While borderline personality disorder (BPD) is linked to genetic and biological factors, including temperament and differences in the brain regions responsible for emotional regulation and behavioral control, it primarily develops in response to childhood abuse, trauma, neglect or instability.
Many of the symptoms, or traits, associated with borderline personality disorder can be understood as attempts to adapt to these chaotic early environments. For this reason, the best borderline personality disorder treatment includes interventions that help people process trauma, relinquish childhood fears and learn how to regulate their emotions.
The primary treatment for borderline personality disorder is therapy. However, treatment occasionally involves medications, especially when someone with BPD has co-occurring disorders.
Medications for Treating Borderline Personality Disorder
One of the characteristics of a personality disorder is that it develops by early adulthood or by the end of adolescence. The reason why symptoms of personality disorders are typically called “traits” is that they are established early in life, retained over time, and experienced more as an aspect of the self than a temporary or circumstantial condition. For this reason, using medications to treat borderline personality disorder is relatively rare.
There are a few other reasons that using medication for borderline personality disorder has not been established as a common practice. One is that people with borderline personality disorder frequently engage in self-harm and make suicide attempts at significantly higher rates than the general population. This makes prescribing medications that could potentially result in a lethal overdose a risky approach. Another reason is that clinicians used to believe that borderline personality disorder was almost impossible to successfully treat and did not believe that pharmacotherapy for the condition was viable.
While mental health professionals still take the potential for self-harm into consideration when prescribing borderline personality disorder medication, they are more likely to determine that such interventions have the potential to be successful. Recent research has revealed that borderline personality disorder responds to many interventions, including medications.
Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant medications that are effective in the treatment of depressive and anxiety disorders. These medications work by increasing the availability of serotonin in the brain. Recent research suggests that this increased availability of serotonin can build new neurons and neuronal connections.
For these reasons, SSRIs are often prescribed to people with borderline personality disorder who have comorbid anxiety and depression. They are sometimes prescribed to improve emotional regulation and impulse control.
The same analysis revealed that the amitriptyline is the only antidepressant effective for people with borderline personality disorder who do not also have depressive or anxiety disorders. However, this medication is highly toxic in large amounts, which makes it dangerous to prescribe to people with borderline personality disorder.
Mood Stabilizers and Anticonvulsants
Due to the instability of mood that is common in people with borderline personality disorder, many people have wondered if medications commonly used to treat bipolar disorder would also effectively treat borderline personality disorder. Medications used to treat bipolar disorder traditionally include mood stabilizers and anticonvulsants, or medications first designed to prevent seizures.
In their clinical review, report that mood stabilizers and anticonvulsants do not effectively regulate mood in most people with borderline personality disorder. However, some mood stabilizers, including lamotrigine and topiramate, have been shown to reduce aggression in people with borderline personality disorder. For this reason, these medications are only recommended for people who have difficulty controlling aggressive behavior.
Since the development of second-generation or atypical antipsychotics in the 1990s and early 2000s, these drugs have increasingly been prescribed for conditions other than psychosis. They are often used to stabilize mood, reduce aggression and improve cognitive symptoms that arise in a wide range of psychiatric conditions. Research supports the use of aripiprazole (Abilify) and olanzapine (Zyprexa) to help people with borderline personality disorder manage aggression, affective instability or impulse control problems.
Therapy Options for Borderline Personality Disorder
Therapy for borderline personality disorder has traditionally focused on helping people regulate emotions, control impulses, manage or prevent crises and counter the cognitive distortions that impact their interpersonal functioning.
Improved understanding of borderline personality disorder has helped treatment move beyond symptom management and coping skill development to the resolution of underlying emotional issues, especially those related to trauma. While traditional borderline personality disorder interventions are still effective and frequently used to treat the condition, trauma-focused therapies have become increasingly popular treatment options.
Psychotherapy is the general term for any form of talk therapy in which a person meets with a therapist to discuss psychological issues and find ways to solve them. It remains the primary intervention for most psychiatric conditions, especially those that respond inconsistently or weakly to medications.
The most traditional form of psychotherapy is psychodynamic psychotherapy, the approach pioneered by psychoanalysts like Sigmund Freud and Carl Jung. The focus in psychodynamic therapy is on helping clients gain insights into the origins of their psychological complexes, which often lie in childhood experiences. By bringing unconscious reactions or beliefs from childhood into the light of conscious awareness, a person can be freed from them and learn how to make more conscious choices about what they believe and how they act as adults.
Since most people with borderline personality disorder grew up in abusive or chaotic homes, their unconscious reactions, beliefs and adaptive strategies were shaped by these environments. A psychodynamic therapist can help a person with borderline personality disorder identify and process past experiences and re-shape beliefs about relationships that were derived from experiences with their parents and other authority figures.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is one of the most thoroughly researched and effective interventions for a wide range of psychiatric conditions. It remains the primary therapy for treating depression, anxiety, obsessive-compulsive disorder and other mental health conditions.
Cognitive behavioral therapy for borderline personality disorder is less popular than CBT for other disorders because cognitive elements are less primary in borderline personality disorder. However, it remains an effective choice for the treatment of certain aspects of the disorder.
CBT can help people with borderline personality disorder:
- Address negative beliefs about people and relationships that provoke their intense emotional reactions to interpersonal conflict
- Identify triggers to self-destructive or impulsive behavior and establish alternative methods for coping with them when they arise
- Learn behavioral techniques for self-soothing and relaxation such as progressive relaxation, visualization and grounding techniques
Dialectical Behavior Therapy
One of the best interventions for borderline personality disorder, dialectical behavior therapy (DBT) was derived from CBT and tailored to specifically address borderline symptoms and traits. It has become one of the most widely used and effective interventions for borderline personality disorder and is now used to treat mood and trauma-based disorders as well.
DBT combines CBT techniques with techniques drawn from meditation and mindfulness practices. The goal of DBT is to help people with borderline personality disorder become more aware of their emotions and learn how to hold them in awareness without acting on them. DBT is specifically designed to improve:
- Emotional regulation
- Distress tolerance
- Impulse control
- Interpersonal effectiveness
DBT often uses a stage-based approach in which a person develops skills in the above four areas to establish more behavioral control before moving on to deeper healing work in therapy.
A 2006 study by Linehan, Comtois, and Murray found that DBT reduced the rate of suicide attempts by half in the group of women that were studied. It also reduced rates of hospitalization and premature cessation of treatment.
A 2007 study by Clarkin, Levy and Lenzenweger found transference-focused (psychodynamic) psychotherapy and CBT to be equally effective in improving mood, reducing anxiety, raising levels of general functioning and improving social outcomes in a group of people with borderline personality disorder.
Mentalization is the process by which people come to understand themselves and others, particularly by developing empathy for. Mentalization-based therapy (MBT) is designed to improve this process. It helps people with BPD establish a more stable sense of self and gain more insight into their emotional processes. It can also help people with BPD improve their interpersonal and conflict resolution skills.
Research by Bateman and Fonagy shows that MBT reduced suicidality, improved treatment retention, decreased hospitalization rates, and increased global functioning in people with borderline personality disorder. In other words, it reduced the negative impacts of borderline personality disorder in similar ways and to a similar extent as DBT.
Eye Movement Desensitization and Reprocessing Therapy
Eye movement desensitization and reprocessing therapy (EMDR) was specifically designed to help people process and heal from trauma. In EMDR, people recall traumatic memories while tracking a visual or auditory signal. The way this particular mechanism works to help people re-process trauma is not clear, but research shows that EMDR is effective in treating trauma-related conditions, especially post-traumatic stress disorder (PTSD).
Other therapeutic interventions that have proven to be effective in treating trauma-related conditions are exposure therapy, cognitive processing therapy (CPT) and trauma-focused CBT techniques like stress inoculation training (SIT). People with borderline personality disorder typically have histories of trauma and can benefit from these interventions when they are ready to address it.
Treatments for Borderline Personality Disorder with Co-Occurring Conditions
Almost half of the people with borderline personality disorder have simultaneous anxiety, mood or substance use disorders, and have at least one lifetime episode of these disorders. It is important that clinicians evaluate clients with borderline personality disorder for co-occurring conditions and address them in treatment.
Most people with borderline personality disorder have comorbid anxiety disorders. The combined effects of these co-occurring conditions can make interpersonal situations especially painful and distressing to navigate.
The primary and most effective treatment plan for anxiety disorders includes SSRIs and CBT. These can be safely used in conjunction with interventions for BPD. Behavioral techniques for relaxation and grounding are especially effective for people with symptoms of anxiety and dissociation, helping them reconnect with their bodies and the present moment.
Slightly more than half of the people with borderline personality disorder have co-occurring mood disorders. About 20 percent of people with borderline personality disorder also have major depressive disorder. Comorbid borderline personality disorder and depression can be an especially destructive combination, significantly increasing the risk of suicide and lowering quality of life.
For people with both borderline personality disorder and depression, interventions that enhance emotional regulation, impulse control and crisis prevention are needed to reduce the risk of suicidal gestures and attempts. As with anxiety, depression is most effectively treated with antidepressants and CBT, which can be incorporated into the integrated treatment of borderline personality disorder and depression.
Co-Occurring Substance Use Disorders
Almost half of the people with borderline personality disorder also have a substance use disorder. Treating addiction in people with borderline can be even more complex than treating other comorbid disorders due to the particular qualities of the condition and the way they are affected by substance use.
In DBT, a stage-based approach is typically used to help people establish a baseline of safety and behavioral control before moving into deeper work to resolve trauma. For this reason, it may be best for people to only enter this first stage of DBT work while establishing a baseline of abstinence from substance use.
A form of DBT has been developed especially for the treatment of substance use disorders (DBT-SUD). In this targeted intervention, DBT skills and principles are applied to recovery from both disorders. This includes DBT skills training focused specifically on preventing a recurrence of substance use. Like other forms of DBT, it incorporates both group and individual work.
Researchers analyzed several studies and found that DBT-SUD was effective in improving both borderline personality and substance use disorders. People who received DBT-SUD had more days free from substance use and greater improvement in their overall psychological functioning. A study by Linehan, Schmidt, and others shows that standard DBT also improved recovery from both borderline personality and substance use disorders.
Clinicians who practice DBT uses a dialectical and collaborative approach. This means they act as accepting allies who help clients explore questions without insisting on one right answer. In DBT-SUD, clinicians consider the benefits of to recovery, treating recurrences of use as learning opportunities rather than treatment failures. This approach melds well with other collaborative approaches, like motivational interviewing, that have proven to be effective in the treatment of substance use disorders.
For people with co-occurring borderline personality and substance use disorders, life can become so chaotic and overwhelming that it seems like it can only get worse. However, with treatment, the chaos can clear and life can become not only manageable but joyful. If you or someone you care about is looking for help with co-occurring substance use and borderline personality disorder, contact a representative from The Recovery Village today to learn how to get started on the path to recovery.