What is borderline personality disorder and its treatment?

What is Borderline Personality Disorder?

Borderline personality disorder (BPD) is a severe mental illness characterized by a pervasive pattern of instability in self-image, interpersonal relationships, and emotional regulation, with onset typically in early adulthood, requiring diagnosis through structured clinical interviews rather than self-report measures. 1

Core Diagnostic Features

BPD requires documentation of characteristic patterns including:

• Repeated suicide attempts and non-lethal self-injury 1
• Pervasive impulsivity affecting multiple life domains 1
• Unstable mood and interpersonal relationships with rapid shifts between idealization and devaluation 1
• Varying self-concept and identity disturbance, manifesting as chronic feelings of emptiness 1
• Dissociative symptoms during periods of stress 1
• Self-damaging behaviors beyond suicidality 1
• Intense, inappropriate anger and difficulty controlling anger 1

The disorder is associated with high morbidity and mortality, including significant suicide risk (2-5% completed suicide rate), with approximately half of young people with BPD reporting self-harm. 1, 2

Diagnostic Approach

Use structured or semi-structured interviews conducted by mental health specialists, not self-report questionnaires, because lack of insight is a core feature of personality disorders. 1 The assessment must include information from multiple sources using developmentally sensitive techniques, confirmation from multiple informants, and systematic evaluation of informant discrepancies. 1

The World Health Organization's ICD-11 framework differentiates BPD by severity (mild, moderate, and severe), with optional specification of maladaptive personality traits. 1

Treatment Framework

First-Line Treatment: Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is the treatment of choice for BPD, with the primary goal of reducing suicidality. 1 DBT involves four core modules delivered over 12-22 weekly sessions:

• Core mindfulness skills to increase present-moment awareness 1, 3
• Interpersonal effectiveness skills for managing relationships and expressing needs 1, 3
• Distress tolerance techniques for crisis situations 1, 3
• Emotion regulation skills to manage affective instability 1, 3

The treatment structure includes weekly individual therapy, skills training groups, telephone consultations, and patient consultation groups. 1 For more severe presentations, consider extending treatment duration beyond 22 sessions. 3

Use motivational interviewing techniques at treatment initiation to enhance engagement, explaining that treatment aims to reduce distress and improve quality of life rather than focusing on personality "flaws." 3

Alternative Evidence-Based Psychotherapies

Other comprehensive psychotherapies with demonstrated efficacy include:

• Mentalization-based treatment (psychodynamic approach) 4
• Transference-focused psychotherapy (psychodynamic approach) 4
• Schema-focused therapy (cognitive-behavioral approach) 4

Each of these lengthy psychotherapies significantly reduces the severity of borderline psychopathology, particularly physically self-destructive acts. 4

Pharmacological Management

No psychoactive medication consistently improves the core features of BPD; pharmacotherapy should target specific comorbid conditions rather than core personality disorder symptoms. 1

Medication Guidelines by Comorbidity

• For comorbid anxiety disorders or major depression: SSRIs (fluoxetine, sertraline) are the preferred choice due to their safety profile, but maintain realistic expectations regarding impact on core BPD symptoms 3
• For affective dysregulation and mood instability: Mood stabilizers such as valproate, lamotrigine, and topiramate have shown benefits for anger, aggression, and affective lability, though evidence is based on small studies 3, 5
• Avoid benzodiazepines for chronic anxiety management due to high risk of disinhibition and dependence in this population 3

Crisis Management

Implement crisis response planning with clear warning signs and coping strategies for acute crises, including suicidal behavior/ideation, extreme anxiety, and psychotic episodes. 1 Use low-potency antipsychotics or off-label sedative antihistamines for short-term acute crisis management rather than benzodiazepines. 1, 3

Family and Environmental Considerations

Conduct comprehensive assessment of family relationship dynamics, levels of conflict, cohesion, and expressed emotion, as these factors contribute significantly to treatment outcomes. 6 Family psychoeducation combined with skills training in communication and problem-solving represents an active treatment component with strong empirical support. 6

Prognosis and Recovery

BPD causes considerable functional impairment, intensive treatment utilization, high societal costs, and premature mortality risk. 1 Life expectancy is significantly shortened compared with the general population. 2 However, many patients report symptom relief with comprehensive, disorder-specific psychotherapy, though lingering problems may persist, emphasizing the value of personalized treatment strategies. 7