How Borderline Personality Disorder Is Treated

Borderline personality disorder (BPD) is characterized by unstable moods, impulsive behaviors, and volatile relationships. It is common in both general and clinical populations, affecting roughly 1.6% of the U.S. population and 20% of the psychiatric inpatient population.

BPD is usually treated with psychotherapy. Unlike other mental disorders, medication is typically not the first-line approach to treating BPD. No medications are approved by the FDA for the treatment of BPD at the moment. This condition cannot be cured, so the goal of treatment is to reduce symptoms and improve quality of life for people with BPD. There is no one-size-fits-all solution. Even so, contrary to what has been previously thought, research has shown that with persistence, people treated for BPD have high rates of remission.

Understanding the Causes of BPD

Borderline personality disorder is caused by a combination of genetic, biological, and environmental factors:

• Family history: People who have a close family member, such as a parent or sibling with the disorder, may be at higher risk of developing borderline personality disorder.
• Brain factors: Studies show that people with borderline personality disorder can have structural and functional changes in the brain especially in the areas that control impulses and emotional regulation. But is it not clear whether these changes are risk factors for the disorder—or caused by the disorder.
• Environmental, cultural, and social factors: Many people with borderline personality disorder report experiencing traumatic life events, such as abuse, abandonment, or adversity during childhood. Others may have been exposed to unstable, invalidating relationships, and hostile conflicts.

Risk factors of BPD overlap with those of other mental disorders that commonly co-occur with borderline personality disorder, including mood disorders like bipolar disorder, anxiety disorder, eating disorders (particularly bulimia), substance abuse, and post-traumatic stress disorder. 

Symptomatically, these conditions also overlap with BPD. For example, a person with borderline personality disorder may have symptoms that meet the diagnosis of major depression, including chronic feelings of emptiness, suicidal thoughts and behaviors, and self-harm.

These factors make seeking treatment much more challenging, and that is why a multifaceted approach to treating BPD is required. 

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a form of psychotherapy (talk therapy) that targets and alters conscious thoughts and observable behaviors while also making a person become more aware of them. Several forms of CBT are specifically designed for treating BPD.

The very nature of borderline personality disorder can make it difficult for people with the disorder to maintain a comfortable and trusting bond with their therapist.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a form of CBT that aims to help remedy the apparent contradictions that plague a person with BPD without invalidating personal experience. “Dialectical” means the interaction of conflicting ideas. In DBT, that means integration of both acceptance and change as necessities for improvement.

The goal of DBT is to address the symptoms of BPD by replacing maladaptive behaviors with healthier coping skills. DBT is available in the form of a skills training group, which is designed to target behavioral skill deficits that are common in patients with BPD, including an unstable sense of self, chaotic relationships, fear of abandonment, emotional lability, and impulsivity and individual psychotherapy.

The four modules of DBT in a skills training group include:

• Core mindfulness:
• Interpersonal effectiveness:
• Emotional regulation
• Distress tolerance

Individual DBT sessions may involve six areas of focus: parasuicidal behaviors, therapy-interfering behaviors, behaviors that interfere with quality of life, behavioral skills acquisition, posttraumatic stress behaviors, and self-respect behaviors.

DBT is effective at reducing self-harm behaviors and suicide attempts, as well as the number of days spent in psychiatric hospitals. One study found at the end of the first treatment year, 77% of patients no longer met criteria for BPD diagnosis. 

Overall response rates have been measured at around 45%, with 31% remaining unchanged and 11% deteriorating. Approximately 15% showed a symptom level equivalent to that of the general population.

Schema-Focused Therapy

Schema-focused therapy works on the premise that people with BPD have four maladaptive life schemas or worldviews that originate in childhood: abandoned/abused child, angry/impulsive child, detached protector, and punitive parent.

Schema-focused therapy takes place in three stages:

• Bonding and emotional regulation
• Schema mode change
• Development of autonomy

The aim is to educate the patient about how these schemas came about during a person’s life and subsequently influence their life patterns, and to replace these unhealthy schemas using four core techniques, including limited reparenting, experiential imagery and dialogue work, cognitive restructuring and education, and behavioral pattern breaking, to help a person with BPD confront daily experiences and past traumatic events. 

Reported improvements following one two-year-long schema-focused therapy program included increased insight, better connection with one’s emotions, increased self-confidence, increased cognitive flexibility in terms of taking alternative perspectives and being less harsh to oneself.

Dynamic Deconstructive Psychotherapy

Dynamic deconstructive psychotherapy (DDP) is a newer option for treatment-resistant BPD. It is a 12-month treatment program that combines translational neuroscience, object relations theory, and deconstruction philosophy in its approach to help people with BPD heal from a negative self-image and maladaptive processing of emotionally charged experiences.

Neuroscience research suggests that individuals having complex behavior problems deactivate the regions of the brain responsible for verbalizing emotional experiences, attaining a sense of self, and differentiating self from other, and instead activate the regions of the brain contributing to hyperarousal and impulsivity. DDP helps people with BPD connect with their experiences and develop authentic and fulfilling connections with others.

This form of therapy works through integrating and verbalizing emotional experiences as well as enhancing interpersonal identity and interactions through greater differentiation of the self and other.

According to one study, approximately 90% of people who undergo a full year of DDP treatment will achieve clinically meaningful improvement, and recovery usually progresses after treatment ends.

Psychodynamic Therapy

Psychodynamic therapy targets the unconscious thought patterns that drive unhealthy conscious thoughts and behaviors. While CBT focuses on thoughts and beliefs, psychodynamic therapy encourages a patient to explore and talk about emotions as well, including those that are contradictory, threatening, or not immediately apparent. The focus is on using therapy to gain emotional, as well as intellectual, insight. 

Other issues that psychodynamic therapy aims to tackle include:

• Understanding avoidance: Psychodynamic therapy also helps people with BPD recognize and overcome the ways they use to avoid distressing thoughts and feelings.
• Identifying patterns: It also focuses on exploring how prior relationships and attachments may provide insight into current psychological problems. 
• Focusing on relationships: It may use the treatment relationship to help patients understand and rework relationship patterns, and help patients see how aspects of their interpersonal experiences originate within the self and counter the tendency to see the outside world (including relationships) as the exclusive source of disappointment or other painful emotion.
• Encouraging free associations: Patients are encouraged to speak as freely as possible about their thoughts, desires, dreams, fears, and fantasies, as they come to mind. 

Like CBT, a few forms of psychodynamic therapy are designed specifically for treating BPD.

Mentalization-Based Therapy

Mentalization-based therapy (MBT) works on the premise that symptoms of BPD stem from an inability or difficulty to mentalize, or the way a person makes sense of themselves and the world around them. A fragile mentalizing capacity vulnerable to social and interpersonal interaction is considered a core feature of BPD. The goal of MBT is to help people with BDP regulate their thoughts and feelings, which allows them to form and maintain interpersonal relationships.

Response rates after a year of treatment have been extremely positive, with patients experiencing general reduction in symptoms and increased psychosocial functioning and overall quality of life. General happiness was also improved and inpatient treatment days were significantly reduced.

Transference-Based Psychotherapy

Transference-based psychotherapy was developed based on the theory that a core feature of BPD is an inability to integrate positive and negative images of self and others, otherwise known as splitting. This form of therapy seeks to help patients see the grey areas in their black-and-white views of both themselves and others. 

It has shown notable improvements in symptoms, including suicidality, depression and anxiety, and psychosocial functioning, as well as personality organization and psychiatric in-patient admissions.

Medications

No medications are approved by the FDA for the treatment of BPD, but some drugs have been found effective in some cases.

Drug used to treat BPD symptoms include:

• Antidepressants are used to treat depressive symptoms like chronic feelings of emptiness and dissatisfaction with life (dysphoria). Examples include tricyclic and tetracyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors (SSRIs).
• Anxiolytics, or anti-anxiety medications, are used to treat symptoms of anxiety, however, they should be used with extra caution because many can be habit-forming, and little research exists to support their use in patients with BPD. Furthermore, some drug classes in this category, like benzodiazepines (e.g. Ativan, lorazepam), may actually worsen BPD symptoms. Due to their potential for abuse, they are not recommended in cases of co-occurring substance use disorder. 
• Antipsychotics like Haldol (haloperidol), Zyprexa (olanzapine), and Clozaril (clozapine) can be used to treat transient psychotic symptoms and thinking problems that may emerge in BPD. These agents can also have mood-stabilizing properties. Research has shown promise in reducing anxiety, paranoia, anger or hostility, and impulsivity in patients with BPD.
• Mood stabilizers may also be useful in conjunction with other forms of treatment. Research shows medications with mood stabilizing properties, such as lithium, can help with the BPD-associated impulsive behavior and rapid changes in emotion.

STEPPS Program

Systems Training for Emotional Predictability and Problem Solving, or simply STEPPS, is a two-person-led cognitive behavioral skills group program designed to be used in conjunction with other treatment methods like psychotherapy and medication for BPD.

Group sessions include up to 12 BPD patients, and take place over 20 weeks with meetings once a week for 2.5 hours in four areas of education meant to help BPD patients understand their diagnosis and develop coping skills. The four areas are psychoeducation, emotion regulation skills, behavioral skills, and emotion handling. It has proven to be an effective intervention with noticeable benefits in impulsivity, negative affectivity, mood, and global functioning achieved after six months.

Prognosis

One way that recovery from BPD has been characterized is by enhanced confidence, better self-understanding, reduced self-blame, and greater self-acceptance.

While improvements in BPD were previously seen as rather rare and prognosis for BPD was considered poor, this has changed over the past two decades. Research now shows many of the most distressing and disabling symptoms of BPD improve during the first few years post-onset. As with other mental illnesses, early detection and intervention have a positive impact on recovery rates and duration.

Now it is well accepted that BPD can have a positive trajectory over time and the rate of remission tends to increase with each subsequent year of treatment. However, functional recovery is more difficult to attain, and many people with BPD will need to revisit treatment options. 

Sustained remission, rather than recovery, is substantially more common, and rates have been shown as high as 78% to 99% in some studies.

A Word From Verywell 

Vast improvements in the way BPD treatment is understood and approached and a strong lean towards combination therapies have greatly improved overall prognosis. Sustained remission is highly possible with treatment. Remember that borderline personality disorder did not develop overnight and treatment may take a long time, but its efficacy makes it a worthwhile pursuit. You should talk to your healthcare provider to find the right combination of treatments for you.