From the Guidelines
The management of borderline personality disorder (BPD) should prioritize dialectical behavior therapy (DBT) as the cornerstone of treatment, given its strong evidence for reducing suicidality and improving emotional regulation, as supported by recent studies such as 1. The most recent and highest quality study, 1, published in 2019, highlights the effectiveness of DBT in reducing nonsuicidal and suicidal self-directed violence among patients with borderline personality disorder. This approach combines elements of cognitive behavioral therapy, skills training, and mindfulness techniques to help patients develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance.
Key components of DBT include:
- Weekly individual therapy sessions
- Group skills training over 6-12 months
- Teaching mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness Other effective psychotherapies, such as mentalization-based therapy, schema therapy, and transference-focused psychotherapy, may also be considered, but DBT remains the most strongly supported treatment option.
Medications, such as selective serotonin reuptake inhibitors (e.g., fluoxetine 20-80mg daily or sertraline 50-200mg daily) and low-dose antipsychotics (e.g., quetiapine 25-300mg daily), may play a supportive role in managing mood symptoms, impulsivity, and aggression during crisis periods, as noted in 1. However, benzodiazepines should generally be avoided due to the risk of addiction and potential for impulsive behavior.
Crisis management strategies, including developing safety plans, identifying triggers, utilizing crisis hotlines, and sometimes brief hospitalizations for acute suicidal risk, are also essential components of BPD treatment, as emphasized in 1. By prioritizing DBT and incorporating these additional treatment elements, patients with BPD can develop emotional regulation skills, improve interpersonal functioning, and establish a more stable self-identity, ultimately leading to significant improvement and recovery.
From the Research
Management of Borderline Personality Disorder (BPD)
The management of BPD involves various psychotherapies and pharmacological interventions.
- Dialectical Behavior Therapy (DBT) is a widely used and effective treatment for BPD, as evidenced by studies 2, 3, 4.
- DBT has been shown to improve suicidality, general psychopathology, and depressive symptoms in patients with BPD, with small to moderate effect sizes 2.
- Other psychotherapies, such as psychodynamic approaches, have also been found to be effective in treating BPD 3.
- The co-occurrence of BPD with Major Depressive Disorder (MDD) can make treatment challenging, and the presence of BPD may be associated with a poorer response to MDD treatment 5.
- Pharmacological interventions, such as selective serotonin reuptake inhibitors (SSRIs), may be used in conjunction with psychotherapy to treat patients with BPD and MDD 5, 4.
Treatment Modalities
- DBT is a structured outpatient treatment that consists of four components: skills training group, individual psychotherapy, telephone consultation, and therapist consultation team 4.
- Other psychotherapeutic approaches, such as mentalization-based treatment, transference-focused psychotherapy, and schema-focused psychotherapy, may also be effective in treating BPD 6.
- Pharmacological interventions may be used to target specific symptoms, such as mood instability or impulsivity, but should be used in conjunction with psychotherapy 4, 6.
Key Considerations
- The treatment of BPD should be individualized and tailored to the patient's specific needs and symptoms 6.
- The presence of comorbidities, such as MDD, should be taken into account when developing a treatment plan 5.
- Ongoing controversies surrounding BPD, such as misdiagnosis and stigma, should be addressed in clinical practice and research 6.