The treatment of Borderline Personality Disorder (BPD) has changed greatly over the past fifty years. With the development of Dialectical Behavior Therapy (DBT) and advancement in medications to manage secondary symptoms and common co-occurring disorders, there is much hope regarding the treatment and outcome of people with BPD. Individuals diagnosed with BPD have many treatment options and supports available.
Therapy for Borderline Personality Disorder
Borderline Personality Disorder impacts roughly 1.5% of people worldwide.2 This disorder is frequently associated with trauma in childhood and a family history of personality disorders. This disorder is chronic and pervasive. Due to the lifelong nature of this disorder, finding and utilizing effective treatment is paramount to meaningful life outcomes. There are several treatment approaches that show success in treating and managing BPD.
The treatment of BPD has involved elements of cognitive behavioral therapy (CBT) for more than a half a century. CBT allows the individual to evaluate, monitor, and change thoughts and beliefs that in turn, impact feelings, experiences, and social relationships. This talk-therapy based approach assists people in gaining awareness of negative and maladaptive thinking, then challenging the individual to change distorted thoughts and beliefs. The cognitive approach to the treatment of BPD has been reorganized into several effective and structured approaches; most namely Dialectical Behavior Therapy (DBT) and Schema-Focused Therapy.
Psychotherapy is the most effective form of treatment for BPD and has been refined and studied for several years. Due to the characterological nature of the disorder, long-term therapy in conjunction with psychopharmaceuticals to manage symptoms appears to be the most effective approach to the treatment of BPD. While DBT is often seen as the most efficacious treatment approach, there are several approaches that can result in positive outcomes and individual growth.
Dialectical Behavior Therapy (DBT)
Developed by Marsha Linehan in the 1970s, DBT is often the treatment of choice for individuals diagnosed with BPD.10 DBT is a multi-dimensional treatment approach originally created to intervene in high suicidality within the BPD population. DBT is now used successfully to treat a myriad of mental health concerns and contains elements of individual and group therapy, crisis phone sessions, and therapy worksheets, allowing the individual many avenues of support.
In general, people report improvement after six months of treatment with significant and lasting change occurring at around two years. DBT focuses on building skills in four areas; mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness.8 This approach to the treatment of BPD blends behaviorism, humanism, and mindfulness to allow for holistic and sustainable progress.
Schema-Focused Therapy
This approach focuses on helping the individual understand maladaptive schema developed in childhood. This approach can be helpful in assisting people in identifying how unmet needs can lead to unproductive patterns in relationships and general living. What was helpful to us as children for our survival or success may be unproductive and facilitate negative social interactions with others in our adulthood.
Schema-focused therapy helps the individual to identify these unhealthy interaction patterns and ways of being in the world to help facilitate meaningful changes that will increase functioning. People with BPD who are participating in schema therapy report improved self-understanding and increased emotional awareness and regulation.9 Schema-focused therapy is showing promising lasting results but more research is needed to confirm the effectiveness of this approach.
Mentalization-Based Therapy (MBT)
This approach for treatment of BPD incorporates the process of mentalizing, which is how we make sense of ourselves and each other in our subjective daily experiences from a cognitive standpoint. MBT is a highly structured and time-limited approach that incorporates interventions to promote the development of mentalizing. This approach to treatment allows people to understand their own feelings and thoughts and create an alternative and healthier perspective.
This approach allows for an increased stabilization in sense of self and monitoring behaviors, which in-turn aids in developing socially-appropriate means of meeting needs. MBT has demonstrated improved individual outcomes with sustained gains when applied specifically to people with BPD.1 Meta-cognitive approaches, or gaining better understanding and intention around thinking about thoughts can lead to better outcomes for people with personality disorders.
Transference-Focused Psychotherapy
A form of psychodynamic psychotherapy, this approach centers around on the idea that BPD develops from “identity diffusion,” or a splitting (black and white perspectives) that starts in childhood and develops into difficult adult relationships and a lack of self-identity, both inherent to BPD. This approach relies on individuals working closely with a psychotherapist to identify and understand dynamics in past relationships, including childhood, with an emphasis placed on your current reactions in the moment.
The goal of transference-focused psychotherapy with BPD is to help people integrate views of self and others in a more effective manner through the therapist identifying interaction patterns and helping the individual to create more satisfying relationships in their present environment.6 This approach to the treatment of BPD has shown to increase reflective functioning, in turn impacting personality organization.3 A transference-focused psychotherapist will likely not provide their advice or opinions, but rather assist the individual in understanding reactions and social interactions.
Other Types Therapy You May Encounter
In addition to the evidence-based and best-practice treatment approaches for the treatment of BPD, other theories and methodologies may be helpful in managing symptoms or facilitating growth. These approaches may help patients with BPD live more meaningful and productive lives and increase relational satisfaction.
Logotherapy
This approach assists people in making meaning of life, which is negatively correlated with BPD symptomology and success in counseling with patients with BPD is linked to finding purpose.7
Gestalt Psychotherapy
Increasing self-and other awareness and learning how to maintain meaningful contact with others is central to this approach and are also some of the primary concerns for individuals with BPD.
Systems Approach or Family Therapy
Due to the heritability of BPD and the difficulty in social/family interaction inherent to this disorder, family therapy is often an approach that can yield lasting and significant outcomes. Incorporating the entire family system into the treatment of BPD allows for new ways of coping while maintaining support for a new approach to life.
Medication for Borderline Personality Disorder
Psychotherapy is the first line of treatment for BPD due to the social and relational components of the disorder. Also, the disorder is housed in the personality which cannot be easily treated with pharmaceuticals. While talk therapy is the treatment of choice for BPD, medication is often used to assist in regulating mood quickly and managing difficult symptoms.
The symptoms of BPD often include feelings related to depression and anxiety, leading to the use of antidepressants, mood stabilizers, and anxiolytics in a holistic approach to treatment of a myriad of symptoms.
Psychotropic medications used to treat BPD should be prescribed by a psychiatrist or psychiatric nurse practitioner. While there are no medications approved by the FDA solely for the treatment of BPD, practitioners are able to prescribe medication for symptoms related to co-occurring disorders of BPD and symptoms of depression, impulsiveness, anger, and anxiety. Medications that are used are off-label, meaning they do not have a FDA approved indication for the treatment but can be prescribed based on the discretion of the practitioner.
Antidepressants
Selective Serotonin Reuptake Inhibitors (SSRIs) and Selective Norepinephrine Reuptake Inhibitors (SNRIs) are antidepressant medications that can be helpful in alleviating some of the depression symptoms that are often a part of this diagnosis. In addition, 80 to 90% of individuals diagnosed with BPD have a co-occurring mood disorder diagnosis and these patients may benefit greatly from adding an antidepressant to their daily routine.2
Antidepressants must be prescribed by a general practitioner, psychiatrist, or psychiatric nurse practitioner/ physician’s assistant and can assist in regulating feelings of depression to allow for adherence to psychotherapy treatment protocols.
Anxiolytics
Anxiety is a common experience for individuals diagnosed with BPD, with up to 88% of people with BPD reporting co-occurring anxiety diagnoses.2 For people who struggle to manage anxiety, an anti-anxiety medication may be helpful. Caution must be taken as many of the medications in this classification can be habit forming and must be prescribed by a general practitioner, psychiatrist, or psychiatric nurse practitioner.
Some of the most common anti-anxiety medications are benzodiazepines that include alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium). In addition, there are non-benzodiazepine anxiety medications that are less addictive, such as buspirone (Buspar). Anti-anxiety medications are often prescribed on an as-needed basis to assist people in managing panic attacks.
Mood Stabilizers
Unstable mood and difficulty with emotional regulation is a primary symptom of BPD and 15% of people diagnosed with BPD also have a co-occurring bipolar diagnosis that may be effectively treated with a mood stabilizer.2 Mood stabilizers are the most commonly prescribed medication for individuals with a BPD diagnosis.4
There are many options within this classification of psychiatric medications and consultation with a psychiatrist or psychiatric nurse practitioner may be necessary. Mood stabilizers such as carbamazepine (Tegretol), sodium valproate (Depakote), olanzapine (Zyprexa) and lamotrigine (Lamictal) can help the patient with mood regulation and avoid severe mood swings that can interfere with functioning.
Other Medications & Procedures
While medication is not a primary form of treatment for BPD, there are various medications and treatment approaches that might be beneficial to people with BPD. Antipsychotic medications, medications to assist in the treatment of substance abuse, and/or treatments focused on healing from trauma are often effective and beneficial for this population. However, caution must be taken with some approaches, such as EMDR, as people with personality disorders may not experience the traditional outcomes of the approach.
All medications come with a risk of side effects. Talk with your prescriber or pharmacist to learn about side effects and find the appropriate medication for you.
Lifestyle Changes & Self-Help Strategies for Borderline Personality Disorder
Individuals diagnosed with BPD can benefit from using coping skills, learning about the disorder, and incorporating self-help strategies into their daily living. Being aware of symptoms, triggers, and coping skills allows people with BPD to be more intentional in social interactions and increase positive relationships.
Some of the best coping skills and self-help strategies practiced by people with BPD include:
- Coping with self harm: People with BPD have a high likelihood of self-injurious behavior and identifying coping skills that will decrease the harm associated with these behaviors is essential in treating BPD.
- Psychoeducation: Gaining a better understanding of the etiology, symptoms, and outcomes associated with BPD can increase an individual’s ability to identify ways of coping with BPD. Reading books like, I Hate You, Don’t Leave Me, can allow an individual with BPD to feel less isolated and gain a stronger sense of what they want to change.
- Improved social skills: Joining a therapy group, taking a course on social skills, or identifying a plan to increase social communication skills is a positive step towards improved functioning for people with BPD. Learning nuances involved in communication, identifying social cues, and gaining awareness of personal communication styles can greatly improve daily life for individuals diagnosed with BPD.
- Mindfulness: Participating in mindfulness activities, such as meditations and groups, can have a lasting beneficial impact on individuals diagnosed with BPD. Increased intentionality and awareness of the moment can help these individuals in increasing quality of life and overall coping.
- Relationship with self: Intentionally focusing on learning about one’s self and participating in activities that will help people with BPD get in touch with themselves can help to decrease symptoms, especially those related to transient sense of self and lack of self-understanding.
- Emotional processing: Whether through psychotherapy or talking to a good friend, finding tools and people to assist in emotional processing is essential for healthy living for individuals diagnosed with BPD. Identifying emotional coping skills and supports during times of emotional dysregulation helps these individuals avoid negative consequences of difficult emotions.
Hospitalization for Borderline Personality Disorder
Individuals diagnosed with BPD make up about 1.6% of our society, yet account for 20% of psychiatric hospitalizations.2 BPD is a chronic disorder that can be severe enough at times to warrant hospitalization to help the patient stabilize from thoughts of harming self or others. The majority of hospitalizations for BPD result from suicide attempts, heightened suicidality, and self-injurious behaviors.
Inpatient hospitalization for BPD may be voluntary or involuntary, meaning the individual may seek to be hospitalized or may require hospitalization against their will. Whether voluntarily or involuntarily entering a psychiatric hospital, the stay may be anywhere from a few days to a few months. BPD patients willfully seeking treatment may participate in intensive outpatient treatment programs after stabilizing during a short-term inpatient stay. Research suggests long-term hospitalizations are not helpful to individuals with BPD and care should be taken to get the patient stabilized and back in the community as soon as possible.5
The process of entering a psychiatric hospital varies from state to state and facility to facility. Upon entering, a patient with BPD can expect an assessment, meeting with a psychiatrist and social worker, and orientation to the daily schedule, including treatment groups and services. The goal of hospitalization is stabilization of mood and keeping the patient safe. Facilities differ in approach to treatment but in general, patients can expect to receive individual and group psychotherapy, medication management, and case management services. Inpatient services can be very expensive and may be covered by insurance providers.
Questions to Ask About Borderline Personality Disorder Treatments
Due to the chronic and severe nature of BPD, selecting appropriate treatments and providers, as well as accessing necessary self-help resources are essential to positive life outcomes. Finding skilled providers who manage treatment from an evidence-based approach is likely to increase overall functioning for anyone diagnosed with BPD. Knowing what to look for and the right questions to ask are important for quality care.
Questions To Ask About Therapy
Ensuring the treatment received is a best-practice approach to the treatment of BPD is important.
It is crucial to intentionally ask questions about the type of therapy approach taken, including:
- What approach do you take with treating BPD and how long have you been treating this population?
- How often do you meet with individuals and how long are appointments scheduled for?
- Do you have a crisis line or resources available? Do you offer contact between sessions?
- What specialized training do you have in treating BPD?
- On average, how long do you see individuals with BPD before they report improvements?
- Do you give therapy homework and what might that look like?
- What struggles do individuals run into when receiving this form of treatment?
- What support do you offer outside of the traditional weekly therapy hour?
Questions To Ask About Medications
Medication is often an important form of treatment for BPD. Meeting with a psychiatrist or psychiatric nurse practitioner to make sure medications are effective and appropriate is an imperative step in effective treatment.
It is also important to ask questions about the efficacy of medication and side effects, such as:
- What is the success rate of this medication in treating my issue?
- How quickly can I expect relief from this medication?
- Is this medication controlled or habit-forming?
- What are the most commonly reported side effects of this medication?
- How long do people report this medication working before needing to find something else?
- Does this medication interact with any other medications or supplements I am taking?
- What do I need to know about taking this medication?
Questions To Ask About Lifestyle & Self Help
Making adjustments to daily living and working to incorporate mindfulness and emotional regulation skills will improve the daily living of individuals with BPD.
When seeking lifestyle changes and self-help strategies, it is important to ask questions about the usefulness and negative effects, such as:
- What do other people with BPD who have used this approach report were the highlights and struggles?
- Is this practice sustainable and helping my overall well-being?
- Does this change/approach help me feel like I am making progress towards more peaceful and positive living?
- What will I have to give up to make this change? What will I gain?
- What supports do I need to allow this change/approach to be effective and lasting?
- What needs are being met through this change/approach?
Additional Resources for Borderline Personality Disorder
The following are helpful additional resources for anyone seeking treatment for borderline personality disorder:
