From the Guidelines
Borderline personality disorder (BPD) is best treated with Dialectical Behavior Therapy (DBT), which has been shown to reduce suicidality and improve emotional regulation skills, as evidenced by a systematic review in 2019 1. The treatment of BPD typically involves a comprehensive approach combining psychotherapy and sometimes medication.
- The gold standard treatment is DBT, which usually involves weekly individual therapy sessions and group skills training over 6-12 months.
- DBT has been found to be effective in reducing nonsuicidal and suicidal self-directed violence among patients with borderline personality disorder, as shown in a systematic review by Hawton and colleagues 1.
- Other effective psychotherapies include Mentalization-Based Therapy (MBT), Schema Therapy, and Transference-Focused Psychotherapy (TFP), although DBT is the most well-studied and widely recommended treatment.
- While no medications are FDA-approved specifically for BPD, certain symptoms may be targeted with medications, such as:
- SSRIs like fluoxetine (20-80mg daily) or sertraline (50-200mg daily) for mood instability and impulsivity.
- Low-dose antipsychotics like quetiapine (25-300mg daily) for anger and cognitive symptoms.
- Mood stabilizers like lamotrigine (25-200mg daily) for emotional dysregulation.
- These medications should be prescribed cautiously, at the lowest effective dose, and regularly reassessed, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.
- Treatment requires patience and consistency, as BPD recovery typically takes time, and building a strong therapeutic alliance is crucial, as is involving family members in psychoeducation when possible.
- The underlying mechanism of effective treatment involves helping patients develop emotional regulation skills, improve interpersonal effectiveness, and establish a more stable sense of identity, as described in the practice parameter for the assessment and treatment of children and adolescents with suicidal behavior by the American Academy of Child and Adolescent Psychiatry 1.
From the Research
Treatment Options for Borderline Personality Disorder (BPD)
The treatment options for BPD include:
- Psychotherapy, which is the treatment of choice for BPD 2
- Dialectical behavior therapy (DBT), a structured outpatient treatment developed by Dr Marsha Linehan for the treatment of BPD 3, 4
- Psychodynamic therapy, which reduces symptom severity more than usual care 2
- Systems training for emotional predictability and problem solving, which is more effective than treatment as usual (TAU) for the treatment of BPD 5
- Schema therapy, transference-focused psychotherapy, acceptance and commitment therapy, manual-assisted cognitive therapy, and cognitive behavioral therapy, which may be more effective than TAU for treating BPD, although the certainty of evidence is low 5
- Pharmacotherapy, such as selective serotonin reuptake inhibitors, which may be prescribed for discrete and severe comorbid mental disorders, such as major depression 2
- Crisis management, which may include prescription of low-potency antipsychotics or off-label use of sedative antihistamines for short-term treatment of acute crisis in BPD 2
Key Components of DBT
The key components of DBT include:
- Skills training group
- Individual psychotherapy
- Telephone consultation
- Therapist consultation team 3
- Teaching behavioral skills that target common symptoms of BPD, including:
- Mindfulness
- Interpersonal effectiveness
- Emotion regulation
- Distress tolerance 3
Effectiveness of Psychotherapies for BPD
The effectiveness of psychotherapies for BPD is supported by various studies, which suggest that:
- DBT is a comprehensive, evidence-based treatment for BPD 3, 4
- Psychotherapies such as DBT, psychodynamic therapy, and systems training for emotional predictability and problem solving can reduce symptom severity and improve functioning in individuals with BPD 2, 5
- No single treatment seems to be the best choice to treat people with BPD compared to other treatments 6