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Perspectives Choi-Kain, Lois W. MD; Albert, Elizabeth B. BA; Gunderson, John G. MD From Harvard Medical School (Drs. Choi-Kain and
Gunderson) and McLean Hospital, Belmont, MA (Drs. Choi-Kain and Gunderson, and Ms. Albert). Original manuscript received 16 October 2015, accepted for publication subject to revision 4 December 2015; revised manuscript received 8 January 2016. Correspondence: Lois W. Choi-Kain, MD, McLean Hospital, 115 Mill St., Belmont, MA 02478. Email:
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click here to go directly to the CME page for further information. doi: 10.1097/HRP.0000000000000113Evidence-Based Treatments for Borderline Personality Disorder: Implementation, Integration, and Stepped Care
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Abstract
There are several treatments that are most often used to manage BPD
Dialectical behavior therapy (DBT) focuses on the concept of mindfulness, or paying attention to the present emotion. DBT teaches skills to control intense emotions, reduce self-destructive behavior, manage distress, and improve relationships. It seeks a balance between accepting and changing behaviors. This proactive, problem-solving approach was designed specifically to treat BPD. Treatment includes individual therapy sessions, skills training in a group setting, and phone coaching as needed. DBT is the most studied treatment for BPD and the one shown to be most effective.
Mentalization-based therapy (MBT) is a talk therapy that helps people identify and understand what others might be thinking and feeling.
Transference-focused therapy (TFP) is designed to help patients understand their emotions and interpersonal problems through the relationship between the patient and therapist. Patients then apply the insights they learn to other situations.
Good Psychiatric Management: GPM provides mental health professionals an easy-to-adopt “tool box” for patients with severe personality disorders.
Medications cannot cure BPD but can help treat other conditions that often accompany BPD such as depression, impulsivity, and anxiety. Often patients are treated with several medications, but there is little evidence that this approach is necessary or effective. People with BPD are encouraged to talk with their prescribing doctor about what to expect from each medication and its side effects. 1
Self-Care activities include: regular exercise, good sleep habits, a nutritious diet, taking medications as prescribed, and healthy stress management. Good self-care can help to reduce common symptoms of BPD such as mood changes, impulsive behavior, and irritability.
1. Zanarini MC, Frankenburg FR. omega-3 Fatty acid treatment of women with borderline personality disorder: a double-blind, placebo-controlled pilot study. Am J Psychiatry. 2003 Jan;160(1):167–9.
Diagnosis
Personality disorders, including borderline personality disorder, are diagnosed based on a:
- Detailed interview with your doctor or mental health provider
- Psychological evaluation that may include completing questionnaires
- Medical history and exam
- Discussion of your signs and symptoms
A diagnosis of borderline personality disorder is usually made in adults, not in children or teenagers. That's because what appear to be signs and symptoms of borderline personality disorder may go away as children get older and become more mature.
Treatment
Borderline personality disorder is mainly treated using psychotherapy, but medication may be added. Your doctor also may recommend hospitalization if your safety is at risk.
Treatment can help you learn skills to manage and cope with your condition. It's also necessary to get treated for any other mental health disorders that often occur along with borderline personality disorder, such as depression or substance misuse. With treatment, you can feel better about yourself and live a more stable, rewarding life.
Psychotherapy
Psychotherapy — also called talk therapy — is a fundamental treatment approach for borderline personality disorder. Your therapist may adapt the type of therapy to best meet your needs. The goals of psychotherapy are to help you:
- Focus on your current ability to function
- Learn to manage emotions that feel uncomfortable
- Reduce your impulsiveness by helping you observe feelings rather than acting on them
- Work on improving relationships by being aware of your feelings and those of others
- Learn about borderline personality disorder
Types of psychotherapy that have been found to be effective include:
- Dialectical behavior therapy (DBT). DBT includes group and individual therapy designed specifically to treat borderline personality disorder. DBT uses a skills-based approach to teach you how to manage your emotions, tolerate distress and improve relationships.
- Schema-focused therapy. Schema-focused therapy can be done individually or in a group. It can help you identify unmet needs that have led to negative life patterns, which at some time may have been helpful for survival, but as an adult are hurtful in many areas of your life. Therapy focuses on helping you get your needs met in a healthy manner to promote positive life patterns.
- Mentalization-based therapy (MBT). MBT is a type of talk therapy that helps you identify your own thoughts and feelings at any given moment and create an alternate perspective on the situation. MBT emphasizes thinking before reacting.
- Systems training for emotional predictability and problem-solving (STEPPS). STEPPS is a 20-week treatment that involves working in groups that incorporate your family members, caregivers, friends or significant others into treatment. STEPPS is used in addition to other types of psychotherapy.
- Transference-focused psychotherapy (TFP). Also called psychodynamic psychotherapy, TFP aims to help you understand your emotions and interpersonal difficulties through the developing relationship between you and your therapist. You then apply these insights to ongoing situations.
- Good psychiatric management. This treatment approach relies on case management, anchoring treatment in an expectation of work or school participation. It focuses on making sense of emotionally difficult moments by considering the interpersonal context for feelings. It may integrate medications, groups, family education and individual therapy.
Medications
Although no drugs have been approved by the Food and Drug Administration specifically for the treatment of borderline personality disorder, certain medications may help with symptoms or co-occurring problems such as depression, impulsiveness, aggression or anxiety. Medications may include antidepressants, antipsychotics or mood-stabilizing drugs.
Talk to your doctor about the benefits and side effects of medications.
Hospitalization
At times, you may need more-intense treatment in a psychiatric hospital or clinic. Hospitalization may also keep you safe from self-injury or address suicidal thoughts or behaviors.
Recovery takes time
Learning to manage your emotions, thoughts and behaviors takes time. Most people improve considerably, but you may always struggle with some symptoms of borderline personality disorder. You may experience times when your symptoms are better or worse. But treatment can improve your ability to function and help you feel better about yourself.
You have the best chance for success when you consult a mental health provider who has experience treating borderline personality disorder.
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Coping and support
Symptoms associated with borderline personality disorder can be stressful and challenging for you and those around you. You may be aware that your emotions, thoughts and behaviors are self-destructive or damaging, yet you feel unable to manage them.
In addition to getting professional treatment, you can help manage and cope with your condition if you:
- Learn about the disorder so that you understand its causes and treatments
- Learn to recognize what may trigger angry outbursts or impulsive behavior
- Seek professional help and stick to your treatment plan — attend all therapy sessions and take medications as directed
- Work with your mental health provider to develop a plan for what to do the next time a crisis occurs
- Get treatment for related problems, such as substance misuse
- Consider involving people close to you in your treatment to help them understand and support you
- Manage intense emotions by practicing coping skills, such as the use of breathing techniques and mindfulness meditation
- Set limits and boundaries for yourself and others by learning how to appropriately express emotions in a manner that doesn't push others away or trigger abandonment or instability
- Don't make assumptions about what people are feeling or thinking about you
- Reach out to others with the disorder to share insights and experiences
- Build a support system of people who can understand and respect you
- Keep up a healthy lifestyle, such as eating a healthy diet, being physically active and engaging in social activities
- Don't blame yourself for the disorder, but recognize your responsibility to get it treated
Preparing for your appointment
You may start by seeing your primary care doctor. After an initial appointment, your doctor may refer you to a mental health provider, such as a psychologist or psychiatrist. Here's some information to help you prepare for your appointment.
What you can do
Before your appointment, make a list of:
- Any symptoms you or people close to you have noticed, and for how long
- Key personal information, including traumatic events in your past and any current major stressors
- Your medical information, including other physical or mental health conditions
- All medications you take, including prescription and over-the-counter medications, vitamins and other supplements, and the doses
- Questions you want to ask your doctor so that you can make the most of your appointment
Take a family member or friend along, if possible. Someone who has known you for a long time may be able to share important information with the doctor or mental health provider, with your permission.
Basic questions to ask your doctor or a mental health provider include:
- What's likely causing my symptoms or condition?
- Are there any other possible causes?
- What treatments are most likely to be effective for me?
- How much can I expect my symptoms to improve with treatment?
- How often will I need therapy sessions and for how long?
- Are there medications that can help?
- What are the possible side effects of the medication you may prescribe?
- Do I need to take any precautions or follow any restrictions?
- I have these other health conditions. How can I best manage them together?
- How can my family or close friends help me in my treatment?
- Do you have any printed material that I can take? What websites do you recommend?
Don't hesitate to ask questions during your appointment.
What to expect from your doctor
A doctor or mental health provider is likely to ask you a number of questions. Be ready to answer them to save time for topics you want to focus on. Possible questions include:
- What are your symptoms? When did you first notice them?
- How are these symptoms affecting your life, including your personal relationships and work?
- How often during the course of a normal day do you experience a mood swing?
- How often have you felt betrayed, victimized or abandoned? Why do you think that happened?
- How well do you manage anger?
- How well do you manage being alone?
- How would you describe your sense of self-worth?
- Have you ever felt you were bad, or even evil?
- Have you had any problems with self-destructive or risky behavior?
- Have you ever thought of or tried to harm yourself or attempted suicide?
- Do you use alcohol or recreational drugs or misuse prescription drugs? If so, how often?
- How would you describe your childhood, including your relationship with your parents or caregivers?
- Were you physically or sexually abused or were you neglected as a child?
- Have any of your close relatives or caregivers been diagnosed with a mental health problem, such as a personality disorder?
- Have you been treated for any other mental health problems? If yes, what diagnoses were made, and what treatments were most effective?
- Are you currently being treated for any other medical conditions?