Psychotherapy and pharmacotherapy are each effective in treating borderline personality disorder. In severely symptomatic patients, psychotherapy reduces suicidality and the utilization of inpatient psychiatric care within the first year of treatment, but drop-out rates are high. Pharmacotherapy reduces impulsivity, hostility, suicidality, and psychoticism over five to twelve week periods after which it may not be effective. The combination of both modalities surmounts the limitations of each, but is difficult to achieve because characteristic features of borderline pathology can undermine efforts at integrating the treatments. The meaning of being given medication, the effect of medication on the therapeutic relationship, issues of control, seduction and dependency, the all-or-nothing tendency to "biologize" or "psychologize," and the therapist's counterreactions to the patient must all be addressed for combined treatment to be
A n individual's set of personality traits is shaped by both biological endowment (i.e., temperament), and patterns learned from life experience. Twin studies have demonstrated that many personality traits have an inheritance factor of 40 to 50%, with the remainder of the variance accounted for by non-shared environmental factors (Bouchard 1994). Temperament may shape one's tendency toward shyness or gregariousness, comfort with novel situations, sensation seeking, sensitivity to intense stimuli, affective lability, responsiveness to reward, level of aggression, and impulsivity. Life experiences, such as early physi-possible. Several clinical vignettes illustrate these issues.