What is the management of borderline personality disorder (BPD)?

From the Guidelines

Dialectical behavior therapy (DBT) is the most effective treatment for managing borderline personality disorder (BPD), as it teaches skills in mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness, and has been shown to reduce suicidality and improve quality of life 1.

Key Components of DBT

• Weekly individual therapy sessions
• Group skills training over 6-12 months
• Focus on developing problem-oriented strategies to increase distress tolerance, emotion regulation, interpersonal effectiveness, and the use of both rational and emotional input to make more balanced decisions

Additional Therapies

• Mentalization-based therapy
• Schema therapy
• Transference-focused psychotherapy

Medication Management

• Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (20-80 mg daily) or sertraline (50-200 mg daily) for mood instability and impulsivity
• Low-dose antipsychotics such as quetiapine (25-300 mg daily) for anger and cognitive-perceptual symptoms
• Mood stabilizers like lamotrigine (25-200 mg daily) for mood swings

Lifestyle Management

• Establishing regular sleep patterns
• Engaging in physical activity
• Avoiding alcohol and drugs
• Building a support network
• Learning to identify triggers

Evidence-Based Recommendation

The 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines support the use of DBT for treating suicidal ideation and behavior in patients with borderline personality disorder 1. A systematic review found that DBT reduces nonsuicidal and suicidal self-directed violence among patients with borderline personality disorder and recent self-directed violence 1. Therefore, DBT should be considered the first-line treatment for managing BPD, with a focus on improving emotional regulation, reducing symptom intensity, and enhancing quality of life 1.

From the Research

Management of Borderline Personality Disorder

• The management of borderline personality disorder (BPD) involves various psychological therapies and interventions, with dialectical behavior therapy (DBT) being a widely used and empirically supported treatment 2, 3, 4, 5.
• DBT is based on cognitive-behavioral principles and consists of four components: skills training group, individual psychotherapy, telephone consultation, and therapist consultation team 2.
• The skills taught in DBT include mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance, which target common symptoms of BPD such as unstable sense of self, chaotic relationships, fear of abandonment, emotional lability, and impulsivity 2.
• Psychotherapy, including DBT, has been shown to reduce BPD symptom severity, self-harm, and suicide-related outcomes, and improve psychosocial functioning compared to treatment-as-usual (TAU) 4.
• Other psychological therapies, such as mentalization-based treatment (MBT) and schema-focused psychotherapy, have also been found to be effective in reducing BPD symptoms and improving functioning 3, 4.
• Pharmacological interventions may be considered as adjunctive care for patients with BPD, particularly for those with comorbid psychiatric symptoms 2.
• Implementation of DBT in public health systems has been found to be effective, but challenges and barriers to implementation exist, and ongoing research and evaluation are recommended 6.

Key Findings

• DBT has been found to be effective in reducing BPD symptom severity, self-harm, and suicide-related outcomes, and improving psychosocial functioning 2, 4, 5.
• Psychotherapy, including DBT, has been found to be more effective than TAU in reducing BPD symptoms and improving functioning 4.
• MBT has been found to be effective in reducing self-harm, suicidality, and depression in patients with BPD 4.
• Implementation of DBT in community settings has been found to be effective, but challenges and barriers to implementation exist 6.

Treatment Approaches

• DBT: a structured outpatient treatment developed by Dr. Marsha Linehan, which consists of four components: skills training group, individual psychotherapy, telephone consultation, and therapist consultation team 2.
• MBT: a psychological therapy that focuses on helping patients develop a better understanding of their own thoughts, feelings, and behaviors, and those of others 4.
• Schema-focused psychotherapy: a psychological therapy that focuses on helping patients identify and change negative patterns of thinking and behavior 3.