What is the DART (Dialectical Approach to managing symptoms of Borderline Personality Disorder) regime in Borderline Personality Disorder (BPD)?

DART Regime in Borderline Personality Disorder (BPD)

The DART (Dialectical Approach to managing symptoms of Borderline Personality Disorder) regime refers to Dialectical Behavior Therapy (DBT), which is the most evidence-based psychotherapeutic approach for treating core symptoms of BPD, particularly for reducing suicidality and emotional dysregulation. 1

Core Components of DBT for BPD

DBT is a comprehensive treatment program that includes several essential components:

1. Core Mindfulness Skills - Teaching patients to be present in the moment and observe thoughts without judgment
2. Interpersonal Effectiveness Skills - Helping patients navigate relationships effectively while maintaining self-respect
3. Distress Tolerance - Developing skills to tolerate painful emotions without resorting to impulsive behaviors
4. Emotion Regulation Skills - Learning to identify, understand, and manage intense emotions 1

Treatment Structure

The typical DBT program for BPD includes:

• Weekly individual therapy sessions
• Weekly group skills training sessions
• Phone coaching for crisis situations
• Therapist consultation team meetings
• Treatment duration typically 1 year 2

For adolescents with BPD features, the structure includes:

• Weekly (acute phase) and biweekly (continuation phase) alternating family skill training
• Individual therapy sessions covering the four core DBT modules
• A longer treatment duration (1 year)
• Single-family skill training format
• Focus on sleep and treatment adherence 2

Efficacy and Evidence Base

DBT is the only psychotherapy shown in randomized controlled trials to consistently reduce suicidality in adults with borderline personality disorder 1. Research has demonstrated that:

• DBT is associated with decreased suicidal ideation, with 83% of adolescents exhibiting decreased suicidal ideation compared to 50% increase in standard care 2
• Patients receiving DBT spend approximately twice as much time in euthymic states 2
• DBT shows significant improvements in depressive symptoms and emotional dysregulation 2

Medication Management with DBT

It's important to note that:

• No medications consistently show efficacy for core BPD features 1, 3
• DBT is designed to be adjunctive to pharmacotherapy when needed 2
• Medications may help with specific symptoms:
  • SSRIs (escitalopram, sertraline, fluoxetine) for comorbid depression or anxiety
  • Low-potency antipsychotics or sedative antihistamines (preferred over benzodiazepines) for acute crisis management 1, 3

Clinical Considerations and Pitfalls

• Patient Selection: DBT may be particularly beneficial for patients with dependent personality traits, childhood emotional abuse history, and social adjustment difficulties 4
• Inpatient Applications: Modified versions of DBT have been used in inpatient settings, often with shorter durations (2 weeks to 3 months) 5
• Comorbidity Management: BPD frequently co-occurs with mood disorders (83%), anxiety disorders (85%), and substance use disorders (78%), which may require additional treatment approaches 3
• Avoiding Polypharmacy: Multiple medications should be avoided, as they increase risk without clear benefit 6

Implementation Challenges

• DBT requires specialized training for providers
• The full DBT program is resource-intensive
• Treatment adherence can be challenging for patients with BPD
• Setting appropriate communication boundaries is essential for effective management 1

For optimal outcomes, patients should be assessed for suicidal ideation, intent, history of attempts, access to lethal means, and impulsivity level before and during treatment 1.