (78).
5. Did the evaluation of the patient include the patient’s history of interpersonal relationships, including family and intimate relationships, and interpersonal functioning?	□	□	□	□	□	__/5	The patient’s history of interpersonal relationships, including family and intimate relationships, is particularly essential to obtain. Such relationships can be supportive and helpful, or they can be unstable or intense in individuals with BPD. A family health history is also important in identifying family members who have a history of personality disorder, particularly BPD or BPD traits, as well as the presence of substance use disorders, other psychiatric disorders, or suicidal behaviors in the family.
6. Was a quantitative measure used to identify and determine the severity of symptoms and impairments of functioning?	□	□	□	□	□	__/5	Although rating scales have primarily been used in research contexts, they can also be used clinically to complement other aspects of the screening and assessment process (64). Self-report rating scales that are free to use and can help identify and determine BPD symptom severity are the 23-item version of the Borderline Symptom List (BSL-23) (79), the Borderline Evaluation of Severity Over Time (BEST) (80), and the Difficulty in Emotional Regulation Scale (DERS) (81). For assessment of functioning, DSM-5 (82) includes the 36-item self- and proxy-administered versions of the World Health Organization Disability Schedule 2.0 (WHODAS 2.0) (83, 84). The WHOQOL-BREF scale (85, 86), developed by the World Health Organization, can also be used.
7. Was the patient assessed for risk of suicide and other self-harming behaviors?	□	□	□	□	□	__/5	It is estimated that self-injurious behavior occurs in more than 90% of individuals with BPD, with suicide attempts in approximately 75% and suicide death in 3%–10% (22, 43–47, 49, 87–91). Because of the heightened risk of suicide attempts and suicide death in individuals with BPD, it is important that patients be monitored for suicide risk, suicide risk assessments be documented, individualized safety plans be developed (92–94), and treatment plans be adjusted or reformulated as clinically necessary.
8. Was the patient assessed for risk of dangerous or aggressive behaviors, including interpersonal aggression and harm to others?	□	□	□	□	□	__/5	Anger and impulsivity are other aspects of emotional dysregulation that are common in individuals with BPD and can be directed inwardly or at others, including the clinician. Aggression may be more likely when antisocial personality features or a substance use disorder are present (95), when anger is intense (96), when impulsivity and intense anger occur in the presence of identity disturbance (97), or when an individual has experienced verbal, emotional, physical, or sexual abuse during adulthood (95). As with suicide risk, it is important for patients to be monitored for risks of aggression, for such risk assessments to be documented, and for treatment plans to be adjusted or reformulated as clinically necessary. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd ed. (64) include detailed information on specific elements to assess when determining a patient’s risk of aggressive behaviors.
9. Was a comprehensive and person-centered treatment plan developed and documented?	□	□	□	□	□	__/5	When treating individuals with BPD, a person-centered treatment plan should be developed, documented in the medical record, and updated at appropriate intervals. Whenever possible, development and updating of the treatment plan should be done in a collaborative fashion with the patient.
							When treating an adolescent, parents or other involved caregivers will be crucial to engage when creating a treatment plan. Patients’ relationships with family members can be heterogeneous, but many adults will also welcome involvement of family members and others (98, 99). Input from these individuals can be vital in developing a full picture of the patient as well as in formulating and implementing a person-centered treatment plan.
							As part of treatment planning, it is important to establish a clear and explicit treatment framework with which the patient agrees (100). This treatment framework can serve as a model for healthy boundaries in other aspects of the patient’s life and typically includes agreements about the goals of treatment sessions (e.g., symptom reduction, personal growth, improvement in functioning), ways to facilitate these goals (e.g., reporting on such issues as conflicts, dysfunction, and impending life changes; completing homework between sessions; developing an individualized safety plan), and what role the patient and clinician are each expected to perform to achieve these goals. Because patients with BPD may have difficulty developing and sustaining trusting relationships, establishing and strengthening the therapeutic alliance will generally be a focus of treatment from the initial session (101–103).
							If the patient is also receiving care from another health professional or when a team-based approach to treatment is used, ongoing coordination of the overall treatment plan needs to be ensured through clear role definitions, plans for management of crises, and regular communication among the clinicians and the patient. Communication and coordination of care may also be needed with primary care or specialty care clinicians who are addressing the patient’s physical health needs.
							In patients with BPD, peer support may help individuals feel less isolated, more understood, and hopeful and may assist them in developing coping skills with input from the perspective of someone with lived experience (104, 105). When peer support is used as part of the treatment plan, it is important to have a specific framework or structure in place (e.g., as with the peer support groups provided by Emotions Matter) (106, 107).
10. Was there a collaborative discussion with the patient about their diagnosis and treatment, including psychoeducation related to BPD?	□	□	□	□	□	__/5	Once a diagnosis of BPD has been established, it is important to discuss the diagnosis with the patient in a collaborative fashion that allows them to ask questions and share their experiences and perspectives. When treating an adolescent, parents or other involved caregivers should also be engaged in the discussion of the diagnostic impression. Disclosure and discussion of a BPD diagnosis is preferred by patients (59, 108), does not adversely affect patient satisfaction (109), is crucial on ethical grounds (110), and is part of good clinical practice (111).
							Disclosing a diagnosis of BPD is also an initial step in discussing treatment options as well as in providing psychoeducation about BPD to patients. In addition, family members and others in the support network will often benefit from receiving educational materials about BPD or being directed to organizations that offer education and support (112–116).

^aInstructions: Choose five adult patients from your current psychiatric caseload who meet diagnostic criteria for BPD. Review their charts to determine whether they have received assessment and treatment that was consistent with key evidence-based recommendations shown in the left-hand column of this table. If yes, check the appropriate box; if no or unknown, leave the box unchecked. Note that the right-hand column provides supporting evidence, resources, and clinical issues that can be considered in relation to a specified recommendation. For additional details, the reader is directed to the full guideline (52).

^bScoring: In the total column, tally the total number of check marks in each row. For any row for which the total is less than five, examine whether clinical or other circumstances explain why practice was not consistent with recommended care. Consider whether changes in your practice or use of any of the suggested clinical tools could strengthen the provision of evidence-based care.

TABLE 3. .

Practice Assessment Tool for the Care of Patients With Borderline Personality Disorder, part 2: treatment of patients meeting diagnostic criteria for borderline personality disorder (BPD) ^a

II. Treatment/management of borderline personality disorder. Does the treatment plan currently include, refer, or consider the following treatment management approaches for borderline personality disorder?	Patient					Number of patients with check mark in row b	Recommendations and clinical resources
	#1	#2	#3	#4	#5
1. Was the patient offered structured psychotherapy that has support in the literature and targets the core features of BPD?	□	□	□	□	□	__/5	Psychotherapy is at the core of treatment for BPD for adolescents and adults. Multiple structured approaches to psychotherapy are available and have been studied in patients with BPD; characteristics of these approaches are summarized in Table 1.
2. Before initiating any new medication, was there a review of the patient’s co-occurring disorders, prior psychotherapies, other nonpharmacologic treatments, past medication trials, and current medications?	□	□	□	□	□	__/5	Psychotherapy is the primary modality recommended for use in the treatment of BPD. Before adding a new medication, it is important to determine whether a current psychotherapy can be optimized or whether a change in the psychotherapeutic approach may be needed. As such, it is crucial to learn about a patient’s past and current psychotherapies, including the types, the clinician’s fidelity to treatment principles, the treatment intensity and duration, and the patient’s experience with therapy if this information was not already obtained as part of the initial evaluations.
							Similarly, it is important to obtain information about other nonpharmacological treatments (e.g., electroconvulsive therapy, transcranial magnetic stimulation, light therapy) and prior medication trials, including the dosages, durations, adherence, effectiveness, and associated adverse effects if this information was not already obtained as part of the initial evaluation. If co-occurring psychiatric symptoms or disorders are present, they may also warrant medication treatment.
3. If medication treatment was provided, was it time-limited, aimed at addressing a specific measurable target symptom, and adjunctive to psychotherapy?	□	□	□	□	□	__/5	Despite the lack of evidence in support of medication treatment from clinical trials (117, 118), there may be circumstances in which treatment with a medication may be considered on clinical grounds. For example, medication to address co-occurring disorders will generally be appropriate to use. In other circumstances, pharmacotherapy may be used on a time-limited basis as an adjunct to psychotherapy for BPD and may help diminish symptoms such as affective instability, impulsivity, or psychotic-like symptoms in individual patients, helping them to remain engaged in treatment or reducing short-term risks of self-harm.
							Prior to prescribing a medication, it is important to educate patients about the adjunctive nature of the medication in treating BPD symptoms and its potential benefits and adverse effects. In particular, medications would not be expected to affect the core features of BPD.
							If a medication is started, the duration of treatment should be time limited, with tapering and discontinuation of the medication, if possible, once symptoms have stabilized.
							While treatment is occurring, patients should receive any monitoring that is necessary for the specific medication (e.g., serum levels for some anticonvulsants, metabolic monitoring for antipsychotics).
4. If the patient has received medications, has there been a review and reconciliation of the medications at least every 6 months to assess the effectiveness of treatment and identify medications that warrant tapering or discontinuation?	□	□	□	□	□	__/5	Appropriate use of pharmacotherapy for BPD includes prescribing as few medications as possible, using medication as an adjunct to treatment with psychotherapy, and selecting medications based on their ability to target specific and prominent symptom clusters (117, 119). Continuous review and reconciliation of medications is critical for avoiding or mitigating prolonged and unnecessary exposure to pharmacotherapy as well as inappropriate polypharmacy (117, 120–125).
							It is important to incorporate plans for tapering or discontinuation of pharmacotherapy because BPD symptoms often fluctuate in intensity and frequency and may no longer require the same medications or medication dosages (123, 126, 127). In addition, medications can frequently be tapered or stopped when patients improve with psychotherapy.

^aInstructions: Choose five adult patients from your current psychiatric caseload who meet diagnostic criteria for BPD. Review their charts to determine whether they have received assessment and treatment that was consistent with key evidence-based recommendations shown in the left-hand column of this table. If yes, check the appropriate box; if no or unknown, leave the box unchecked. Note that the right-hand column provides supporting evidence, resources, and clinical issues that can be considered in relation to a specified recommendation. For additional details, the reader is directed to the full guideline (52).

^bScoring: In the total column, tally the total number of check marks in each row. For any row for which the total is less than five, examine whether clinical or other circumstances explain why practice was not consistent with recommended care. Consider whether changes in your practice or use of any of the suggested clinical tools could strengthen the provision of evidence-based care.

The left column of the tool inquires whether a specific quality-related action was taken. The middle portion of the tool provides checkboxes to record whether the action was taken for up to five patients who are being reviewed. It is important to note that the American Board of Psychiatry and Neurology Improvement in Medical Practice program requires review of at least five patients as part of each PIP unit; however, larger samples will provide a more accurate estimate of the quality of care within a practice. The last column of the tool provides guideline-supported recommendations and clinical resources to assist in identifying knowledge gaps and engaging in practice improvement efforts.

After using the PIP tool to assess the pattern of care provided to patients, the physician should determine whether specific aspects of care need to be improved. Assessment and treatment recommendations provided in the practice guideline are generally intended to be relevant to most individuals. However, patients vary widely in their preferences for treatment, clinical presentation, history of treatment and prior response, presence of co-occurring physical and psychiatric conditions, and other factors that may influence clinical decision making. Because patients with BPD have high levels of co-occurring psychiatric and other medical conditions, divergence from evidence-based recommendations may occur. Deviations from guidelines may also arise when recommended treatments have been tried but have not led to full response of symptoms or return to baseline levels of functioning. In addition, practice guidelines and quality indicators are often derived from findings of efficacy and effectiveness trials in which stringent enrollment criteria are used; thus, individuals in clinical trials often differ in important ways from those seen in routine clinical practice. Although this tool is intended to highlight current evidence-based assessment and treatment recommendations for patients with BPD, justifiable variations from recommended care may occur.

Guided by the PIP tool findings and a subsequent practice assessment, physicians may determine that deviations from the items on the PIP tool are clinically appropriate and justified, or they may choose to acquire new knowledge and modify their practice to improve quality. For example, if patients with BPD in a physician’s current psychiatric caseload are not routinely screened and monitored for suicide risk, an area for improvement could involve implementation of suicide risk assessments and, as needed, development of individualized safety plans. Use of the PIP tool may also highlight potential treatment service gaps, which may include, for example, lack of availability of treatments aimed specifically at BPD (53, 54) or treatments for adolescents and emerging adults with BPD. It is hoped that this tool, together with the evidence-based guideline, may be useful in optimizing use of evidence-based treatment and advocating for increased availability of critically needed core services to help improve the lives and functioning of individuals with BPD.

Another goal of this PIP tool is to address common misconceptions about BPD (55–57). A considerable amount of stigma exists toward BPD, including self-stigma, and patients with BPD often experience discrimination within the health care system (55, 57–59). Clinician education through use of this PIP tool can be helpful in emphasizing that treatment of BPD is effective and that many patients with BPD will improve with treatment (4, 60–63).