Stone Michael H
Columbia College of Physicians and Surgeons, 225 Central Park West, New York City, NY 10024, USA.
World Psychiatry. 2006 Feb;5(1):15-20.
There are currently three major psychotherapeutic approaches to the management of borderline personality disorder (BPD): the psychodynamic, the cognitive-behavioral, and the supportive. There are special varieties within each: e.g., transference-focused psychotherapy (psychodynamic) or dialectic behavioral therapy (cognitive-behavioral). Though differing in basic conceptions and in methodology, all approaches aim at the amelioration of both the symptom-aspects that dominate the clinical picture at the outset, and the personality difficulties that remain apparent after the symptoms have been alleviated. The term "management" implies a focus on the more serious aspects of the borderline picture. These can be pictured hierarchically as to their level of seriousness, and there is universal agreement about the nature of this hierarchy. Therapists must pay attention first to suicidal and self-mutilative behaviors. Next, one deals with any threats to interrupt therapy prematurely. Third in order of seriousness: non-suicidal symptoms such as (mild to moderate) depression, substance abuse, panic and other anxiety manifestations, or dissociation. Psychopharmacological treatment will often be used adjunctively to help control any target symptoms, which usually fall into such categories as cognitive-perceptual, affect dysregulation, or impulsive/ behavioral dyscontrol. Therapists must then be alert to any signs of withholding, dishonesty, or antisocial tendencies, since these have an adverse effect on prognosis. When all these disruptive influences are (to the extent possible) dealt with, therapists will next take up milder symptoms such as social anxiety or lability of mood. Throughout this initial process, the personality-disorder attributes of BPD will become more apparent, and will usually emerge with greater clarity, once the serious symptoms have been dealt with. The management issues will gradually be supplanted with the overlapping and enduring personality issues: inappropriate anger, abrasiveness, manipulativeness, demandingness, jealousy, "all-or-none" thinking and the extreme attitudes (idealization/devaluation) that accompany such thinking, masochistic traits, etc. Under ideal circumstances, the borderline patient will have "graduated" toward a higher level of function, where (acute) management issues have been adequately dealt with or have receded into the background. Psychotherapy, individual and group, becomes the dominant intervention, with such goals as psychic integration, skills training, and the fostering of long-range ambitions relating to friendships, partner choice, and work.
目前，治疗边缘型人格障碍（BPD）主要有三种心理治疗方法：心理动力学疗法、认知行为疗法和支持性疗法。每种疗法又有其特殊变体，例如，移情聚焦心理治疗（心理动力学疗法）或辩证行为疗法（认知行为疗法）。尽管这些疗法在基本概念和方法上存在差异，但它们的目标都是改善那些在疾病初期主导临床表现的症状，以及在症状缓解后仍然明显的人格障碍。“治疗”一词意味着关注边缘型人格障碍更为严重的方面。这些方面可按严重程度进行分层描述，并且对于这种分层的性质已达成普遍共识。治疗师必须首先关注自杀和自残行为。其次，处理任何可能过早中断治疗的威胁。按严重程度排序第三的是：非自杀性症状，如（轻度至中度）抑郁、药物滥用、惊恐发作及其他焦虑表现，或解离症状。药物治疗通常作为辅助手段，帮助控制任何目标症状，这些症状通常属于认知 - 感知、情感失调或冲动/行为失控等类别。治疗师还必须警惕任何隐瞒、不诚实或反社会倾向的迹象，因为这些对预后有不利影响。当所有这些干扰因素（尽可能）得到处理后，治疗师接下来会处理较轻的症状，如社交焦虑或情绪易变性。在整个初始过程中，一旦严重症状得到处理，BPD的人格障碍特征将变得更加明显，通常会更加清晰地显现出来。治疗问题将逐渐被重叠且持久的人格问题所取代：不适当的愤怒、粗暴、操纵性、苛求、嫉妒、“非此即彼”思维以及伴随这种思维的极端态度（理想化/贬低）、受虐特质等。在理想情况下，边缘型人格障碍患者将“进阶”到更高的功能水平，此时（急性）治疗问题已得到充分处理或已退居次要地位。个体和团体心理治疗成为主要干预手段，其目标包括心理整合、技能训练以及培养与友谊、伴侣选择和工作相关的长远抱负。
