Treatment of Borderline Personality Disorder

Author: 
R. Skip Johnson

A widespread belief that continues to exist among mental health professionals is that treatment of Borderline Personality Disorder does very little for patients with the disorder.  Are they right or have they fallen behind the times?

Today, many therapists shy away from even suggesting that a patient fits the criteria, reminiscent of a time when professionals were afraid of telling patients that they had cancer.

However, according to Kenneth R Silk, MD. Professor of Psychiatry at the University of Michigan, and Scientific Program Chairman of the American Psychiatric Association, much has changed in the last 10–15 years and much of the mental health system has not yet caught up.

There is strong evidence from the McLean Study of Adult Development (Harvard University) that 40% of patients with borderline personality disorder remit after 2 years, with 88% no longer meeting the criteria after 10 years(1). In the Collaborative Longitudinal Personality Disorders Study, findings suggest that about one-half of those who meet Borderline Personality Disorder on admission no longer meet DSM-IV criteria 24 months later(2).

There are a number of well-designed controlled studies in support of effective treatment for Borderline Personality Disorder patients such as dialectical behavioral therapy(3) and other more straightforward cognitive behavioral therapies(4), to psychodynamic and psychoanalytically based therapies, which include mentalization-based therapy(5) and transference-focused psychotherapy(6), to the blend of cognitive and dynamic therapies in schema-focused therapy(7). And there is recent work with Systems Training for Emotional Predictability and Problem Solving (STEPPS) as an adjunct to treatment that is showing great promise.


Dialectical Behavioral Therapy (DBT)

Mentalization-based Therapy

Transference-focused Psychotherapy

Schema-focused Therapy

Systems Training for Emotional Predictability and Problem Solving (STEPPS)


 

A Change in Attitude Regarding the Treatment of Borderline Personality Disorder

Not surprisingly, as therapies that appear to be effective emerge, there are now articles urging that patients be informed of their Borderline Personality Disorder diagnosis(8)

Borderline Personality Disorder is a spectrum disorder, meaning there is a broad spectrum of severity and patients with less severe manifestations have an easier path to recovery; and all things being equal, younger individuals generally tend to be more responsive to therapy than older.

Borderline Personality Disorder Treatment Gap

As promising as these developments are - and they are promising - there are some very practical issues.  There is a significant difference between the number of those who would benefit from treatment and the number of those who are treated. The so called “treatment gap” is a function of the disinclination of the afflicted to submit for treatment, an under diagnosing of the disorder by healthcare providers, and the limited availability and access to state-of-the-art treatments.

  1. Patient Commitment. As a healthcare professional or family member, motivating individuals to embrace the diagnosis of Borderline Personality Disorder and stay committed for months to a treatment program is also a challenge - especially given the inclinations of someone with this disorder.   The fact that Borderline Personality Disorder is highly stigmatized makes this all the more difficult.
  1. Diagnosis. Another challenge is getting individuals diagnosed in the current healthcare environment and standards of care. Unless there is an acute crisis, such a a suicide attempt, Borderline Personality Disorder is often only diagnosed after treatment of the secondary or comorbid afflictions (e.g., depression), or more easily treatable afflictions (e.g., bipolor disorder) fail.
  1. Access. Finding access to these therapies can be a challenge.  These state-of-the-art treatments that are not readily available from family physicians, pastoral counselors, licensed social workers, masters degreed family practitioners, or even many psychologists. It's not that these techniques are highly sophisticated and beyond the capability of community mental health practitioners, it is more a lack of training of practitioners. These are new methods and not many practitioners have been trained.

References

1.Amarine MC, Frankenburg FR, Hensen J, Reich DB, Silk KR: Predictions of the 10-year course of borderline personality disorder. Am J Psychiatry 2006; 163:827–832

2.Grilo CM, Sanislow CA, Gunderson JG, Pagano ME, Yen S, Amarine MC, Shea MT, Sodol AE, Stout RL, Morey LC, McGlashan TH: Two-year stability and change of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Consult Clin Psychol 2004; 72:767–775
 
3.Linehan MM, Armstrong H, Suarez A, Allmon D, Heard HL: Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48:1060–1064
 
4.Davidson K, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, Palmer S: The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. J Personal Disord 2006; 20:450–465
 
5.Bateman A, Fonagy P: The effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 1999; 156:1563–1569
 
6.Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF: Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry 2007; 164:922–928
 
7.Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A: Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 2006; 63:649–658
 
8.Lequesne ER, Hersh RG: Disclosure of a diagnosis of borderline personality disorder. J Psychiatr Pract 2004; 10:170–176