What is the recommended treatment for an adult with borderline personality disorder?

Treatment for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is the first-line treatment for borderline personality disorder, as it is the only psychotherapy proven in randomized controlled trials to reduce suicidality and core BPD symptoms in adults. 1

Primary Treatment: Psychotherapy

DBT as the Gold Standard

• DBT should be initiated for any adult with BPD, particularly those with recent self-harm, suicide attempts, or chronic suicidal ideation. 1
• DBT directly targets the core features of BPD through four essential skill modules: emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. 1, 2
• Standard DBT consists of weekly individual therapy plus weekly group skills training over a one-year period. 1
• Meta-analysis demonstrates moderate to large beneficial effects of DBT over treatment as usual for anger (SMD -0.83), parasuicidality (SMD -0.54), and mental health outcomes (SMD 0.65). 3

Alternative Evidence-Based Psychotherapies

When DBT is unavailable or not tolerated, consider these alternatives with demonstrated efficacy:

• Mentalization-Based Treatment (MBT) in both partial hospitalization and outpatient settings shows statistically significant improvements in BPD core pathology and associated psychopathology. 3
• Transference-Focused Psychotherapy (TFP) demonstrates effectiveness for BPD severity and associated symptoms. 3
• Schema-Focused Therapy (SFT) shows superiority over TFP in one direct comparison for BPD severity and treatment retention. 3
• Systems Training for Emotional Predictability and Problem Solving (STEPPS) has moderate certainty evidence supporting effectiveness over treatment as usual. 4

All commonly used psychotherapies improve BPD severity, symptoms, and functioning, with no strong evidence that any one psychotherapy is definitively superior to another beyond DBT's robust evidence base for suicidality reduction. 4

Role of Pharmacotherapy

Critical Limitation

• Psychotherapy is the treatment of choice; no medication consistently improves core borderline personality features. 1, 5
• Medications should only target specific comorbid conditions (depression, anxiety, substance use disorders present in 78-85% of BPD patients) or acute crises. 1, 5

Medication Guidelines for Comorbidities

• For comorbid major depression, prescribe SSRIs (escitalopram, sertraline, or fluoxetine). 5
• Avoid benzodiazepines as they may increase disinhibition in BPD patients. 1, 5
• For acute crisis management (suicidal behavior, extreme anxiety, psychotic episodes), use low-potency antipsychotics like quetiapine or off-label sedative antihistamines like promethazine, preferred over benzodiazepines. 5

Special Populations

Adolescents (Ages 14-18)

• Use DBT-A (DBT for Adolescents) for teenagers displaying borderline personality traits, suicidal behaviors, or severe emotional dysregulation. 1
• DBT-A is organized into two 12-week stages using simplified language appropriate for adolescents. 1
• DBT-A mandates family participation in skills-training groups to improve the home environment, with family members modeling and reinforcing adaptive behaviors. 1
• DBT-A reduces psychiatric hospitalization rates among suicidal adolescents with borderline features. 1

Pre-Treatment Assessment Requirements

Before initiating DBT or other psychotherapy:

• Confirm the patient's ability to establish a therapeutic alliance and reliably inform the therapist about suicidal preoccupations. 1
• DBT was developed for non-psychotic patients; acute psychotic symptoms must be stabilized before DBT initiation. 1
• Screen for depression, anxiety disorders, substance use disorders, and bipolar disorder, as they are common comorbidities. 1
• Conduct thorough suicide risk assessment, evaluate family psychiatric history, and assess childhood trauma history. 1

Common Pitfalls to Avoid

• Do not use antidepressants or benzodiazepines as primary treatment for BPD core symptoms—they do not address the fundamental pathology. 6, 5
• Do not prescribe benzodiazepines for crisis management in BPD due to disinhibition risk. 1, 5
• Do not attempt DBT without the complete treatment structure (individual therapy plus group skills training)—partial implementation reduces effectiveness. 1
• Do not delay psychotherapy while attempting medication trials for core BPD symptoms, as this wastes critical treatment time. 5