Day # 136: Psychotherapy for Borderline Personality Disorder

Today we will continue our current theme of cluster B personality disorders as we discuss psychotherapy for borderline personality disorder.


See day #135 (BPD part 1) for a a full discussion on the diagnostic criteria, epidemiology, pathogenesis, and clinical pearls for BPD.


Today's Content Level: All levels (Beginner, Intermediate, Advanced)



INTRODUCTION 1, 2

  • The first-line treatment for borderline personality disorder (BPD) is psychotherapy. There are a number of specific therapies that have been shown to reduce the core symptoms of BPD as well as comorbid symptoms.

  • Adjunctive use of pharmacotherapy for comorbidities, targeted symptoms, and periods of acute decompensation may also be useful.



PSYCHOTHERAPY 3, 4


General Principles

  • Psychoeducation: education plays an important role in the initial treatment of BPD. Collaboratively discussing the definition, clinical features, likelihood of diagnosis, effective treatment options, and good prognosis can enhance therapeutic alliance and reduce the anxiety about a highly stigmatized diagnosis.

  • Safety plan: >75% of BPD patients attempt suicide, often with frequent attempts and self-injurious behaviors. Develop a safety plan for patients with chronic suicidal ideation and focus on learning coping strategies and prevent maladaptive patterns of behavior.

  • Choosing a type of therapy: there are a number of specific forms of therapy that have been shown to reduce the core symptoms of BPD, reduce comorbid symptoms (depression, anxiety, etc.), reduce self-harming behaviors and suicide, and improve quality of life. Specific therapies will be discussed below.

  • Common factors: common elements of therapy include emphasizing current functioning and relationships, providing validation but also helping them accept responsibility for their actions, and setting appropriate boundaries. Different strategies are used to target the core symptoms of BPD such as mood instability, impulsivity, and interpersonal functioning.


Dialectical Behavioral Therapy (DBT) 5

  • DBT is a well-studied variation of cognitive behavioral therapy. It is often considered the gold standard treatment for borderline personality disorder.

  • It was originally created for the treatment of BPD, but it has been adapted to treat other mental health conditions.

  • Treatment includes a focus on 4 overarching skills to include 1) mindfulness, 2) distress tolerance, 3) interpersonal effectiveness, and 4) emotion regulation.

  • DBT consists of weekly individual psychotherapy, group therapy where patients are taught behavioral skills, and phone coaching in which patients can call the therapist between sessions to receive guidance on coping with difficult situations. "DBT-informed" treatment incorporates the principles of DBT but doesn't require all the aspects or stages of the complete program.

  • Compared to non-manualized therapies, DBT has been shown to reduce several key outcome measures including suicidality, self-injurious behaviors, and hospitalizations.


Mentalization-Based Therapy (MBT) 6

  • MBT is a modified form of psychodynamic therapy that also incorporates cognitive techniques. It has been shown to be effective for affect regulation, impulsivity, and attachment.

  • Mentalization is the ability to be attentive to the mental states of oneself and of others. MBT is based on a theory that borderline PD symptoms such as impulsivity and mood instability are a result of an individual's reduced capacity to mentalize.

  • Patients are taught to observe their states of mind at each moment and to generate alternative perspectives of subjective experiences of themselves and others. It is believed that recovery of mentalization helps patients build relationship skills as they learn to better regulate their thoughts and feelings.


Transference-Focused Psychotherapy (TFP) 7

  • TFP is a modified form of psychodynamic therapy based on the object relations theory.

  • Transference is a phenomenon in which the feelings a person had about an important relationship (a parent, for example) are unconsciously redirected or transferred to the present situation. It usually concerns feelings from a primary relationship during childhood.

  • TFP involves exploration, confrontation, and interpretation of transference in the relationship between the patient and therapist. The aim is to then use these insights to improve the patient's current relationships and perceptions of others.

  • Studies comparing TFP with other forms of therapy for BPD show varying degrees of success.


“Good psychiatric management” (GPM) 8

  • GPM is a treatment for BPD that does not require specialized provider training or an intensive therapy schedule. It was developed to address shortages of mental health professionals with training and experience in treating severe personality disorders.

  • GPM can be used by general clinicians including non-mental health practitioners and focuses on psychoeducation, active case management, goal setting, and interpersonal skills.

  • A randomized trial compared GPM to DBT and found similar reductions in suicidal and self-injurious episodes, BPD symptoms, and improved functioning.


Others 9

  • Cognitive Behavioral Therapies (CBT): cognitive techniques to address distorted cognitions and behavioral strategies to improve social and emotional functioning.

  • Schema-Focused Therapy (SFT): combines aspects of CBT, psychodynamic therapy, and interpersonal therapy. Schemas are mental structures and patterns of thinking that are often rooted in early childhood experiences.

  • Systems Training for Emotional Predictability and Problem Solving (STEPPS): CBT-oriented group therapy that includes skills training and family education. Primarily used as an adjunct to non-CBT oriented psychotherapies.



CONCLUSION






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