What is the recommended treatment for borderline personality disorder?

Treatment for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is the first-line treatment for borderline personality disorder, demonstrating superior efficacy in reducing high-risk behaviors and core symptoms compared to treatment as usual. 1

First-Line Treatment: Dialectical Behavior Therapy

DBT is currently the only empirically supported treatment for BPD, with multiple randomized controlled trials demonstrating its effectiveness. The traditional DBT program consists of four key components:

1. Skills training group - Teaching behavioral skills in four modules:

   • Mindfulness
   • Interpersonal effectiveness
   • Emotion regulation
   • Distress tolerance

2. Individual psychotherapy - One-on-one sessions focused on applying skills to specific challenges

3. Telephone consultation - Crisis support between sessions

4. Therapist consultation team - Support for therapists to maintain treatment fidelity 2

Recent systematic reviews of randomized controlled trials have shown that DBT significantly improves:

• Self-injurious behaviors
• Suicidal ideation
• Emergency service utilization
• Hospitalization rates
• General psychopathology and depressive symptoms 1

Treatment Duration and Efficacy

Standard DBT typically lasts 12 months, with benefits lasting up to 24 months after treatment completion. A 2023 systematic review found that both short-term and standard DBT improved suicidality in BPD patients with small to moderate effect sizes 1. Research shows DBT results in better retention rates and greater reductions in self-mutilating and self-damaging impulsive behaviors compared to usual treatment 3.

Alternative Psychotherapeutic Approaches

While DBT has the strongest evidence base, psychodynamic therapy has also shown efficacy with medium effect sizes (standardized mean difference between -0.60 and -0.65) compared to usual care 4.

Role of Pharmacotherapy

There is no evidence that any psychoactive medication consistently improves core symptoms of BPD 4. However, pharmacotherapy may be appropriate for treating specific comorbid conditions:

• For comorbid major depression: SSRIs such as escitalopram, sertraline, or fluoxetine may be prescribed
• For acute crisis management: Low-potency antipsychotics (e.g., quetiapine) or off-label use of sedative antihistamines (e.g., promethazine) are preferred over benzodiazepines 4

Crisis Management and Safety Planning

For patients with BPD experiencing suicidal behavior or ideation:

• Safety planning interventions are strongly recommended, including:

  • Identification of warning signs and triggers
  • Development of internal coping strategies
  • Creation of healthy distracting activities
  • Listing social supports and professional resources
  • Implementing means restriction planning 5

• The Safety Planning Intervention (SPI) has demonstrated a 43% reduction in suicidal behavior when implemented with follow-up calls 5

Common Pitfalls to Avoid

1. Insufficient treatment duration - BPD requires longer-term treatment, with benefits lasting up to 24 months after treatment completion 5

2. Neglecting suicidality - Always assess and address suicidal ideation as part of the treatment plan 5

3. Relying solely on medication - Psychotherapy remains the treatment of choice for BPD, with medications serving only as adjunctive treatment for specific comorbid conditions 4

4. Discontinuing treatment prematurely - BPD treatment requires persistence, as improvements may take time to manifest and stabilize