Treatments of Borderline Personality Disorder

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Adapted from

Borderline Personality Disorder, which affects about two percent of the general population, is a mental disorder that is characterized by pervasive patterns of instability in affect regulation, impulse control, interpersonal relationships and self-image[1]. Symptoms are accompanied by suicidal thoughts and attempts to inflict self-harm[2]. The management of borderline personality disorder poses a challenge to mental-health professionals due to the lack of effective treatments available. In the past two decades, new treatment options, like specialized psychotherapies, have emerged, but their availability remains limited[2]. These newly developed specialized psychotherapies have been proven to largely reduce the symptoms experienced by borderline personality disorder patients and can maintain their reduction over time[2]. Apart from the implementation of psychotherapies in the management of this disorder, pharmacotherapies have also been introduced. Some medications show promise, but overall, treating patients with drugs is limited and not as beneficial as the use of specialized psychotherapies[2].


Mood Stabilizers

Mood stabilizers are considered to be a kind of psychiatric medication that implemented in the treatment of mood disorders. Mood disorders are often characterized by the existence of a persistent exaggerated mood state[3]. The following is also witnessed in borderline personality disorder through the presence of feelings of anxiety, agitation, irritation, anger, self-harming behaviors (suicidal ideas and behaviors) and depressive symptoms. Mood stabilizers, like divalproex sodium and lithium carbonate, positively affect a borderline personality patient’s mood state by decreasing the symptoms pertaining to instabilities in their mood states. In a multicenter, randomized, double blind, placebo-controlled study conducted by Hollander and his colleagues, it was discovered that divalproex sodium was superior to the placebo in treating impulsive aggression, irritability and global severity[4]. In other words, divalproex also reduced signs of irritation, anger and self-harming behavior in borderline personality disorder patients[5]. Sodium plays a role in reducing symptoms related to fluctuations in mood state. Similarly, in a six week double blind placebo controlled study, experimenters discovered that lithium carbonate also reduced signs of irritation, anger and self-harming behavior in borderline personality disorder patients[5].


Antipsychotics are mainly used in the management of psychosis. Similar to the symptoms presented by patients with psychosis, those with borderline personality disorder are also haunted by delusions, hallucinations and disordered thoughts[3]. Psychiatrists prescribe drugs like asenapine and a combination of sertraline and aripiprazole, to aid in the management process of patients who suffer from the psychotic effects of borderline personality disorder. Martín-Blanco et al. tested the benefits of asenapine by conducting an open-label study, where patients were exposed to the drug for an eight week time period. At the end of the study it was concluded that asenapine is effective in treating not only psychosis-like symptoms, but impulsive and cognitive symptoms as well, by decreasing impulsive behaviors and thereby producing better cognition[6]. The negative effects presented by the existence of psychotic-like symptoms diminish when patients are treated with a combination of sertraline and aripiprazole. It is important to note that this way of treatment is only effective for patients who have previously responded to sertraline. Bellion and his colleagues examined the effects of the combination of sertraline and aripiprazole on patients with borderline personality disorder. It was concluded the combination treatment reduces impulsivity as it targets psychotic-like symptoms and overall improved the patient’s psychopathology[7]. In other words, this treatment is most beneficial to patients who exhibit high levels of impulsive behavior and dissociative thoughts.

Is it Really Working?
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Adapted from


The most important class of antidepressants that are beneficial to individuals with borderline personality disorder are selective serotonin reuptake inhibitors (SSRIs). SSRIs are used to treat symptoms related to lability, impulsivity and aggression[8]. Rinne et al, examined the effects of the SSRI fluvoxamine on borderline personality disorder patients by conducting a double-blind placebo controlled randomized trial. In this trial patients were exposed to fluvoxamine for six weeks followed by a follow-up twelve weeks after the start date. It was discovered that fluvoxamine improved fluctuations between different moods, but had no effect on impulsivity and aggression[8]. Other antidepressants like fluoxetine have also been shown to have positive effects on borderline personality disorder patients. For instance, in an 8 week open-label trial, patients showed signs of decreased impulsivity, hostility, paranoia, irritability, anxiety, obsessive-compulsive symptoms and were less likely to engage in activities related to substance abuse[9].


Dialectic Behavioral Therapy

An essential feature of borderline personality disorder is emotional dysregulation. Emotional dysregulation is characterized by an uncontrollable and rapid onset of a sad mood, in which the individual finds it very difficult to be able to calm down[10]. This in turn is responsible for the production of impulsivity, which is another core feature of this disorder. Patients suffering from emotional dysregulation are often encouraged to look to dialectic behavioral therapy for help. Dialectic behavioral therapy is a form of psychotherapy that incorporates individual therapy and group skills training to address specific behavioral, cognitive and emotional symptoms[11].It teaches patients how to regulate their emotions and tolerate stressful situations to avoid and limit episodes of behavioral dysregulation[11]. A number of studies have been conducted to prove the positive outcomes produced by this form of treatment, but one conducted by Linehan et al, is worth mentioning. In a two year randomized trial study, it was discovered that dialectic behavioral therapy was exceptional in the reduction of episodes related to parasuicidal behavior. Subjects were half as likely to partake in suicidal and self-injurious acts and maintained this behavior over the following two years, thereby verifying that this treatment does have prolonging effects on patients[12].

Mentalization-Based Therapy

Mentalization-based treatment aims to increase the patient’s awareness of his or her own feelings and those of others[10]. In other words, it teaches patients how to mentalize, which is the ability to be attentive to one’s own mental states and those of others[13]. Patients with borderline personality disorder have impaired mentalization capabilities, thus resulting in problems pertaining to the regulation of their emotions and controlling their impulsivity[13]. Therefore, practitioners suggest the mentalization-based treatment to help patients regulate their emotions and thoughts, thus allowing them to have a more stable sense of self and providing them with the ability to create relationships that will be maintained over time. To verify the claims mentioned above, Bateman and Fonagy conducted an eight year follow up study where participants were asked to return five years after the completion of the treatment. Patients receiving mentalization-based treatment showed a decrease of self-mutilatory and suicidal behavior coupled with better social and interpersonal functioning six months after treatment onset[14]. These results remained consistent until the end of the treatment and continued to appear five years after the cessation of treatment[14]. In other words, the beneficial effects produced by this method of treatment do continue to exist even after the discontinuation of treatment.

Transference-Focused Psychotherapy

Transference-focused psychotherapy is based on Kernberg’s theory of early childhood trauma. Kernberg explains that excessive childhood aggression can cause a split in the child’s negative and positive images of him or herself and those around him[10]. The child is unable to merge the two images, thus causing an unrealistic perception of him or herself and of those around him. In other words, borderline personality disorder patients display high levels of negativity which leads to the inability to achieve an integrated sense of self[11]. Therefore, the primary goal set out by this treatment is to achieve a more integrated sense of self by eliminating the presence of self-destructive behavior. In a ninety patient multiwave study supervised by Clarkin et al, patients were randomly assigned to undergo either transference-focused psychotherapy, dialectical behavior therapy or a supportive treatment where medication was incorporated. All three treatments showed positive changes in depression, anxiety, global functioning and social functioning, but transference-focused psychotherapy was superior to the rest in developing secure integration and a greater reflective capacity[15].

Schema-Focused Approach vs. Treatment as Usual
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Adapted from Farrell et al. (2009)[16] This figure shows the changes in DIB
(measures social adaptation, impulse/action patterns, affects, psychosis and interpersonal relations),
BSI (focuses on symptoms, experiences and treatment),
SCL-90 (measures global severity, anxiety, anger-hostility and psychoticism),
and GAF (occupational, social and psychological functioning) between patients who were underwent
the schema-focused psychotherapy and those who took take in treatment as usual.
It can be concluded that those who took part in the schema-focused psychotherapy
showed greater signs of symptom reduction and overall global improvement.

Schema-Focused Approach

Borderline personality disorder patients possess four dysfunctional schemas that are responsible for their sustained psycho-pathology and dysfunction[11]. Schema-focused approach strives to achieve a functional schema state where the patient is no longer controlled by his or her dysfunctional schemas. This mode of therapy incorporates behavioral, cognitive and experimental techniques to help insure the reduction of symptoms related to identity disturbance, dissociation/paranoia and physically self-destructive acts[11]. The effectiveness of the schema-focused approach was studied by Farrell and her colleagues in an eight month study where patients were exposed to either a treatment as usual or a combination of treatment as usual with the schema focused approach. Significant reduction in global severity of psychiatric symptoms and overall improved functioning was seen when patients were exposed to a combination of treatment as usual and schema focused approach[16]. At the end of treatment, 94% of those exposed to the combination treatment no longer met the diagnostic criteria for borderline personality disorder[16]. In other words, the schema focused approach was proven to be effective in reducing all major symptoms of borderline personality disorder which include impulsive behavior, self-injurious behavior and self-hatred.

1. Lieb, K., M. C. Zanarini, C. Schmahl, M. M. Linehan, and M. Bohus. (2004) Borderline Personality Disorder. The Lancet, 364.(9432): 453-461.
2. Biskin, R. S., & Paris, J. (2012). Management of Borderline Personality Disorder. Canadian Medical Association Journal, 184(17): 1897-1902.
3. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. text rev.).
4. Hollander, E., Tracy, K. A., Swann, A., Coccaro, E., McElroy, S., Wozniak, P., et al. (2003). Divalproex in the Treatment of Impulsive Aggression: Efficacy in Cluster B Personality Disorders. Neuropsychopharmacology, 28, 1186-1197.
5. Belli, H., Ural, C., & Akbudak, M. (2012). Borderline Personality Disorder: Bipolarity, Mood Stabilizers and Atypical Antipsychotics in Treatment. Journal of Clinical Medicine Research, 4(5), 301-308.
6. Martín-Blanco, A., Patrizi, B., Villalta, L., Gasol, X., Soler, J., Gasol, M., et al. (2013). Asenapine in the Treatment of Borderline Personality Disorder: An Atypical Antipsychotic Alternative. International Clinical Psychopharmacology, 29, 120-123.
7. Bellino, S., Paradiso, E., & Bogetto, F. (2008). Efficacy and Tolerability of Aripiprazole Augmentation in Sertraline-Resistant Patients with Borderline Personality Disorder. Psychiatry Research, 161(2), 206-212.
8. Rinne, T., den Brink, W. v., Wouters, L., & Dyck, R. v. (2002). SSRI Treatment of Borderline Personality Disorder: A Randomized, Placebo-Controlled Clinical Trial for Female Patients with Borderline Personality Disorder. American Journal of Psychiatry, 159(12), 2048-2054.
9. Zanarini, M. (2004). Update on Pharmacotherapy of Borderline Personality Disorder. Current Psychiatry Reports, 6(1), 66-70.
10. Zanarini, M. C. (2009). Psychotherapy of Borderline Personality Disorder. Acta Psychiatrica Scandinavica, 120(5), 373-377.
12. Linehan, M. M., Comtois, K., Murray, A., Brown, M., Gallop, R., Heard, H., et al. (2006). Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry, 63(7), 757-766.
13. Bateman, A., & Fonagy, P. (2010). Mentalization Based Treatment for Borderline Personality Disorder. World Psychiatry, 9, 11-15.
14. Bateman, A., & Fonagy, P. (2008). 8-Year Follow-Up Of Patients Treated For Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment As Usual. American Journal of Psychiatry, 165(5), 631-638.
15. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). [ Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study]. American Journal of Psychiatry, 164(6), 922-928.
16. Farrell, J., Shaw, I., & Webber, M. (2009). A Schema-focused Approach to Group Psychotherapy for Outpatients with Borderline Personality Disorder: A Randomized Controlled Trial. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 317-328.

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