Treatment of Borderline Personality Disorder

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.

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.

Borderline Personality Disorder Treatments

1. Dialectical Behavioral Therapy (DBT)
2. Mentalization-based Therapy
3. Transference-focused Psychotherapy
4. Schema-focused Therapy
5. Systems Training for Emotional Predictability and Problem Solving (STEPPS)

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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