Treatment of Borderline personality Disorder

People seeking treatment for Borderline personality disorder (BPD) are likely to feel stigmatized in their interactions with mental health crisis teams and in emergency departments. BPD is seen as a lifelong disorder that is untreatable; such presentations often evoke negative reactions from caregivers. Some might even find such presentations unnecessary over-utilisation of mental health resources. In fact, patients with BPD can be cautiously optimistic about their prognosis as many treatments exist that can profoundly improve their lives.

When to diagnose Borderline?

BPD can often be identified in adolescents and young adults, and it is good time to look for the core symptoms and its stability. A preventative approach recommends early psychological intervention to modify the course of the illness and limit inter-personal dysfunction. Although the course of BPD is generally positive, some patients do experience relapses over time.

Evidence-Based Treatments for BPD

Dialectical Behavioral Therapy (DBT)

The most well known treatment for BPD is DBT. Developed by Marsha Linehan, this form of treatment is offered in a structured fashion, focused on skills acquisition and behavioural shaping. DBT formulates the problems of BPD as a result of the transaction between individuals born with high emotional sensitivity and “invalidating environments”. This aligns to some extend with the inverted iceberg hypothesis of Borderline personality which Dr Divakaran uses to hypothesise BPD.

The inverted iceberg hypothesis.

Core DBT interventions based on symptoms:

  • Emotional sensitivity- Skills acquisition and mindfulness training.
  • Fear of abandonment- Validation by therapist, telephone support
  • Identity distortion- Improve self-efficacy and interpersonal efficiency though one on one and group sessions.

Mentalization-Based Treatment (MBT)

Mentalization refers to the capacity human beings to imagine the thoughts and feelings in one’s own and other’s minds to understand world within and around us. Any shortcoming in this skill will lead to unstable self-image, chronic trust issues and conflict with others. MBT proposes that patients to operate with pathological certainty about other’s motives, thus disconnecting from reality, and a desperate need for proof of feelings through action.

Core MBT interventions based on BPD symptoms:

  • Emotional sensitivity: Strengthening the patient’s capacity to mentalize under the stress of attachment activation.
  • Fear of  abandonment- guided self exploration of emotional and interpersonal situation through a more grounded mentalizing stance. Involves individual and group therapy formats.
  • Identity distortion- Maintenance of mentalizing through hyper-activated attachment.

Transference-Focused Psychotherapy (TFP)

Transference-focused psychotherapy (TFP) is a psychoanalytically oriented psychotherapy. Kernberg defined identity diffusion, primitive defense mechanisms (e.g., splitting), unstable reality testing, internally and externally expressed aggression, and conflicted internal working models of relationships as key features of personality disorders at borderline level of organization.

Core TFP interventions based on BPD symptoms:

  • Emotional sensitivity- internally and externally expressed aggression joined examined in therapy by interpretation of transference.
  • Fear of abandonment- Reduce splitting of good and bad aspects of themselves and others.
  • Identity distortion- Described as identity diffusion by Kernberg, resolved through fostering more balanced and integrated ways of thinking about oneself.

Schema-Focused Therapy (SFT)

Schema-focused therapy (SFT) is a type of cognitive therapy focused on generating structural changes to a patient’s personality. This is done through encouraging attachment between therapist and client in a process described as “limited re-parenting”.

Therapy focuses on four schema modes of BPD:

  • detached protector
  • punitive parent
  • abandoned/abused child
  • angry/impulsive child.

These dysfunctional patterns are modified through a variety of cognitive, behavioural and experiential techniques to be replaced by more functional alternatives.

What is the evidence for Medical treatment (pharmacological treatment) of Borderline personality disorder?

The evidence is divided when it comes to the medical (pharmacological) treatment of Borderline personality Disorder (BPD). Despite this, in clinical practice most individuals receive some form of pharmacological management.

Personality disorders are enduring maladaptive patterns of thinking and behaviour, hence are less likely to be modified by pharmacological intervention. However, medical and psychiatric co-morbidity is a norm than an exception in borderline personality. Hence treatment is often directed towards the superficial psychological states such as depression and anxiety rather than the core symptoms of BPD.

Some professional groups such as American Psychiatric Association (APA) proposed a symptom-targeted approach to treat specific BPD symptom domains. For instance, Anti-depressants such as SSRIs may be used for affective dysregulation and impulsivity, and low-dose atypical antipsychotics for “cognitive-perceptual” symptoms such as paranoia and dissociation. However, other authorities such as those in UK do not support such conclusions. There is some emerging data that medications might alleviate some of these symptoms to a mild to moderate degree. To bring some clarity to this issue, we have summarised some of the latest findings in this regard.

Data from recent meta-analysis may be summarized as below

BPD symptomEvidence based medication
Mood swingsAnti-psychotics –Haloperidol, Aripiprazole, Olanzapine

Mood stabilisers-Lamotrigine, Valproate, Topiramate

Impulsive behaviors and AngerLamotrigine and Topiramate

Aripiprazole

Cognitive-perceptual eg:Hearing voicesAripiprazole , Olanzapine
Co-morbid depression and anxietyAnti-depressants
Fear of abandonmentNo medical treatment
Feeling of emptinessNo medical treatment
Identity disturbanceNo medical treatment

Reference: Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What Works in the Treatment of Borderline Personality Disorder. Current behavioral neuroscience reports, 4(1), 21–30. https://doi.org/10.1007/s40473-017-0103-z

As discussed in the section on Borderline personality elsewhere on this website, the core symptoms can be divided into impulsive and compulsive symptoms. This is driven by the hypothesis that the observed symptoms are the result of the trait-environment interaction. For example, a young girl with perfectionism is more likely to compulsively ask for reassurance from their partner about the future of their relationship. On the contrary, those with significant impulsive traits may impulsively break-up from their partner when they are in doubt. Impulsive traits respond to mood stabilizers where as compulsive symptoms respond to Anti-depressants. Very often these traits are equally prominent and hence would benefit from a combination of both.

At Mindoc, we strive to provide a tailored treatment program for those with Borderline personality, which may involve psychotherapy alone, or a combination of medications and psychotherapy. This is often done in a shared care model with your psychologist. Book online today to arrange an appointment with one of our psychiatrists.