Psychiatric Annals

IMPROVING THE PRACTICE OF SPLIT TREATMENT 

Split (Collaborative) Treatment for Patients With Personality Disorders

Kenneth R Silk, MD

Abstract

Split treatment is a particularly apt term for patients with personality disorders. When one individual is providing psychological or other "psychotherapeutic" treatment and another individual is managing the medications, this is often referred to as collaborative treatment. However, in this instance the term split treatment is appropriate because in the thinking of both the treating parties and the patient, things may frequently seem more split than collaborative.

The key to the successful treatment of patients with personality disorders is to avoid the split and replace it with integration and coordination not only for various aspects of the treatment and the treating parties, but also for the patients. One can appreciate how, when one individual is providing medication management and another is providing psychotherapy, the situation is ripe for contradictions, discontinuities, and disagreements among all involved. These patients dichotomize and view situations, people, and feelings in the extreme.12 "In contemporary treatment situations that include a patient, a therapist, a pharmacotherapist, and a pill, the transference issues can become more complex than the landing patterns of airplanes at an overcrowded airport."3

This article presents several factors that should be taken into consideration when the psychological treatment of a patient with a personality disorder is conducted by someone other than the individual who is providing psychopharmacologic treatment. Although these factors and issues can apply to all situations of collaborative or split treatment, they are particularly relevant when the treatment involves a patient with a personality disorder.

BACKGROUND CONSIDERATIONS IN THE PHARMACOLOGIC TREATMENT OF PATIENTS WITH PERSONALITY DISORDERS

Although the number of studies reporting on the use of psychopharmacologic agents for patients with personality disorders is growing, there is little research evidence for the use of any single particular pharmacologic agent for any specific personality disorder.4-5 However, currently there is a set of algorithms on the pharmacologic treatment of borderline personality disorder.6 Additional approaches to the pharmacologic treatment of patients with personality disorders have been proposed.7-8 A recent, up-to-date review of the pharmacologic treatment of borderline personality disorder is available elsewhere,9 and the specifics of such pharmacologic treatment are not discussed here.

Biologic studies of the dimensions of psychopathology that appear to be involved in many cases of personality disorders,10 as well as studies of elements of temperament and character that lead to the development of personality disorders,11 may hold great promise by causing us to create more efficacious and specific pharmacologic agents for these problems. Currently, the irregularity and inconsistency with which patients with personality disorders respond to medications and the uncertainty of the response to placebo among them create problems. Also, these patients tend to be sensitive to side effects. Thus, it is clear that prescribing medications for these patients can frequently become a quagmire of confusing physiological, interpersonal, and other psychological reactions not only for them, but also for their psychiatrists.12

This article provides several concrete suggestions or procedures that can help us approach the process of collaborative pharmacologic-psyehological treatment of patients with personality disorders. Although much of the information would appear most applicable to the pharmacologic treatment of patients with borderline personality disorder or others belonging to the dramatic cluster, the group most studied among the Axis II disorders, the principles outlined here can easily be applied across the entire spectrum of diagnoses that comprise Axis ? disorders.

CONSIDERATIONS IN SPLIT TREATMENT

This article covers the following issues regarding prescribing medication for patients with personality disorders when the treatment is split between a psychotherapist and a psychopharmacologist: (1) understanding the relationship between the therapist and the prescriber; (2) understanding the meaning of the medication to the therapist and the prescriber;…

Split treatment is a particularly apt term for patients with personality disorders. When one individual is providing psychological or other "psychotherapeutic" treatment and another individual is managing the medications, this is often referred to as collaborative treatment. However, in this instance the term split treatment is appropriate because in the thinking of both the treating parties and the patient, things may frequently seem more split than collaborative.

The key to the successful treatment of patients with personality disorders is to avoid the split and replace it with integration and coordination not only for various aspects of the treatment and the treating parties, but also for the patients. One can appreciate how, when one individual is providing medication management and another is providing psychotherapy, the situation is ripe for contradictions, discontinuities, and disagreements among all involved. These patients dichotomize and view situations, people, and feelings in the extreme.12 "In contemporary treatment situations that include a patient, a therapist, a pharmacotherapist, and a pill, the transference issues can become more complex than the landing patterns of airplanes at an overcrowded airport."3

This article presents several factors that should be taken into consideration when the psychological treatment of a patient with a personality disorder is conducted by someone other than the individual who is providing psychopharmacologic treatment. Although these factors and issues can apply to all situations of collaborative or split treatment, they are particularly relevant when the treatment involves a patient with a personality disorder.

BACKGROUND CONSIDERATIONS IN THE PHARMACOLOGIC TREATMENT OF PATIENTS WITH PERSONALITY DISORDERS

Although the number of studies reporting on the use of psychopharmacologic agents for patients with personality disorders is growing, there is little research evidence for the use of any single particular pharmacologic agent for any specific personality disorder.4-5 However, currently there is a set of algorithms on the pharmacologic treatment of borderline personality disorder.6 Additional approaches to the pharmacologic treatment of patients with personality disorders have been proposed.7-8 A recent, up-to-date review of the pharmacologic treatment of borderline personality disorder is available elsewhere,9 and the specifics of such pharmacologic treatment are not discussed here.

Biologic studies of the dimensions of psychopathology that appear to be involved in many cases of personality disorders,10 as well as studies of elements of temperament and character that lead to the development of personality disorders,11 may hold great promise by causing us to create more efficacious and specific pharmacologic agents for these problems. Currently, the irregularity and inconsistency with which patients with personality disorders respond to medications and the uncertainty of the response to placebo among them create problems. Also, these patients tend to be sensitive to side effects. Thus, it is clear that prescribing medications for these patients can frequently become a quagmire of confusing physiological, interpersonal, and other psychological reactions not only for them, but also for their psychiatrists.12

This article provides several concrete suggestions or procedures that can help us approach the process of collaborative pharmacologic-psyehological treatment of patients with personality disorders. Although much of the information would appear most applicable to the pharmacologic treatment of patients with borderline personality disorder or others belonging to the dramatic cluster, the group most studied among the Axis II disorders, the principles outlined here can easily be applied across the entire spectrum of diagnoses that comprise Axis ? disorders.

CONSIDERATIONS IN SPLIT TREATMENT

This article covers the following issues regarding prescribing medication for patients with personality disorders when the treatment is split between a psychotherapist and a psychopharmacologist: (1) understanding the relationship between the therapist and the prescriber; (2) understanding the meaning of the medication to the therapist and the prescriber; (3) understanding the meaning of the medication to the patient; (4) understanding and conveying to both the therapist and the patient the limitation of the effectiveness of the medication; (5) understanding at the outset of the prescribing process the role of the medication in the overall treatment and the treatment plan for the patient; (6) understanding and conveying to the therapist and the patient the potential lethality of the medication; and (7) understanding the relationship of interpersonal crises and affective storms to the timing of medication initiation or dosage change.

Understanding the Relationship Between the Therapist and the Prescriber

As changes in the delivery of health care in the United States move forward, it appears that psychological treatment is more frequently being delivered by a nonphysician clinician, whereas pharmacotherapy is being delegated to a physician or a psychiatrist.13 This arrangement has been called the "pharmacotherapy-psychotherapy triangle,"14 and it demands respect from each treater for what the other treater is doing.13,15 This respect does not imply that each member of the team be well skilled in what the other individual is doing, but each must certainly respect what the other is doing.

Although it would be useful for each to respect the other as a colleague or even as a person, this level of familiarity, respect, or both may not be necessary. What is necessary is that the psychotherapist believes that pharmacologic intervention is a useful and at times necessary modality, and that the psychopharmacologist believes that psychotherapy in some of its forms is a valuable intervention in its own right.

If this mutual respect does not exist, then the patient, especially if he or she has a personality disorder, will sense this attitude and will join with one of the treaters in devaluing (and perhaps eventually not participating in or acting out in or around) the other treatment modality. Further, the patient will begin to wonder why one treater would send him or her for a treatment intervention that the treater himself or herself does not believe in.

As more specifics of the delivery of mental health care become dictated by "third-party providers," psychiatrists may feel that they are being forced into an uneasy alliance in providing "medical backup" for therapists whose work they do not respect or about which they do not know much.16 Psychotherapists experience a similar situation when limited because of payer rules or clinic policy to referring patients to a psychopharmacologist whom they feel has little respect for or tolerance of psychological issues of patients.

A successful combined psychotherapeuticpsychopharmacologic effort requires not only that the psychopharmacologist and the psychotherapist have respect for and some basic understanding of what each is trying to accomplish, but also that the two approaches be coordinated.17 Psychological issues may modify or determine how contacts around medication issues take place. For example, a histrionic dependent young woman became infatuated with the prescribing psychiatrist. She would become stimulated, almost to erotomania, when the psychiatrist would call her at home in the evening. She felt that the phone contacts were preliminary to dates. It was agreed that the phone contacts should take place only during daytime office hours.

The prescribing psychiatrist should clarify and discuss with the psychotherapist his or her beliefs in the efficacy or the lack of usefulness of psychotherapy for the particular personality disorder of the particular patient being considered. Psychotherapy for a patient in any diagnostic category cannot proceed constructively if the individual concurrently prescribing psychotropic medications for the patient does not believe that psychotherapy is useful. Several questions need to be answered. Will phone calls be permitted between sessions in the one treatment if they are not "permitted" as part of the other treatment? How will pills be prescribed and in what quantities? Will there be contact between the treaters with each change in dosage or type of medication, and should discussions between the treaters take place before the change? How frequently will discussions between the two treaters take place? What issues brought up to the psychopharmacologist should be directed back to the psychotherapist, and will the psychotherapist be notified that issues have been directed back to the psychotherapy?15

The psychotherapist needs to have respect for the psychopharmacologist and the intervention of psychopharmacology.17 The psychotherapist need not be an expert in psychotropic drugs, but he or she should be aware of the specificity and the limitations of psychopharmacologic treatment. Psychotherapists should have rudimentary knowledge of both the therapeutic effects and the side effects of frequently used medications. Both the psychotherapist and the pharmacotherapist need to be aware that patients may use the medications as transitional objects (ie, as a way to feel "connected with" the treaters).18 Patients with personality disorders often appear fixed at a transitional object level of functioning,1 and they may employ medications as transitional objects. Psychological meaning that becomes connected to medications may increase or decrease their effectiveness.19 In this context, one can appreciate the complexity of the patient's reaction and resistance to changing or altering medications, especially when the reaction appears out of proportion to the actual therapeutic benefit the patient is deriving from the medications.20

Unless many issues are clarified beforehand between the therapist and the prescriber, expectations may run counter to reality and the combined treatment, particularly in this patient group, will probably fail. It should be made clear to the patient that information will flow freely between the psychopharmacologist and the psychotherapist, and the patient should sign a release of information that will permit this exchange of information.

The psychopharmacologist and the psychotherapist need to agree on the perceived efficacy and limitations of each of the interventions. They should be able to appreciate that progress among patients with personality disorders is often slow, punctuated by periods of improvement and regression. They should acknowledge between themselves that the long-range prognosis is often guarded. Such acknowledgment may prevent one from blaming the other when a prolonged lack of progress or regression in the treatment makes the entire effort frustrating. A formal contract between the treaters may provide guidance and clarity to each treater (especially given the chaos, confusion, and differing perspectives that arise in treatment) and may also formalize the arrangement should medicolegal issues arise. The contract should delineate the role of each treater and the expected frequency and range of or limitations on each treater 's communication.21,22 The patient should be informed that such an agreement exists.

Much of what is diagnosed as symptoms as displayed by patients with personality disorders reflects chronic maladaptive interpersonal functioning across a wide range of settings. Thus, interpersonal dysfunction cannot and should not be ignored, dismissed, or denied. Wherever interpersonal dysfunction occurs in the therapeutic process, it needs to be discussed not only between the two treaters, but also among the treaters and the patient. Transference is not solely reserved for transference-oriented psychotherapy19-23 and "pharmacotherapy is [also] an interpersonal transaction."24

Mutual cooperation between the psychotherapist and the psychopharmacologist can be undercut if the patient is convinced that he or she has a "chemical imbalance." Patients often state that they have been told that they are suffering from a chemical imbalance. Certainly, all feelings, cognitions, and behaviors are biochemically mediated. However, an equally important issue may be how feelings and cognitions are motivated psychologically rather than how they are mediated biologically. People are complex and psychology and physiology play on each other. Both of these points need consideration rather than deciding which is paramount.22 If both the psychopharmacologist and the psychotherapist believe in this interplay, then it will be easier for the patient to accept that uncertainty, ambivalence, limitation, and cooperation are part of everyday existence.

Understanding the Meaning of the Medication to the Therapist and the Prescribe!

In a study of patients with borderline personality disorder for whom the decision to prescribe medications was made, 65% of the respondent psychotherapists felt that pessimism about patients' progress in the therapy was the reason for their decision to consider medications.25 The patients, on some level, must have sensed this pessimism.

However, the decision to refer a patient for psychopharmacologic treatment need not come out of a pessimistic framework. First, the referral for psychopharmacologic treatment can be viewed as an opportunity for consultation.22 A well-trained psychopharmacologist can evaluate both Axis I and Axis ? diagnostic possibilities in a patient. The psychopharmacologist, in seeing the patient initially, has a view that is probably less contaminated by transference or countertransference issues that can confound any treatment, particularly that of a patient with a personality disorder. Second, the referral may result in a better understanding of the patient, his or her symptoms, and how and when the symptoms and symptom complexes arise.

The aura around the referral will be different if the referral comes out of pessimism rather than a curiosity for a second opinion or a growing appreciation of the patient and his or her symptoms. Thus, understanding the meaning of the medication to both the therapist and the prescriber becomes an important consideration.

However, if the psychopharmacologist thinks that it is about time that the therapist finally decided that the only thing that can help this patient is medication, then the psychotherapist will not really have available a true "second" opinion from an open-minded, balanced second party. Again, understanding the meaning of the medication to both the therapist and the prescriber becomes an important consideration.

Unfortunately, referral for medication often comes not as part of an overall treatment plan, but rather because the therapist, the patient, or the patient's family feels that the psychotherapy has not progressed in the maimer hoped or because the patient continues to experience crises.25 In these circumstances, one can appreciate how the referring psychotherapist could develop a feeling of failure. This sense of failure may be unconsciously conveyed to the patient. Yet, if the referring psychotherapist has little genuine belief in the efficacy of medications and is simply making the referral to appease someone, then the pharmacotherapist may feel that the psychotherapist is somehow saying, "Okay. Now you give it a try. I challenge you to see if your stuff works."

The use of medications for a patient with a personality disorder should not be an afterthought, something that arises in the course of a treatment that is not going well or that has become bogged down. It makes good therapeutic sense to introduce early in the treatment, perhaps as early as when the initial treatment plan is discussed with the patient, the idea that medications may be something that could be useful sometime during the course of the treatment. It is important to present the idea that the introduction of medications may be useful not because the therapy is failing, but precisely because the therapy is working. The patient will probably be more receptive, collaborative, and cooperative if the possibility of a referral for medication is stated by the therapist at the outset of treatment.

It is helpful when there is an ongoing professional understanding between the psychotherapist and the psychopharmacologist and when they share responsibility for several patients.3 Communication can become freer between them. The prescriber should ask the therapist why he or she wants the medication at this time. Where is the pressure for medications coming from? How does the therapist think the medication will change the therapeutic relationship? The psychopharmacologist should be able to tell the psychotherapist if he or she feels that the psychotherapist's wishes for the desired effect from the medication are unrealistic, and what might under the best of circumstances be considered a reasonable response to the medication.

Understanding the Meaning of the Medication to the Patient

Patients with personality disorders (and probably all patients in general) may feel that the decision to introduce medications represents either a failure on the part of the psychotherapy to work or a giving up on them by the psychotherapist. On the other hand, in some instances, patients may experience the introduction of medication as a hopeful sign, as an additional modality that might help speed the progress of treatment.13,25-26

Understanding what the medication means to the patient is crucial because whenever medication is introduced into any therapy, it has repercussions on the transference.12,19 Particularly in patients with personality disorders, transference can take on its own reality and has a great propensity to spill out into other aspects of these patients' lives. Transference feelings and reactions to life outside of the session seem to occur among patients with personality disorders with greater frequency and intensity than they do among patients with neuroses.27 Failure of both (or either) the therapist and the psychopharmacologist to appreciate the strength and ubiquity of the transference (and corresponding countertransference) reactions that the patient may have in response to the possibility of medications may further complicate an already complex treatment.

Transference reactions among these patients are probably impossible to eliminate. However, they may be milder, more understandable, and perhaps interpretable if the idea of possibly using medications is introduced early on in the treatment. Statements that outline how medications might be useful sometime in the course of therapy and how the issue of medications would be approached during the course of therapy should be made at the outset of treatment. The introduction of such information may encourage a dialogue that allows the free exchange of information and provides an opportunity to explore particular meanings that medications may have to a patient. For example, a middle-aged man had a younger sister with severe developmental disabilities and aggressive behavior. She had been taking antipsychotic medications most of her life. When the psychopharmacologist suggested lowdose neuroleptics to try to mollify some of the man's cognitive distortions, paranoid thinking, and dissociations, he balked not at the idea of medication, but at the idea that the psychopharmacologist would suggest medications from the same class that had been given to his sister.

When medications are discussed at the beginning of treatment, several questions should be answered. What might be indications for treatment with medication? Who might prescribe medications? Is there a chance of becoming "addicted" to the medications? What effect on one's life or self-image might occur after starting to take the medications? In a non-crisis situation, the patient may provide clear indications of what transferential issues might occur if and when medications are introduced. It is hoped that such an approach would allow the psychotherapist to express his or her attitudes about medications at a point when there was no crisis, transference reactions had not fully developed, a spirit of cooperation (either active or passive) existed in the therapy, and a clearer dialogue could occur.

Understanding and Conveying to Both the Therapist and the Patient the Limitations of the Effectiveness of the Medication

The therapist, even if a nonphysician clinician, should have a clear understanding of what medications can and cannot accomplish. Further, the therapist should gain knowledge about these issues at moments of calm, for it is challenging to learn in the midst of a crisis. This parallels the issue of introducing the idea of medications to patients at moments of calm rather than crisis. The therapist who tries to learn about medications during a therapeutic impasse or in the midst of an overpowering affective storm during the therapy will not have a clear and reasonable appreciation of medications and may, in many circumstances, develop unrealistic wishes regarding the power of medications.

The closer a patient's symptom complex is to the full symptom complex of an Axis I disorder, the greater the chance that medications may be effective for some or all of those symptoms. There is substantial overlap between Axis I and Axis II disorders.28 However, patients with Axis I disorders who have comorbid Axis ? disorders respond less well and less reliably to pharmacologic and other somatic treatments,29·30 Nonetheless, a serious attempt should be made to identify and treat the comorbid or underlying Axis I disorder. On the other hand, the more the "symptoms" that one wishes to alter relate to interpersonal issues, emotional lability in the face of rejection, impulsive rage in the face of real or perceived narcissistic injury, and passivity and dependency in the face of opportunity, the greater the chance that medications will be ineffective.

Understanding at the Outset of the Prescribing Process the Role of the Medication in the Overall Treatment and the Treatment Plan for the Patient

The discussion of the possibility of using medications sometime during the course of treatment should take place early in treatment. It is probably best that the discussion takes place when the overall goals and limitations of the treatment are being reviewed.

When we think of the treatment of patients with personality disorders, we should not think of the concept of cure. In truth, probably no psychiatric illness is really "curable," but certainly each has the possibility of being modified, put into remission, and made dormant for years if not decades. This does not mean that an illness will always return, but, nonetheless, the idea of "cure" does not seem to fit well with what we understand about the longevity, course, and vulnerability of mental illness.

The preferred treatments for patients with personality disorders appear to be those that teach how to cope better and how to react to stressors less destructively. These goals can be accomplished by helping to develop increased awareness of cognitive rigidities and distortions, to diminish affective lability, passivity, or both, and to increase the time frame between crises while reducing their amplitude.17 A medication may help a patient remain calmer so that he or she might be able to seek out and employ coping skills more constructively. Medications in their own right may reduce impulsivity and emotional lability and then may promote more calm during which constructive rather than impulsive responses can be recruited. Medications may smooth out and improve mood so that hopelessness and emptiness are not felt so globally. Thus, they provide opportunities to experience life in more affectively balanced and cognitively neutral states.

Therapy for patients with character disorders needs to set a series of realistic and limited goals early on. It is in the context of such discussions of overall goals and limitations of therapy that the idea of the possibility of medications, their possible therapeutic effects, and their realistic limitations can be introduced.

Understanding and Conveying to the Therapist and the Patient the Potential Lethality of the Medication

Psychotropic medications can be lethal, particularly the tricyclic antidepressants. Carbamazepin, monoamine oxidase inhibitors, lithium, valproate, and benzodiazepines also have significant morbidity and mortality associated with overdose.

Patients with borderline personality disorder are known to have a reasonably high (approximately 10%) rate of successful suicide.31'32 The patients at highest risk appear to be males younger than 30 years who abuse substances.31,32 However, when treating patients with personality disorders, a therapist can never be sure that they will not overdose with medications.

The prescription of medication demands a relationship between the prescriber and the patient.19 The risks of any medication and the specific risks involved with a particular medication need to be clearly stated, and the patient needs to know that the process of pharmacologic treatment, similar to the process of psychotherapeutic treatment, can be successful only if there is a spirit of cooperation. Feelings can be expressed verbally, but when they are acted on, serious physical and emotional sequelae can result. The psychotherapist also needs to be aware of the risks of medication in general, as well as the particular risks associated with a given medication. The therapist needs to appreciate the interaction of medication with alcohol and substances. The use and abuse of these agents must be monitored closely, especially when there is a history of substantial use of illicit drugs or alcohol.

The potential for suicide needs to be continually assessed. If the therapist or the psychopharmacologist is fearful that the patient may overdose, this issue should be discussed openly. If the therapist becomes aware of an increasing potential for suicide, he or she should notify the psychopharmacologist immediately.

Understanding the Relationship of Interpersonal Crises and Affective Storms to the Timing of Medication Initiation or Dosage Change

In the best of circumstances, medication should be introduced into treatment in a controlled manner with much forethought. However, it is not always possible to plan. Interpersonal crises and affective storms, combined with the patient's interpersonal demandingness, helplessness, and passivity, put enormous pressure on the therapist and, in turn, on the referred to psychopharmacologist to do something, change something, and diminish the pain. There is no evidence that medications change interpersonal functioning, although crises among patients with personality disorders frequently occur in the context of these interpersonal situations or failures.

Effective pharmacotherapy involves identifying a pattern of reasonably persistent symptoms and choosing the most appropriate medication to attack the specific symptom or symptom complex. It is not possible to treat all of the symptoms without resorting to polypharmacy, which is a dangerous and confusing practice, especially among patients for whom psychological motivation and biologic mediation are inexorably intertwined. Attempts should be made to have the patient weather the crisis without sudden changes in medication. Patients should be informed that after a crisis has passed, the pharmacologic treatment can be reevaluated in a calmer moment.17

Some pharmacologic changes ox additions can be made during a crisis, but such a decision needs careful consideration and needs to not reinforce the concept that the only way to get a medication changed is to have a crisis. Perhaps a few doses of a minor tranquilizer may help quell some of the anxiety that accompanies the crisis, but this pharmacologic intervention should be brief and the total number of pills prescribed restricted. Although there may ultimately be a need to prescribe minor tranquilizers on a regular basis, this decision should not be made at a time of crisis.

CONCLUSION

For patients with personality disorders, treatment - pharmacologic or otherwise - remains empirical. There is scant information on the pharmacologic treatment of personality disorders. Two separate dimensions are involved in the effective pharmacologic treatment of patients with personality disorders.

The first dimension involves the choice of pharmacologic agent. This should be based on the target symptoms selected for change. Currently, interpersonal crises and affective storms cannot be treated successfully with medications. A pharmacologic treatment should be tried long enough to determine whether the targeted symptom or behavioral dimension has actually improved. We need to be modest in our goals and seek responses in clearly defined but limited areas of symptomatology. If one medication does not lead to improvement in the defined area, then it should be stopped, new dimensions or targets should be determined, and a different medication should be tried long enough for response.

The second dimension involves the actual process of prescribing the medication during the course of the treatment, particularly when the psychotherapy and the pharmacotherapy are being managed by different individuals. The idea that medication may be used in the treatment should be introduced at the outset of therapy When there is split or collaborative treatment, the seven issues that have been discussed in this article should be considered.

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10.3928/0048-5713-20011001-10

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