First-Line Therapy 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 is recommended by the American Academy of Child and Adolescent Psychiatry as the most effective psychiatric treatment for this population. 1, 2
Why DBT is the Treatment of Choice
DBT directly targets the core pathology of BPD—emotional dysregulation, impulsivity, chaotic relationships, and self-harm behaviors—through four essential skill modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. 1, 3
Meta-analyses demonstrate moderate to large statistically significant effects of DBT over treatment as usual for reducing anger, parasuicidal behavior, and improving mental health. 4
DBT was specifically developed for patients with BPD who are at heightened risk for suicidal and non-suicidal self-directed violence, combining cognitive behavioral therapy, skills training, and mindfulness techniques. 2
Required Treatment Structure
Standard DBT consists of weekly individual therapy sessions plus weekly group skills training over one year, covering the four core modules sequentially. 1, 2
For adolescents (ages 14-18), use DBT-A, which is organized into two 12-week stages with simplified language and mandates family participation in skills-training groups to improve the home environment. 1
DBT-A reduces psychiatric hospitalization rates among suicidal adolescents with borderline features, with approximately 83% showing decreased suicidal ideation versus 50% of standard-care peers who show increased ideation. 1
When to Initiate DBT
Initiate DBT for any adult with BPD who has recent self-harm, suicide attempts, or chronic suicidal ideation. 1
Before starting DBT, confirm the patient's ability to establish a therapeutic alliance and reliably inform the therapist about suicidal preoccupations. 1
Acute psychotic symptoms must be stabilized before DBT initiation, as DBT was developed for non-psychotic patients. 1
Role of Pharmacotherapy
Psychotherapy is the treatment of choice; no medication consistently improves core borderline personality features. 1
Use medications only to target specific comorbid conditions (depression, anxiety disorders, substance use disorders, bipolar disorder) or acute crises, not as primary treatment for BPD itself. 1
Avoid benzodiazepines as they may increase disinhibition in BPD patients. 1
Alternative Evidence-Based Psychotherapies
While DBT has the strongest evidence base, other psychotherapies show efficacy when DBT is unavailable:
Mentalization-based treatment (MBT) in partial hospitalization or outpatient settings demonstrates statistically significant effects on BPD core pathology and associated symptoms. 4
Schema-focused therapy (SFT) shows superiority over transference-focused psychotherapy for BPD severity and treatment retention in head-to-head comparison. 4
Systems training for emotional predictability and problem solving (STEPPS) has moderate certainty evidence of effectiveness over treatment as usual. 5
Common Pitfalls to Avoid
Do not use unstructured supportive therapy as primary treatment; BPD requires structured, disorder-specific interventions with predictable frameworks. 6
Do not rely on pharmacotherapy alone; psychotherapy must be the foundation of treatment. 1
Do not initiate DBT without ensuring access to both individual therapy and group skills training components, as both are essential. 1, 2