PRACTICE RECOMMENDATIONS • Evaluate a patient’s sense o f iden tity and interpersonal relationships fo r clues o f a personality disorder (PD). ®

PRACTICE RECOMMENDATIONS • Evaluate a patient’s sense o f iden tity and interpersonal relationships fo r clues o f a personality disorder (PD). ®

“Difficult” Patient? Or Is It a Personality Disorder? D avid Kealy, m s w , Paul I. S te inberg , m d , frcpc, John S. O grodniczuk, PhD

The patient who always seems to be in crisis may actually have a personality disorder. Employing these techniques can benefit the patient and improve your interaction.

PRACTICE RECOMMENDATIONS • Evaluate a patient’s sense o f

iden tity and interpersonal relationships fo r clues o f a personality disorder (PD). ®

• Use validation, prom ote m entalization, and manage countertransference to help patients w ith PDs. ®

• Consider medications such as antidepressants or antipsychotics fo r patients w ith PDs, bu t only as adjuncts to psychotherapy and only to ta rge t specific symptoms, such as impulsive aggression, (b)

Strength of recommendation (SOR) (a) G ood-quality patient-oriented

evidence (b) Inconsistent or lim ited-quality

patient-oriented evidence (c) Consensus, usual practice,

opinion, disease-oriented evidence, case series

Bob, age 48, comes to his family practice provider (FPP) to ask for authoriza­ tion for extended medical leave from his job as an electrician. He frequently misses days at work and complains of stress on the job, saying his coworkers look down on him and make cruel jokes at his expense. He reports having chronic interpersonal conflicts and no significant relationships with family members or friends. Bob refuses a referral to a psychiatrist because he fears he w ill be “locked up and forced to take medications.”

If Bob were your patient, how would you proceed?

Personality disorders (PDs) are patterns of inflexible and mal­adaptive personality traits and behaviors that cause subjective distress and significant social or occupational impairment.1 An individual with a PD tends to have a limited repertoire of responses

to the rough-and-tumble of life, with coping mechanisms that often perpetuate difficulty and distress. Examples include distrust and sus­ piciousness of others’ motives (paranoid PD); disregard and violation of the rights of others (antisocial PD); instability in interpersonal re­ lationships, self-image, and affect (borderline PD); and social inhibi­ tion, feelings of inadequacy, and hypersensitivity to negative evalua­ tion (avoidant PD).1

FPPs may view patients with PDs as “difficult patients” because of their frequent crises and the interpersonal problems they bring into the clinician-patient relationship.2,3 Help, of course, can come in the way of a referral to a psychotherapist who specializes in treating PDs. But you can also make use of some evidence-based psychotherapy techniques to improve your patients’ lives and the quality of the clini­ cian-patient relationship. This article focuses on identifying and man­ aging PDs in family practice, using practical strategies drawn from empirically supported therapies.

PDS ARE MORE COMMON THAN YOU MIGHT SUSPECT The overall prevalence of PD in the community ranges from 4.4% to 14.8%, with no consistent pattern of sex differences.4 Between 31.4% and 45.5% of psychiatric outpatients and up to 24% of primary care patients likely meet criteria for at least one PD.5’7 PDs impede recov-

David Kealy, Paul I. Steinberg, and John S. Ogrodniczuk are in the Department o f Psychiatry a t the University o f British Columbia, Vancouver. This article originally ap­ peared in The Journal o f Family Practice (2014;63[12]:697-703).

40 Clinician Reviews • FEBRUARY 2015 c lin ic ia n re v ie w s .c o m

T A B L E 1

DSM-5 Personality Disorders

Personality disorder Key features

Paranoid Distrust and suspiciousness; others are regarded as having malevolent intentions

Schizoid Persistent detachment from social relationships; restricted emotional expression

Schizotypal Reduced capacity fo r interpersonal relationships; cognitive or perceptual distortions; eccentric behavior

Antisocial Violation o f the rights o f others; impulsive and irresponsible behavior; lack o f remorse

Borderline Unstable interpersonal relationships; unstable identity and emotions; impulsivity

Histrionic Excessive yet superficial emotionality; attention-seeking behavior

Narcissistic Grandiose fantasies; need fo r adm iration; lack o f empathy

Avoidant Social inh ibition; feelings o f inadequacy; fear o f criticism or rejection

Dependent Submissive and clinging behavior; excessive need fo r advice and reassurance

Obsessive-compulsive Preoccupation w ith orderliness, perfectionism, and control

Personality change due to another medical condition

Persistent personality disturbance directly related to a physiological condition (eg, temporal lobe lesion)

Other specified personality disorder and Unspecified personality disorder

Meets general criteria fo r a personality disorder, but (1) has a PD th a t is not included in the DSM-5 classification or (2) has traits o f several PDs, but not meeting criteria fo r any single PD

A b b re v ia tion s : DSM-5, Diagnostic and Statistical Manual o f Mental Disorders, 5 th ed; PD, p e rsona lity d iso rde r Source: A m e rican Psychiatric A ssoc ia tion . 2 0 1 3 .1

ery from other mental disorders,8 increase the risk for suicide,9 and are associated with substance abuse, impulsivity, and violence.1011 Personality pathology also is associated with greater incidence of serious medical illness12,13 and reduced social functioning.14 Not surprisingly, patients with PDs frequently use medical and social services.15

PDs tend to be underdiagnosed, perhaps partly because of concern about stigmatization, but also due to difficulties in identifying and classifying these disorders. Published in 2013, the American Psychi­ atric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) originally was to include a major revision of PDs—reflecting concern about the limitations of PD categories—but ultimately the existing categories were retained (see Table l).1 There is considerable overlap among PD

categories; many patients meet the criteria for more than one PD, but it is unlikely that they actually have several distinct PDs. Other patients—perhaps even the majority—are best diagnosed with “unspecified personality disorder” because they do not neatly fit into one of these categories.

SUSPECT YOUR PATIENT HAS A PD? Evaluate these two areas Identifying patients who have PDs in primary care is useful for two reasons: to explore the option of spe­ cialty treatment for patients who may be amenable to it, and to improve management of the patient’s complaints in the primary care setting, including a smoother clinician-patient interaction. In either case, determining the specific DSM-5 diagnosis is less important than recognizing core personality

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impairment: an ingrained disturbance in one’s per­ ceptions of self and others. This can be done by pay­ ing attention to how the patient adapts to life’s chal­ lenges and if he or she has problematic interpersonal tendencies, including difficulties in the clinician- patient relationship.

Unfortunately, assessing and diagnosing PDs in the primary care setting can be challenging. Limited time doesn’t allow for extensive, personality-focused interviews. Self-report screening tools are limited, because patients may underreport key interpersonal problems such as lack of empathy. Furthermore, very few patients seek help from their FPP in addressing personality dysfunction; PDs typically are identified while investigating other complaints.

The most reliable and useful areas to evaluate in a patient you suspect may have a PD are identity (one’s sense of who one is and can be) and interpersonal re­ lationships, including the capacity for empathy and intimacy. 1617 These should be considered longitudi­ nally and in the context of the individual’s stage of development. For example, identity is generally less stable among adolescents compared to middle-aged adults.

A cohesive sense of identity allows one to em­ brace life’s tasks and challenges, to develop and strive toward personal goals, and to handle setbacks and disappointments. A person with a stable identity may develop a depressive reaction to difficult life cir­ cumstances, but with some assistance can generally bounce back and re-engage in his or her personal goals. By contrast, an individual with an unstable sense of self may feel chronically insecure and emp­ ty, with limited capacity to constructively deal with life’s ups and downs. Patients with borderline PD, for example, try to manage a fragmented identity by frantically clinging to others, while narcissistic pa­ tients tend to suppress a fragile sense of self by put­ ting forth an arrogant and entitled attitude.

How does the patient interact with others? As is the case with identity, an individual’s capacity for interpersonal functioning is developed early in life, through interactions with primary caregivers. Men­ tal maps of who we are and what we can expect from others are formed and reinforced in attachment relationships, such as those with our parents; trau­ matic attachments, including abuse or neglect by a caregiver or loved one, are strongly associated with PD. 18,19 The resulting belief structures guide subse­ quent interpersonal functioning, and become in­ teractively reinforced. For example, a person whose

internal map of relationships includes others aban­ doning him might behave in a clingy manner, which may ultimately induce others to reject him, thus cre­ ating a self-fulfilling prophecy.

Distorted interpersonal expectations can impair a person’s capacity for sustained intimate connec­ tions (a troubled relationship history is characteris­ tic of PDs) and limit empathic functioning.20 Other people’s actions may be interpreted according to the patient’s belief structures rather than with an open mind about the other person’s experience.

Focus on the c lin ic ian -p a tie n t re la tionsh ip The interpersonal dysfunction of patients with PDs will often surface in the clinician-patient relation­ ship, serving as a clue to broader interpersonal dys­ function. An FPP’s relatively innocuous oversight, for example, might be taken as proof of suspected incompetence in the eyes of a patient with paranoid or narcissistic tendencies. Or a patient with a recur­ rent complaint who repeatedly rejects the clinician’s interventions probably oscillates between seeking and rejecting nurturance in other relationships, as well. A patient who tends to make sarcastic remarks regarding the clinician’s earnest efforts likely holds negative views of others and sabotages potentially positive interactions.

So what strategies are best for managing these types of scenarios? Bringing up a potential diagnosis of PD may be a delicate matter for the FPP; patients might experience this as a jarring diagnosis in the absence of a thorough psychiatric evaluation. If the FPP decides to explore whether the patient is open to discussing the relationship between moods, be­ haviors, and personality features, he or she can be­ gin this conversation by noting that, as with physical health, we all have our vulnerabilities and that these vulnerabilities may be strengthened through spe­ cialist consultation and support. In this way, the pa­ tient can view a referral as an opportunity to explore herself with professional support. If a psychiatrist or psychotherapist colleague does become involved, it is important to clarify the roles of treatment provid­ ers and to communicate with one another, should difficulties arise.

EVIDENCE SUPPORTS TWO FORMS OF PSYCHOTHERAPY Treatment for PDs has seen considerable growth over the past decade, largely due to research on therapies that target the troubling self-injurious and

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suicidal features of borderline PD. Considerable evidence shows that specialized psychotherapy can significantly reduce suffering and improve function­ ing among these patients. The two major evidence- based treatments for patients with borderline PD are dialectical behavior therapy (DBT) and psychody­ namic therapy.

DBT is an intensive cognitive-behavioral ap­ proach that teaches patients how to regulate their emotions and develop an accepting, mindful atti­ tude toward their mental experience.21 Several ran­ domized controlled trials (RCTs) have demonstrated the effectiveness of DBT in reducing hospitalizations and self-injurious and suicidal behavior in patients with borderline PD.22

Psychodynamic therapy, which focuses on help­ ing patients discover how unconscious conflicts in­ fluence their present moods and behaviors, has also been validated by multiple RCTs for patients with borderline PD.23’25 Like DBT, empirically supported psychodynamic therapy tends to be structured, long­ term (> 12 months), and often intensively delivered in multiple sessions per week. However, a recent study found that a less-intensive, general psycho­ dynamic therapy, along with occasional medication management, was equivalent to intensive DBT.26

Although the research has focused primarily on borderline PD, these approaches can be applied to other PDs. These therapies focus on understanding one’s emotional and behavioral patterns, developing a healthy self-concept, and improving interpersonal relationships—areas that are relevant treatment tar­ gets across all PD types.

Indeed, studies of day treatment programs that explicitly welcome patients with a range of PD types have had promising findings.27 Day treatment in­ volves an intensive array of therapies, mostly in a group format; patients work together to support and embolden one another to make positive changes. Unfortunately, FPPs may be challenged to find ap­ propriate services for patients who are amenable to psychotherapy; public mental health resources tend to lag far behind best practices in the case of PD.

MEDICATION MIGHT IMPROVE SYMPTOMS, NOT PERSONALITY DEFICITS Most research on pharmacotherapy for PDs has fo­ cused on borderline PD; findings have been mixed and fairly limited.28 Medication cannot address underlying identity and relational deficits and will not result in re­ mission of PD. Nonetheless, judicious, circumscribed

use of medications to target specific symptoms may be helpful for some patients. Selective serotonin reuptake inhibitors can reduce anger and impulsive aggression in patients with borderline PD.28’29

Atypical antipsychotics may help reduce impul­ sive aggression or transient psychotic symptoms.28’30 For example, olanzapine and aripiprazole can re­ duce anxiety, anger/aggression, paranoia, and inter­ personal sensitivity in borderline PD.3132 Mood stabi­ lizers such as valproate, lamotrigine, and topiramate may also help some borderline patients, although they do so by reducing impulsivity and aggression rather than improving core unstable identity and affect.28,29

Carefully obtained informed consent is necessary because of the danger of adverse effects with many of these medications; for example, antipsychot­ ics have been associated with metabolic syndrome and weight gain that can threaten a patient’s already fragile self-image.33 Polypharmacy is also a poten­ tial problem: Well-intentioned clinicians may be prompted to offer multiple medications in response to patients’ unremitting complaints of distress, when a psychotherapeutic approach may need to be the primary treatment. The bottom line is that medica­ tions do not resolve personality dysfunction and are best used symptomatically as adjuncts to psycho­ therapy.28,30

STEPS YOU CAN TAKE DURING THE OFFICE VISIT Although it is not feasible for most FPPs to provide comprehensive treatment for PD, key elements from specialized therapies can be integrated into your management of these patients. Steps you can take include using validation, promoting mentalization, and managing countertransference.

Validation, which is a component of DBT, is pro­ viding the expressed acknowledgement that the pa­ tient is entitled to her feelings. This is not the same as agreeing with a position the patient has taken on an issue, but rather conveying the sense that one sees how the patient might feel the way she does. A study of women with borderline PD and substance abuse found a validation intervention by itself was signifi­ cantly helpful.34 Validation can contribute to a “cor­ rective emotional experience.” For instance, your supportive acknowledgement of a patient with a his­ tory of abuse or neglect may counter the patient’s ex­ pectation of being invalidated, and over time this can reduce the patient’s defensive rigidity.

Mentalization. Psychodynamic treatment in-

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table 2 Case Vignettes: Practical Tips for Managing Patients With Personality Disorders

CASE 1. Amy B, age 26, is a graduate student who lives with her boyfriend. She complains to her family practice provider (FPP) of lifelong depression, emptiness, and frequent “meltdowns.” Although never suicidal, she secretly cuts her arms after arguments with her boyfriend. She demands to be seen urgently when in crisis, but when she comes in, she indignantly discards her FPP’s advice. Diagnosis: Borderline personality disorder (PD) with narcissistic features Treatment plan: Medication could be considered to target impulsive aggression, but would best serve as an adjunct to specialized psychotherapy. Supportive management can preserve a collaborative relationship and promote referral to dialectical behavior therapy or psychodynamic therapy. Validation: “You’ve really been in a lot of emotional pain lately.” Mentalizing: “I think sometimes you feel so awful you can barely stand it, and perhaps you feel that help isn’t there right when you need it. But we can think about these issues now—try to put your feelings into words.” Managing countertransference: The FPP feels perplexed and rejected—feelings that Ms. B probably struggles with herself. The clinician regards these feelings as a reflection of Ms. B’s unstable self-image. He calmly sets limits regarding her use of urgent appointments.

CASE 2. Bill C, age 35, is unemployed and lives with his parents. Recently he went to the emergency department for suicidal ideation. He feels resentful that others seem to “have it all.” Mr. C has been fired from several jobs due to outbursts; he feels his supervisors were all inept. He fantasizes about becoming a famous musician- then he will be appreciated and admired. Several antidepressants have had little effect. Diagnosis: Narcissistic PD Treatment plan: Mr. C’s “depression” is likely related to feelings of emptiness, resentment, and an underdeveloped identity. Additional antidepressants are unlikely to be helpful, and he should be encouraged to consider psychotherapy. His FPP should limit giving advice, as Mr. C may resent and devalue his clinician, and sabotage the treatment relationship. Validation: “It’s hard for you when you see others moving forward while you feel so stuck.” Mentalizing: “Let’s try to think about your thoughts and feelings a bit more—maybe we can identify some of what’s going on under the surface.” Managing countertransference: The FPP feels frustrated by Mr. C’s immaturity and sense of entitlement. He refrains from lecturing Mr. C about developing a work ethic, realizing Mr. C would only feel more embittered.

volves a similar tack; clinicians empathize with the patient’s emotional state while also demonstrating a degree of separateness from the emotion.23-25 This promotes mentalization in the patient—the abil­ ity to contemplate one’s own and others’ subjective mental states. 18 Mentalization is often impaired in PD patients, who presume to “know” what others are thinking. A patient, for instance, “just knows” that her friend secretly hates her, based on a vaguely worded text message.

You can help patients with mentalization by tak­ ing an inquisitive “not knowing” stance and by em­ phasizing a collaborative and reflective approach toward a given problem—to examine the issue to­

gether, from all sides. You can point out that while a patient is entitled to feel whatever he is feeling, it may not be in his best interest to act on the feel­ ings without adequately considering the potential consequences of the action. This helps the patient to distinguish thoughts, feelings, and impulses from behavior. It also teaches the value of anticipatory thinking, impulse control, and affect regulation.

Countertransference. Managing your emotional reactions to a patient with PD is a well-documented challenge.35 Your feelings about the patient, known as countertransference, can range from considerable concern and sympathy to severe frustration, bewil­ derment, and frank hostility. A common reaction is

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the sense that one must “do something” to respond to the patient’s emotional distress or interpersonal pressure. This may trigger an impulse to give advice or offer tests or medications despite knowing that these are unlikely to be helpful. A more useful response may be to tolerate such feelings and listen empathically to the patient’s frustration. Recognizing subtle counter­ transference can guard against extreme reactions and maintain an appropriate clinical focus. Discussion with a trusted colleague can be helpful.

Psychodynamic approaches consider managing countertransference to be a therapeutic interven­ tion, even when psychotherapy is not explicitly be­ ing carried out. Strong emotional responses may re­ flect something that the patient needs the clinician to experience, as the patient cannot bear to experi­ ence it himself. The patient needs to see—and learn from—the clinician’s handling of unbearable (for the patient) feelings. This occurs at a level of uncon­ scious communication and may be repeated over time. Although not discussed with the patient, a cli­ nician’s capacity for self-containment and provision of undisrupted, good medical care is in itself a psy­ chotherapeutic accomplishment.

Based on Bob’s history of interpersonal conflicts and perceived persecution by coworkers, the FPP consults with a psychotherapist colleague, who says Bob’s chronic mis­ trust and social isolation suggest he may have a severe identity disturbance and unspecified PD with paranoid and schizoid features. Because Bob refuses to see a therapist, his FPP decides to focus on promoting small improvements in Bob’s interpersonal interactions and reducing absentee­ ism at work.

The FPP validates Bob’s feelings (” it can be very stress­ ful to constantly feel like others are at odds with you”) and tries to promote mentalizing (“I want to understand more about what you think regarding your work situation and your coworkers. Let’s try to look at this from all perspec­ tives— maybe we can come up with some new ideas.”)

Despite wanting to help his patient, the FPP feels un­ easy and reluctant to engage with Bob, who likely evokes such feelings to keep others at a distance. The FPP tactfully seeks to remain Bob’s ally without endorsing his distorted interpretation of events. Given Bob’s paranoid rejection of therapy, the FPP refrains from making further such recom­ mendations. The FPP’s interventions, however, may help Bob warm to the idea of further help over time, and the FPP’s supportive stance will help to ameliorate the patient’s distress. (Additional examples of how to use the strategies described in this article can be found in Table 2.) CR

REFERENCES 1. American Psychiatric Association. Diagnostic and Statistical Manual of

Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Associa­ tion; 2013.

2. Hahn SR, Thompson KS, Wills TA, et al. The difficult clinician-patient relationship: somatization, personality and psychopathology. J Clin Epi­ demiol. 1994:47:647-657.

3. Schafer S, Nowlis DP. Personality disorders among difficult patients. Arch FamMed. 1998;7:126-129.

4. Paris J. Estimating the prevalence of personality disorders in the com­ munity. J Pers Disord. 2010;24:405-411.

5. Newton-Howes G, Tyrer P, Anagnostakis K, et al. The prevalence of personality disorder, its comorbidity with mental state disorders, and its clinical significance in community mental health teams. Soc Psychiatry Psychiatr Epidemiol. 2010;45:453-460.

6. Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 2005;162:1911-1918.

7. Moran P, Jenkins R, Tylee A, et al. The prevalence of personality dis­ order among UK primary care attenders. Acta Psychiatr Scand 2000;102:52-57.

8. Newton-Howes G, Tyrer P, Johnson T. Personality disorder and the out­ come of depression: Meta-analysis of published studies. Br J Psychiatry. 2006;188:13-20.

9. Blasco-Fontecilla H, Baca-Garcia E, Dervic K, et al. Severity of personal­ ity disorders and suicide attempt. Acta Psychiatr Scand. 2009119149- 155.

10. Colpaert K, Vanderplasschen W, De Maeyer J, et al. Prevalence and determinants of personality disorders in a clinical sample of alcohol-, drug-, and dual-dependent patients. Subst Use Misuse. 2012;47:649- 661.

11. Yu R, Geddes JR, Fazel S. Personality disorders, violence, and antisocial behavior: A systematic review and meta-regression analysis. J Pers Dis­ ord. 2012;26:775-792.

12. Frankenburg FR, Zanarini MC. The association between borderline per­ sonality disorder and chronic medical illnesses, poor health-related life­ style choices, and costly forms of health care utilization. J Clin Psychiatry. 2004;65:1660-1665.

13. Lee HB, Bienvenu OJ, Cho SJ, et al. Personality disorders and traits as pre­ dictors of incident cardiovascular disease: Findings from the 23-year fol­ low-up of the Baltimore ECA Study. Psychosomatics. 2010;51:289-296.

14. Skodol AE, Gunderson JG, McGlashan TH, et al. Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compul­ sive personality disorder. Am J Psychiatry. 2002;159:276-283.

15. Bender DS, Dolan RT, Skodol AE, et al. Treatment utilization by patients with personality disorders. Am J Psychiatry. 2001;158:295-302.

16. Livesley WJ. An empirically-based classification of personality disorder. J Pers Disord. 2011;25:397-420.

17. Bender DS, Morey LC, Skodol AE. Toward a model for assessing person­ ality functioning in DSM-5, part I: a review of theory and methods. J Pers Assess. 2011;93:332-346.

18. Fonagy P, Gergely G, Jurist EL, et al. Affect Regulation, Mentalization, and the Development of the Self. New York, NY: Other Press; 2002.

19. Yen S, Shea MT, Battle CL, et al. Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-com­ pulsive personality disorders: findings from the collaborative longitudinal personality disorders study. J Nerv Ment Dis. 2002;190:510-518.

20. Morey LC, Stagner BH. Narcissistic pathology as core personality dysfunc­ tion: comparing DSM-IV and the DSM-5 proposal for narcissistic person­ ality disorder. J Clin Psychol. 2012;68:908-921.

21. Lynch TR, Chapman AL, Rosenthal MZ, et al. Mechanisms of change in dialectical behaviour therapy: theoretical and empirical observations. JClin Psychol. 2006;62:459-480.

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23. Clarkin JF, Levy KN, Lenzenweger MF, et al. Evaluating three treatments

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for borderline personality disorder: a multiwave study. Am 1 Psychiatry. 2007:164:922-928.

24. Gregory RJ, DeLucia-Deranja E, Mogle JA. Dynamic deconstructive psy­ chotherapy versus optimized community care for borderline personality disorder co-occurring with alcohol use disorders: a 30-month follow-up. J Nerv Ment Dis. 2010;198:292-298.

25. Bateman A, Fonagy P. Randomized controlled trial of outpatient mental- ization-based treatment versus structured clinical management for bor­ derline personality disorder. Am J Psychiatry. 2009;166:1355-1364.

26. McMain SF, Links PS, Gnam WH, et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166:1365-1374.

27. Ogrodniczuk JS, Piper WE. Day treatment for personality disorders: a review of research findings. Harv Rev Psychiatry. 2001;9:105-117.

28. Paris J. Pharmacological treatments for personality disorders. Int Rev Psychiatry. 2011;23:303-309.

29. Ripoll LH, Triebwasser J, Siever LJ. Evidence-based pharmacotherapy for personality disorders. in tJ Neuropsychopharmacol. 2011;14:1257-1288.

30. Steinberg PI. The use of low-dose neuroleptics in the treatment of patients with severe personality disorder: An adjunct to psychotherapy. BCMJ. 2007;49:306-310.

31. Zanarini MC, Frankenburg FR. Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebo controlled pilot study. J d in Psychiatry. 2001;62:849-854.

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33. Silk KR. The process of managing medications in patients with borderline personality disorder. J Psychiatr Pract. 2011;17:311-319.

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35. Rossberg Jl, Karterud S, Pedersen G, et al. An empirical study of coun­ tertransference reactions toward patients with personality disorders. Compr Psychiatry 2007;48:225-230.

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