There is No First-Line Medication for Borderline Personality Disorder
Psychotherapy—not medication—is the first-line treatment for BPD, with dialectical behavior therapy and psychodynamic therapy demonstrating medium effect sizes (standardized mean difference -0.60 to -0.65) for reducing symptom severity, while no psychoactive medication consistently improves the core symptoms of BPD. 1
Why Medications Are Not First-Line for BPD
No medication has demonstrated efficacy for the core symptoms of BPD, which include identity disturbance, chronic feelings of emptiness, unstable interpersonal relationships, and fear of abandonment 1
Psychotherapy is needed to attain lasting improvements in personality functioning and overall outcomes, whereas medications only target state symptoms and trait vulnerabilities 2
The first-line management for BPD is psychosocial treatment, not drugs, with medications only considered as adjuncts to psychotherapy when clearly indicated 3
When Medications May Be Considered
For Comorbid Mental Disorders (Not BPD Itself)
SSRIs (escitalopram, sertraline, or fluoxetine) may be prescribed specifically for discrete and severe comorbid major depression, not for BPD symptoms themselves 1
SSRIs are effective in decreasing severity of depressed mood, anxiety, and anger mainly in subjects with a concomitant affective disorder, with uncertain effects on impulsive behaviors in BPD 4
Drug treatment is warranted when patients have co-occurring mental disorders such as major depression, but should only be used as an adjunct to psychosocial treatment with clear, collaborative goals that are regularly reviewed 3
For Acute Crisis Management Only
For short-term treatment of acute crisis (suicidal behavior, extreme anxiety, psychotic episodes, or behavior endangering the patient or others), low-potency antipsychotics like quetiapine or off-label sedative antihistamines like promethazine are preferred over benzodiazepines 1
These medications are for crisis stabilization, not ongoing treatment of BPD 1
Evidence for Specific Symptom Clusters (When Psychotherapy Alone Is Insufficient)
Affective Dysregulation and Impulsive-Behavioral Dyscontrol
Mood stabilizers (topiramate, valproate, lamotrigine) and second-generation antipsychotics (olanzapine, aripiprazole) can be useful for treating affective symptoms and impulsive-behavioral dyscontrol 4
Guidelines recommend antidepressants and mood stabilizers for these symptom dimensions, though evidence is stronger for mood stabilizers 2
Cognitive-Perceptual Symptoms
Antipsychotics significantly improve cognitive symptoms (transient paranoid ideation, dissociative symptoms) in patients with BPD 4
Guidelines recommend antipsychotics specifically for cognitive-perceptual symptoms 2
Critical Prescribing Hazards in BPD
Major prescribing hazards include polypharmacy, overdose, and misuse—these risks are particularly elevated in BPD patients 3
Use single drugs prescribed in limited quantities for a limited time, and stop drugs that are ineffective 3
Benzodiazepines should be avoided in favor of low-potency antipsychotics or sedative antihistamines during acute crises 1
Common Pitfalls to Avoid
Do not prescribe medications as primary treatment for BPD—this represents a fundamental misunderstanding of the disorder and delays effective psychotherapy 1, 3
Do not continue ineffective medications—regularly review treatment goals and discontinue drugs that are not meeting specific, measurable objectives 3
Do not use medications to treat core BPD symptoms like identity disturbance, emptiness, or unstable relationships—these require psychotherapy 1
Avoid polypharmacy, which is common but not evidence-based in BPD treatment 3