Have We Reached a Consensus on the Management of Borderline Personality Disorder?

In this article series, we look at clinical guidelines from around the globe. For a feasible approach, we have chosen a sample of eight international guidelines for this review on the management of borderline personality disorder. The purpose is not to make an in-depth comparison of all existing guidelines, but to highlight the areas of greatest overlap and considerable differences.

In summary

• There is broad consensus that outpatient psychotherapy should be the primary treatment for borderline personality disorder (BPD)

• There are no medications approved for the treatment of BPD

• Guideline consensus has not been reached on pharmacotherapy for treating core symptoms of BPD due to lack of available evidence

• Many guidelines exist for the treatment of BPD; however, guidance varies by region, highlighting the importance of understanding what is recommended in your country

• The heterogeneous presentation and complexity of BPD necessitates personalization of therapy for individuals living with the disorder

BPD is a severe mental health condition characterized by a pervasive and challenging pattern of symptoms including emotional dysregulation, unstable self-identity, fear of abandonment, intense and unstable interpersonal relationships, impulsivity, and suicidal or self-harming behaviors.^1–3 In addition to the burdensome symptomatology, the disorder is associated with severe morbidity and high societal costs.^1,2 Globally, the estimated prevalence rate of BPD ranges from 0.7 to 2.7%.⁴

Countries and key organizational bodies are putting their heads together to reach a consensus on how best to manage this complex condition. The heterogeneity in clinical presentation means that no two patients are alike, and a one-size-fits-all approach to diagnosis and treatment does not address the complex needs for many people living with BPD.^3,4 Here, we review eight guideline recommendations from across the globe. While the broad brushstrokes of these recommendations tend to align across most countries, the details are less generalizable (Table 1). Healthcare professionals (HCPs) are reminded to consult the guidelines specific to their region or country, if available, before embarking on a course of treatment.

The preferred method for BPD diagnosis still varies between countries

In most clinical settings, patients with suspected BPD will be assessed using clinical interviews.¹ While there is consensus from most countries on the use of semi-structured interviews for diagnosis, there are some who are less convinced of their utility.⁵ Swedish guidelines indicate that the use of semi-structured interviews alone is not sufficient to formulate the diagnosis of a personality disorder, and instead suggest adopting the LEAD (Longitudinal Expert All Data) principle as the gold standard⁵ – referring to a clinician who has demonstrated their competence to make an assessment based on a thorough clinical interview and taking all available data into account.⁶ Meanwhile, the UK favors utilization of community mental health services to gain diagnostic evidence.^5,7

There is broad consensus in current guidelines that outpatient psychotherapy should be the primary treatment for BPD

Psychotherapy has become a mainstay for the treatment of BPD, with research demonstrating moderate but clinically relevant effects on reducing symptom severity, self-harm, suicidality, and impaired psychosocial functioning.⁸ Psychotherapy targets key symptom domains such as emotional dysregulation through dialectal behavioral therapy (DBT), and interpersonal relationships through mentalization-based therapy (MBT).⁸ Recognition of its utility is reflected across the board, with outpatient psychotherapy preferred in most guidelines.^5,9

Primary pharmacological treatment of BPD represents an unmet need in the treatment landscape

No medications have been approved by regulatory agencies for the treatment of BPD.^1,9 However, as many as 96% of patients with the disorder who seek treatment will be prescribed medication for associated symptoms, and polypharmacy is common.⁹ The most frequently prescribed medications are antidepressants, anxiolytics, antipsychotics, and mood stabilizers.¹ Pharmacotherapy is often used to relieve peripheral symptoms of BPD such as depression or anxiety, although its usefulness in BPD has not been established.^1,10 Recommendations of clinical practice guidelines regarding pharmacotherapy for BPD vary (Table 1). For example, the National Institute for Health and Care Excellence (NICE) guidelines recommend against the use of available drug treatment for the management of core symptoms,⁷ while the American Psychiatric Association (APA) acknowledges the role of certain pharmacological agents for targeting symptoms such as affective dysregulation or impulsivity.¹¹ Other guidelines view pharmacotherapy as adjunctive to psychotherapy or for the treatment of comorbid conditions commonly associated with BPD (e.g. anxiety and depression).

As there are no randomized controlled clinical trials in BPD that compare psychotherapy to pharmacotherapy, it is difficult to discern the best course of action for patients.¹² It is important to note, however, that psychotherapy may not be an option for some. Non-availability of qualified therapists or patient unwillingness to participate in therapy may necessitate the use of medications to augment or replace psychosocial interventions.¹²

Treating patients with BPD continues to be a challenging area of psychiatry

While diagnosis rates of BPD are on the rise, it remains a challenging and frustrating condition to treat.^13,14 The heterogeneity of the disorder,³ combined with a lack of approved pharmacological treatments,¹ creates challenges for patients and HCPs alike. With scientific advancements and a better understanding of the core psychopathology of BPD, there is hope that the future will hold better options for treatment and generate a global consensus for the management of this disorder.

 

This document is for educational purposes and is not intended to replace approved clinical guidelines. Readers are advised to refer to their country-specific guidelines when making clinical decisions.

Note: The latest version of the International Classification of Diseases (ICD)-11 no longer includes BPD as a separate condition. NICE is currently exploring if the current recommendations can be aligned with ICD-11 or if withdrawal is needed.

Further reading

• Chanen AM, et al. Diagnosis and Treatment of Borderline Personality Disorder in Young People. Curr Psychiatry Rep 2020;22:25.
  A review of recent research concerning the diagnosis and treatment of BPD in young people, including appropriate age for detection, suitability of current classification methods, and treatment.

• Stone MH. Borderline Personality Disorder: Clinical Guidelines for Treatment. Psychodyn Psychiatry 2022;50:45–63.
  This article discusses the complexity of BPD and how this contributes to the daunting task of establishing guidelines for its treatment.

• Stone, BM. The Pathogenesis of Borderline Personality Disorder: Evolution of Evidence and Treatment Implications for Two Prominent Models. Psychol Rep 2022; [ePub ahead of print] 332941221127618.
  This article provides a detailed description of two empirically supported models of the etiology of BPD (Tripartite Model of the Development of BPD and the Biosocial Development Model of BPD), the decades of research supporting these models, similarities, differences, treatment implications, the latest research, and future directions in BPD.

Guideline Digest: Borderline Personality Disorder. Connecting Psychiatry. Published May 2023.

SC-US-75909

SC-CRP-13482

April 2023