Developments in Diagnosis and Treatment of People With Borderline Personality Disorder

Sathya Rao; Parvaneh Heidari; Jillian H. Broadbear


Curr Opin Psychiatry. 2020;33(5):441-446. 

In This Article

Evidence-based Treatments

Several psychotherapeutic approaches are effective in the treatment of BPD and cost-effective in the short term.[29] These include DBT (for which the largest evidence-base exists), mentalization-based treatment, transference focused psychotherapy, schema-focused therapy and systems training for emotional predictability and problem-solving. All target the four psychopathological domains of BPD (emotional regulation; impulse control; behavioural and interpersonal skills); it is unclear which works better and for whom.[30,31]

The field is moving toward a 'common factors' approach,[32] utilizing principles shared by these specialized treatments. 'Common factors' treatment frameworks such as Good Psychiatric Management and Structured Clinical Management can be incorporated into generalist psychological treatments without the need for years of expensive training and specialization. High-quality generalist treatments are superior to current standard psychological treatments and have similar outcomes to the specialist treatments.[33–35] Generalist BPD treatment training increases clinician willingness to work with people with BPD[36] and provides an alternative treatment for BPD when specialist treatment is unavailable.

A common factors approach can be utilized within stepped-care models, which comprise treatment options of differing durations and intensities to meet the changing needs of patients. These can be offered across various settings and are amenable to integration with other medical or psychiatric treatments for holistic management of cooccurring disorders.[37] Generalist treatments may be suitable for the newly diagnosed or for young people in whom maladaptive behaviours are not entrenched. If symptoms do not improve with generalist treatment, referral to a more specialized treatment may be considered. An important aspect of stepped-care approaches is that they enable people to make informed choices about treatment pathways that best suit their needs; this leads to better engagement and outcomes.[33]

Stepped-care approaches that are of short duration tend to be psychoeducation-focused with a group or individual format.[38] Some specialized treatments have been adapted for particular contexts, such as briefer versions for inpatient settings.[39] The importance of incorporating a 'recovery' framework within treatment is clear.[40,41]

There are still no nonpsychotherapeutic interventions indicated for the treatment of BPD, despite some preliminary evidence for medications providing symptomatic relief.[42] Despite the lack of rigorous trials providing evidence of their efficacy, extensive use of polypharmacy,[43] electroconvulsive therapy[44] and transcranial magnetic stimulation[45] is frequently observed. Exploration continues for novel approaches including the use of oxytocin.[46] The frequency with which mental and medical comorbidities are diagnosed in people with BPD also contributes to the use of nonpsychotherapeutic treatments in this population.[47]

People with BPD also have more physical health comorbidities including cardiovascular disease, obesity, diabetes, reproductive hormonal disturbance and chronic pain syndromes.[48,49] The relationships between BPD and physical health are complex,[48,49] contributing to the estimated 20-year reduction in life expectancy.[48] Holistic screening and development of comprehensive treatment plans may help address this.