Borderline Personality Disorder Treatment & Management

The treatment of BPD is largely based on psychotherapeutic interventions, however, patients with BPD may also present with symptoms, such as anxiety, depression, transient psychosis that can be managed with medication. Patients with borderline personality disorder (BPD) are often impulsive thereby increasing their risk of overdoses of their prescribed medication. Antidepressants, lithium, and other mood stabilizers must be prescribed with caution and monitored carefully as part of an ongoing therapeutic relationship. Because of their relative safety, selective serotonin reuptake inhibitors (SSRIs) are the agents of choice for treating symptoms of anxiety and depression. Antipsychotic medication treatment may become necessary to manage psychotic symptoms, albeit their use is associated with potential adverse effects (eg, tardive dyskinesia or neuroleptic malignant syndrome).

Suicidal behavior may be a chronic problem. Although patients with BPD often threaten suicide due to poor emotion regulation and poor frustration tolerance, a clinician must never ignore suicide threats or attempts. In children and adolescents, any suicidal ideation or attempt should be treated with a thorough psychiatric evaluation and appropriate inpatient hospitalization to ensure the patient’s safety.

Because of the boundary issues in patients with BPD, boundaries must be strictly observed. These patients are particularly likely to be seductive, test boundaries, and even to make false allegations.

If BPD or borderline disorder of childhood is suspected, a child psychiatrist or other appropriately trained mental health professional should be consulted.

Inpatient care is generally not indicated, unless the goals of treatment are well defined. However, some individuals with BPD need to be hospitalized as a result of suicidal or other self-injurious behavior. The hospital stay should be as short as possible; all but the briefest hospitalizations are likely to lead to regression.

Many individuals have chronic suicidal ideation. In such cases, therapists are placed in a difficult position. They must weigh the following factors:

• The intensity of the individual’s thoughts

• The risk that the individual will do something impulsive

• The safety net the person has in the community

• The likelihood that the patient will call before doing anything

• The likelihood that the suicide attempt will prove fatal if the patient does take action to hurt himself or herself

The therapist’s willingness to be constantly available by phone and to make frequent calls to monitor the patient and provide support can affect the level of safety. Some therapists find it necessary to hospitalize their BPD patients when they go on vacation because the risk of self-injurious behavior is so high. Major depressive disorder and poor social adjustment increase the risk of a suicide attempt.

Psychotherapy, such as Dialectical Behavior therapy (DBT) is often a first line approach for BPD and has been shown to be useful and effective despite the challenges of patent regression, overwhelming affect, and impulsive behavior.

Kernberg, historically, prior to the development of DBT believed that psychoanalytic therapy was the most effective approach, however currently this type of treatment is not considered the first line of intervention. ^[11] The goal of this type of therapy is to resolve pathologic internalized representations of interpersonal relationships. The therapist requires adequate support systems, including access to prolonged hospitalization, which might be necessary.

A second view regarding psychotherapy for BPD is that the regressive transference resulting from analytically oriented treatment is often detrimental to the patient. According to proponents of this view, a supportive, reality-oriented approach in which the goal of therapy is a gradual social adjustment in the framework of a realistic therapeutic relationship is more beneficial.

A third view is that experiences are more likely to benefit the patient than explanations are. Thus, the therapist remains calm, without anxiety or anger, while remaining emotionally available. In this setting, the patient can learn to tolerate the hateful and destructive feelings that arise because of transference and, eventually, to replace them with more constructive and positive reactions. The patient also internalizes a calm, soothing supportive object.

Dialectic behavior therapy (DBT) is a modification of standard cognitive-behavioral techniques designed specifically for the treatment of BPD. ^{[6, 28]} Currently, DBT is the only data-supported therapy for BPD. Although DBT was developed as an outpatient program, it has been modified for use in hospital settings and among more diverse populations. Its focus is on teaching patients the following 4 skills:

• Mindfulness (attention to one’s experience)

• Interpersonal effectiveness (predominantly assertiveness)

• Emotional regulation

• Distress tolerance without impulsivity

In randomized clinical trials, DBT was more effective than usual treatment in reducing suicidal and self-injurious behaviors, treatment dropout, hospitalizations, and self-reports of anger and anxious ruminations. ^{[1, 2, 29]} Increased rates of global adjustment were observed after 1 year of treatment, and these gains were maintained over the subsequent year.

In the treatment of children with BPD traits, family-oriented interventions appear to be both more beneficial to the patient and less likely to further undermine parental self-esteem. Many studies of these children highlight the importance of early acquisition of self-control for predicting a good developmental outcome. In 1982, Hanson et al demonstrated that most children and adolescents with BPD traits appear to benefit from structured day programs with strong behavioral management components. ^[7]

Historically, treatment of patients with BPD has been difficult. In any treatment approach, the therapist must combine elements of conflict resolution and social learning to minimize and limit aggression and impulsivity. Consultants must be readily available, and the therapist must have access to appropriate hospitalization for periods of severe regression and heightened suicidal risk.

However, the therapist must also limit inpatient treatment whenever possible, both because of the increased costs and because of the inherent difficulties with inpatient treatment of this population (including possible severe regression after admission and destructive countertransference enactments when staff training or supervision is less than ideal). Several authors have reported that offering a truly appropriate and adequate course of treatment costs substantially less than using crisis interventions when required.

Patients with BPD tend to have strong placebo responses to medication; thus, impressive short-term improvement might occur but then fade unexpectedly. Impulsivity, affective instability, and psychosis are the significant manifestations of borderline pathology that might necessitate pharmacologic treatment.

SSRIs are strongly preferred to the other classes of antidepressants. Benzodiazepines are contraindicated because they reduce inhibitions and are therefore likely to increase impulsivity; furthermore, patients with BPD are prone to sedative addiction. Risperidone and naltrexone may be considered.

Selective serotonin reuptake inhibitors

When used at high doses, SSRIs appear to reduce impulsivity and aggression; however, their antidepressant effects are less impressive than those of other drugs. An important advantage of SSRIs is their relative safety; this is especially important because patients with BPD commonly take overdoses of their prescribed medication. The use of TCAs, lithium, and other mood stabilizers is usually not indicated without specific relevant symptoms and a strong, ongoing therapeutic relationship.

Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with TCAs. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered in the treatment of a child or adolescent with a mood disorder.

Special concerns in children

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory stating that most SSRIs are not suitable for use by persons younger than 18 years for treatment of “depressive illness.” After review, this agency decided that the risks that SSRI therapy poses to pediatric patients outweigh the benefits, except in the case of fluoxetine, which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in children being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declined rather than rose with the use of antidepressants. To date, this is the largest study to have addressed this issue. ^[30]

The evidence currently available does suggest that obsessive-compulsive disorder (OCD) and other anxiety disorders treated with SSRIs are associated with an increased risk of suicide.

Other agents

Low-dose neuroleptics are effective in the short term for control of transient psychotic symptoms, as well as agitation. Antipsychotic agents have long been used to control impulsivity and aggression in patients with BPD, though SSRIs are preferred because of their more benign adverse effect profile. If the use of an antipsychotic agent is necessary, butyrophenones should be avoided in favor of atypical agents such as risperidone. ^{[31, 32, 33]}

In 1999, Bohus et al reported a significant reduction in the duration and intensity of dissociative symptoms in a small number of patients with BPD during treatment with naltrexone, an opiate receptor antagonist. ^[8] Evidence suggests that alterations of the endogenous opiate systems contribute to dissociative symptoms in patients with BPD. In a case report, naltrexone appeared to decrease self-injurious behavior in a 3-year-old boy. ^[34]

Patients usually require long-term psychotherapy with an appropriate therapist in an individual setting, a group setting, or both.

Both the time to attainment of recovery from BPD and the stability of recovery vary from patient to patient. In a study involving 290 inpatients with BPD, 93% attained a remission of symptoms lasting at least 2 years, 86% attained a remission lasting at least 4 years, and 50% achieved recovery. ^[35] Recovery from BPD seems difficult for many patients to attain; however, once it is attained, it can be relatively stable over time.

A separate study found that a 10-year course of BPD is associated with high rates of remission, low rates of relapse, and severe social functioning impairment, which is persistent. ^[36]