There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years.
There is growing evidence for the role of psychotherapy in the treatment of people with BPD, with indications that both comprehensive and non-comprehensive psychotherapeutic interventions may have a beneficial effect.
Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD,[3] though drop-out rates may be problematic.
[4] University of Washington psychology professor Marsha Linehan is credited with developing the first empirically supported standard treatment for BPD, termed dialectical behavioral therapy (DBT).
The treatment emphasizes balancing acceptance and change (hence dialectic), with the overall goal of helping patients not just survive but build a life worth living.
[8] DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.
Specifically, DBT has been found to significantly reduce self-injury, suicidal behavior, impulsivity, self-rated anger and the use of crisis services among borderline patients.
The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy and traumatic childhood experiences.
Approaches such as DBT and schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior.
A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.
[21] Transference-focused psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization).
[26] Mentalization-based treatment, developed by Peter Fonagy and Antony Bateman, rests on the assumption that people with BPD have a disturbance of attachment due to problems in the early childhood parent-child relationship.
[27] Fonagy and Bateman hypothesize that inadequate parental mirroring and attunement in early childhood lead to a deficit in mentalization, "the capacity to think about mental states as separate from, yet potentially causing actions";[28] in other words the capacity to intuitively understand the thoughts, intentions and motivations of others, and the connections between one's own thoughts, feelings and actions.
Mentalization failure is thought to underlie BPD patients' problems with impulse control, mood instability and difficulties sustaining intimate relationships.
[3] The UK's National Institute for Health and Clinical Excellence (NICE) in 2009 advises against the use of medication for treating borderline personality disorder, recommending that they only be considered for comorbid conditions.
[33] A Cochrane review from 2006 arrived at the same conclusion, but a 2010 update found that some pharmacological interventions (second generation antipsychotics, mood stabilisers and dietary supplementation with omega 3 fatty acids) might provide beneficial effects.
[34] However, the authors warned that total BPD severity is not significantly influenced by any drug and that the evidence generated by the review was based on single study effect estimates.
Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients.
One meta-analysis of two randomly controlled trials, four non-controlled open-label studies and eight case reports has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms.
A random controlled trial by Lieb (2010) found mood stabilizer valproate semisodium showed a significant decrease in interpersonal conflicts and depression.
[52] Efficacy studies often assess the effectiveness of interventions when added to "treatment as usual" (TAU), which may involve general psychiatric services, supportive counselling, medication and psychotherapy.
One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing dialectical behavioral therapy and taking the antipsychotic olanzapine show significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill,[53] although they also experienced weight gain and raised cholesterol.
[55] In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this.
In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist can contribute.
It has been argued that diagnostic categorization can have limited utility in directing therapeutic work in this area, and that in some cases it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.