EVIDENCE SUPPORTS TWO FORMS OF PSYCHOTHERAPY
Treatment for PDs has seen considerable growth over the past decade, largely due to research on therapies that target the troubling self-injurious and suicidal features of borderline PD. Considerable evidence shows that specialized psychotherapy can significantly reduce suffering and improve functioning among these patients. The two major evidence-based treatments for patients with borderline PD are dialectical behavior therapy (DBT) and psychodynamic therapy.
DBT is an intensive cognitive-behavioral approach that teaches patients how to regulate their emotions and develop an accepting, mindful attitude toward their mental experience.21 Several randomized controlled trials (RCTs) have demonstrated the effectiveness of DBT in reducing hospitalizations and self-injurious and suicidal behavior in patients with borderline PD.22
Psychodynamic therapy, which focuses on helping patients discover how unconscious conflicts influence their present moods and behaviors, has also been validated by multiple RCTs for patients with borderline PD.23-25 Like DBT, empirically supported psychodynamic therapy tends to be structured, long-term (> 12 months), and often intensively delivered in multiple sessions per week. However, a recent study found that a less-intensive, general psychodynamic therapy, along with occasional medication management, was equivalent to intensive DBT.26
Although the research has focused primarily on borderline PD, these approaches can be applied to other PDs. These therapies focus on understanding one’s emotional and behavioral patterns, developing a healthy self-concept, and improving interpersonal relationships—areas that are relevant treatment targets across all PD types.
Indeed, studies of day treatment programs that explicitly welcome patients with a range of PD types have had promising findings.27 Day treatment involves an intensive array of therapies, mostly in a group format; patients work together to support and embolden one another to make positive changes. Unfortunately, FPPs may be challenged to find appropriate services for patients who are amenable to psychotherapy; public mental health resources tend to lag far behind best practices in the case of PD.
MEDICATION MIGHT IMPROVE SYMPTOMS, NOT PERSONALITY DEFICITS
Most research on pharmacotherapy for PDs has focused on borderline PD; findings have been mixed and fairly limited.28 Medication cannot address underlying identity and relational deficits and will not result in remission of PD. Nonetheless, judicious, circumscribed use of medications to target specific symptoms may be helpful for some patients. Selective serotonin reuptake inhibitors can reduce anger and impulsive aggression in patients with borderline PD.28,29
Atypical antipsychotics may help reduce impulsive aggression or transient psychotic symptoms.28-30 For example, olanzapine and aripiprazole can reduce anxiety, anger/aggression, paranoia, and interpersonal sensitivity in borderline PD.31,32 Mood stabilizers such as valproate, lamotrigine, and topiramate may also help some borderline patients, although they do so by reducing impulsivity and aggression rather than improving core unstable identity and affect.28,29
Carefully obtained informed consent is necessary because of the danger of adverse effects with many of these medications; for example, antipsychotics have been associated with metabolic syndrome and weight gain that can threaten a patient’s already fragile self-image.33 Polypharmacy is also a potential problem: Well-intentioned clinicians may be prompted to offer multiple medications in response to patients’ unremitting complaints of distress, when a psychotherapeutic approach may need to be the primary treatment. The bottom line is that medications do not resolve personality dysfunction and are best used symptomatically as adjuncts to psychotherapy.28,30
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