From the Guidelines
The most effective psychodynamic approach for treating a female with paranoid personality disorder and borderline personality disorder (BPD) is Dialectical-Behavioral Therapy (DBT), as it has been shown to reduce suicidality in adults with BPD 1. This approach focuses 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. DBT typically involves individual and group sessions over the course of a year, with four components or modules: Core Mindfulness Skills, Interpersonal Effectiveness Skills, Distress Tolerance, and Emotion Regulation Skills.
- The Core Mindfulness Skills module aims to diminish identity confusion and self-dysregulation through teachings of Zen meditation to enhance emotional control.
- The Interpersonal Effectiveness Skills module enables interpersonal problem-solving through assertiveness training and makes the patient more aware of their goals in an interpersonal situation.
- The Distress Tolerance module reduces impulsivity by teaching acceptance and tolerance of painful situations with self-soothing and distraction from pain.
- The Emotion Regulation Skills module identifies emotions, reduces emotional vulnerability, and increases positive events. Individual therapy is given weekly, focusing on reviewing a weekly diary documenting suicidal and self-destructive behavior, behaviors that interfere with treatment and quality of life, and use of new skills. Given the complexity of treating paranoid personality disorder and BPD, DBT should be considered the primary treatment approach, with medication considered adjunctive to psychotherapy. Medications such as selective serotonin reuptake inhibitors (SSRIs) or low-dose atypical antipsychotics might be used to manage emotional dysregulation, impulsivity, and paranoid ideation, but the therapeutic relationship and skills training in DBT are crucial for addressing the underlying psychological mechanisms of both disorders 1.
From the Research
Psychodynamic Approaches for Treating Borderline Personality Disorder (BPD)
- Transference-focused psychotherapy (TFP) is a psychodynamic approach that has been empirically supported for the treatment of BPD 2, 3.
- Good psychiatric management (GPM) is another evidence-supported treatment that may be used in a complementary, flexible manner with TFP to provide a spectrum of psychodynamically informed care 2.
- Mentalization-based therapy, dialectical behavior therapy, and schema therapy are also evidence-based treatments for BPD, but no approach has been proven to be superior to others 4, 5.
Treatment of Paranoid Personality Disorder
- There is limited research on the treatment of paranoid personality disorder, but psychodynamic approaches such as TFP may be beneficial in addressing the underlying pathology of internal object relations 3.
- A comprehensive treatment plan for a female patient with both paranoid personality disorder and BPD may involve a combination of psychodynamic psychotherapy, such as TFP or GPM, and other evidence-based treatments for BPD 2, 4, 5.
Considerations for Treatment
- The patient's cognitive style and capacity for introspection should be taken into account when determining the most suitable psychotherapeutic approach 6.
- Flexibility is necessary in treatment, as patients with BPD may require supportive and limit-setting interventions, psychotropic medications, and programs to help combat substance abuse 6.
- A careful and extensive family history for mood disorders should be taken to identify potential genetic links to bipolar disorder, which may inform treatment decisions 6.