From the Guidelines
General psychiatric management for borderline personality disorder should prioritize dialectical behavior therapy (DBT) as the primary intervention, given its proven effectiveness in reducing suicidality and improving emotional regulation, as demonstrated in a randomized controlled trial 1. The treatment involves developing problem-oriented strategies to increase distress tolerance, emotion regulation, interpersonal effectiveness, and the use of both rational and emotional input to make more balanced decisions. DBT typically involves individual and group sessions over the course of a year, but a modified version for adolescents (DBT-A) has been developed, which requires the participation of a relative in the skills training group and has shown promise in reducing rates of psychiatric hospitalization 1. Key components of DBT include:
- A Core Mindfulness Skills module to diminish identity confusion and self-dysregulation
- An Interpersonal Effectiveness Skills module to enable interpersonal problem-solving through assertiveness training
- A Distress Tolerance module to reduce impulsivity by teaching acceptance and tolerance of painful situations
- An Emotion Regulation Skills module to identify emotions, reduce emotional vulnerability, and increase positive events Individual therapy is given weekly, focusing on reviewing a weekly diary documenting suicidal and self-destructive behavior, and conducting a behavioral analysis of each behavior problem to understand its function and identify constructive solutions 1. Medications may be used adjunctively to target specific symptoms, but should not be the primary intervention, and medication trials should be time-limited with clear targets for symptom improvement. Crisis management, including safety planning for suicidal ideation and self-harm behaviors, is essential, and clinicians should avoid frequent hospitalization, focusing instead on brief admissions when necessary for safety, followed by structured outpatient care 1.
From the Research
General Psychiatric Management Guidelines for Borderline Personality Disorder
The general psychiatric management guidelines for borderline personality disorder (BPD) involve a combination of psychodynamically informed therapy and symptom-targeted medication management, as recommended by the American Psychiatric Association (APA) guidelines for BPD 2.
Key Components of General Psychiatric Management
- Psychodynamically informed therapy: This approach focuses on helping patients understand and manage their emotions, behaviors, and relationships 2.
- Symptom-targeted medication management: This involves using medications to target specific symptoms of BPD, such as mood stabilizers, antidepressants, and anti-anxiety medications 3, 2.
Comparison with Dialectical Behavior Therapy
Studies have compared the effectiveness of general psychiatric management with dialectical behavior therapy (DBT) for BPD. One study found that both treatments were equally effective in reducing suicidal and non-suicidal self-injurious episodes, as well as improving symptoms of BPD, depression, and anxiety 2.
Factors Influencing Treatment Response
Research has identified patient characteristics that influence treatment response, including psychiatric symptom severity, BPD impulsivity symptoms, dependent personality traits, childhood emotional abuse, and social adjustment 4. These factors can help inform treatment selection and improve outcomes for patients with BPD.
Delivery of Dialectical Behavior Therapy
Dialectical behavior therapy can be delivered effectively through email, providing a more accessible alternative to in-person treatment for patients with BPD 5. This approach has been shown to be as effective as in-person DBT in reducing symptoms of BPD and improving emotional regulation.