What is the recommended treatment for a girl with borderline personality disorder?

Treatment of Borderline Personality Disorder in Girls

Dialectical Behavior Therapy (DBT) is the recommended first-line treatment for girls with borderline personality disorder (BPD) due to its demonstrated efficacy in reducing suicidal ideation, self-injurious behaviors, and emotional dysregulation. 1, 2

Evidence-Based Treatment Approach

First-Line Treatment: Dialectical Behavior Therapy

DBT has shown consistent effectiveness for BPD and consists of four core modules:

1. Mindfulness Skills - Developing present-moment awareness
2. Interpersonal Effectiveness Skills - Improving relationship management
3. Distress Tolerance - Building capacity to tolerate distress without harmful behaviors
4. Emotion Regulation Skills - Learning to identify and manage intense emotions

DBT is structured into multiple components that work together 3:

• Weekly individual therapy sessions
• Weekly skills training groups
• Telephone consultation for crisis management
• Therapist consultation team meetings

The most recent evidence indicates that both standard DBT and shorter-term adaptations can significantly improve suicidality in BPD patients with effects lasting up to 24 months after treatment completion 4.

Treatment Duration and Format

• A typical course of DBT requires longer-term commitment (approximately 12 months) 1
• More severe cases may require extended treatment, with benefits observed for up to 24 months 4
• Short-term interventions are often inadequate for addressing core BPD symptoms 1

Efficacy of DBT

DBT has demonstrated superiority over treatment as usual in multiple studies:

• Better treatment retention rates 5
• Greater reductions in self-mutilating behaviors 5
• Decreased frequency of emergency service visits 4
• Reduced hospitalization rates 4
• Improvements in general psychopathology and depressive symptoms 4

Risk Assessment and Management

Given the high risk of self-harm and suicide in BPD, comprehensive risk assessment is essential:

• Always assess for suicidal ideation and self-harm behaviors 1
• Evaluate specific risk factors including:
  • Previous suicide attempts
  • Current suicidal thoughts and plans
  • Access to means
  • Social support and isolation
  • Recent losses or stressors

Common Pitfalls to Avoid

1. Insufficient treatment duration - BPD requires longer-term treatment; short interventions are typically inadequate 1

2. Neglecting suicidality assessment - Always assess and address suicidal ideation as part of the treatment plan 1

3. Overreliance on medication - There is no evidence that any psychoactive medication consistently improves core symptoms of BPD 2

4. Inadequate crisis management - Implement a clear safety plan with specific strategies for managing acute distress 1

5. Inconsistent application of DBT principles - All four components of DBT should be implemented for optimal outcomes 3

Role of Medication

While psychotherapy is the treatment of choice for BPD, medication may be considered for specific comorbid conditions:

• For comorbid major depression: SSRIs such as escitalopram, sertraline, or fluoxetine 2
• For acute crisis management: Low-potency antipsychotics (e.g., quetiapine) may be used short-term 2
• Benzodiazepines should be avoided due to risk of dependence and potential for misuse 2

Inpatient Treatment Considerations

For severe cases requiring hospitalization:

• Inpatient DBT adaptations have shown effectiveness in reducing suicidal ideation and self-injurious behaviors 6
• Inpatient stays can function as an "intensive orientation" to outpatient DBT services 6
• Duration of inpatient DBT typically ranges from two weeks to three months 6

DBT remains the most evidence-based approach for treating BPD in adolescents, with demonstrated effectiveness in reducing high-risk behaviors and improving emotional regulation, which directly impacts morbidity, mortality, and quality of life outcomes.