Editing Borderline personality disorder (section)

==Management==
{{Main|Management of borderline personality disorder}}
The main approach to managing BPD is through [[psychotherapy]], tailored to the individual's specific needs rather than applying a one-size-fits-all model based on the diagnosis alone.<ref name =Lei2011/> While medications do not directly treat BPD, they are beneficial in managing comorbid conditions like depression and anxiety.<ref>{{cite web|url=http://www.nice.org.uk/Guidance/CG78/NiceGuidance/pdf/English|title=CG78 Borderline personality disorder (BPD): NICE guideline|publisher=Nice.org.uk|date=28 January 2009|access-date=12 August 2009|url-status=live|archive-url=https://web.archive.org/web/20090411104754/http://www.nice.org.uk/Guidance/CG78/NiceGuidance/pdf/English|archive-date=11 April 2009}}</ref> Evidence states short-term hospitalization does not offer advantages over community care in terms of enhancing outcomes or in the long-term prevention of suicidal behavior among individuals with BPD.<ref>{{cite journal|vauthors=Paris J|s2cid=28921269|title=Is hospitalization useful for suicidal patients with borderline personality disorder?|journal=Journal of Personality Disorders|volume=18|issue=3|pages=240–247|date=June 2004|pmid=15237044|doi=10.1521/pedi.18.3.240.35443}}</ref>

===Psychotherapy===
[[File:Dialectical Behavior Therapy Cycle EN.jpg|thumb|right|The stages used in [[dialectical behavior therapy]]]]Long-term, consistent psychotherapy stands as the preferred method for treating BPD and engagement in any therapeutic approach tends to surpass the absence of treatment, particularly in diminishing self-harm impulses.<ref name="BPD_therapies">{{cite journal|vauthors=Zanarini MC|title=Psychotherapy of borderline personality disorder|journal=Acta Psychiatrica Scandinavica|volume=120|issue=5|pages=373–377|date=November 2009|pmid=19807718|pmc=3876885|doi=10.1111/j.1600-0447.2009.01448.x}}</ref> Among the effective psychotherapeutic approaches, dialectical behavior therapy (DBT), [[schema therapy]], and [[psychodynamic]] therapies have shown efficacy, although improvements may require extensive time, often years of dedicated effort.<ref>{{cite journal|vauthors=Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P|title=Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis|journal=JAMA Psychiatry|volume=74|issue=4|pages=319–328|date=April 2017|pmid=28249086|doi=10.1001/jamapsychiatry.2016.4287|hdl=1871.1/845f5460-273e-4150-b79d-159f37aa36a0|s2cid=30118081|url=https://research.vu.nl/en/publications/845f5460-273e-4150-b79d-159f37aa36a0|access-date=12 December 2019|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232025/https://research.vu.nl/en/publications/efficacy-of-psychotherapy-for-borderline-personality-disorder-a-s|url-status=live|hdl-access=free}}</ref>

Available treatments for BPD include [[dynamic deconstructive psychotherapy]] (DDP),<ref>{{cite book|vauthors=Gabbard GO|date=2014|title=Psychodynamic psychiatry in clinical practice|edition=5th|publisher=American Psychiatric Publishing|location=Washington, D.C.|pages=445–448}}</ref> [[mentalization-based treatment]] (MBT), [[schema therapy]], transference-focused psychotherapy, dialectical behavior therapy (DBT), and general psychiatric management.<ref name="Gund2011" /><ref name="Choi-Kain_2017">{{cite journal|vauthors=Choi-Kain LW, Finch EF, Masland SR, Jenkins JA, Unruh BT|title=What Works in the Treatment of Borderline Personality Disorder|journal=Current Behavioral Neuroscience Reports|volume=4|issue=1|pages=21–30|year=2017|pmid=28331780|pmc=5340835|doi=10.1007/s40473-017-0103-z}}</ref> The effectiveness of these therapies does not significantly vary between more intensive and less intensive approaches.<ref name="LinksShah2017">{{cite journal|vauthors=Links PS, Shah R, Eynan R|title=Psychotherapy for Borderline Personality Disorder: Progress and Remaining Challenges|journal=Current Psychiatry Reports|volume=19|issue=3|page=16|date=March 2017|pmid=28271272|doi=10.1007/s11920-017-0766-x|s2cid=1076175}}</ref>

[[Transference focused psychotherapy|Transference-focused psychotherapy]] is designed to mitigate absolutist thinking by encouraging individuals to express their interpretations of social interactions and their emotions, thereby fostering more nuanced and flexible categorizations.<ref name="Bliss_2014">{{cite journal|vauthors=Bliss S, McCardle M|date=1 March 2014|title=An Exploration of Common Elements in Dialectical Behavior Therapy, Mentalization Based Treatment and Transference Focused Psychotherapy in the Treatment of Borderline Personality Disorder|journal=Clinical Social Work Journal|volume=42|issue=1|pages=61–69|doi=10.1007/s10615-013-0456-z|s2cid=145079695|issn=0091-1674}}</ref> [[Dialectical behavior therapy]] (DBT), on the other hand, focuses on developing skills in four main areas: interpersonal communication, distress tolerance, emotional regulation, and mindfulness, aiming to equip individuals with BPD with tools to manage intense emotions and improve interpersonal relationships.<ref name="Bliss_2014" /><ref>{{cite book|vauthors=Livesay WJ|chapter=Understanding Borderline Personality Disorder|title=Integrated Modular Treatment for Borderline Personality Disorder|year=2017|pages=29–38|place=Cambridge, England|publisher=[[Cambridge University Press]]|doi=10.1017/9781107298613.004|isbn=978-1-107-29861-3|url=https://zenodo.org/record/4384573|access-date=14 March 2024|archive-date=25 December 2020|archive-url=https://web.archive.org/web/20201225055919/https://zenodo.org/record/4384573|url-status=live}}</ref><ref name="Choi-Kain_2017" />

[[Cognitive behavioral therapy]] (CBT) targets the modification of behaviors and beliefs through problem identification related to BPD, showing efficacy in reducing anxiety, mood symptoms, suicidal ideation, and self-harming actions.<ref name="NIH2016" />

[[Mentalization-based treatment|Mentalization-based therapy]] and transference-focused psychotherapy draw from [[psychodynamic]] principles, while DBT is rooted in cognitive-behavioral principles and [[mindfulness]].<ref name="BPD_therapies" /> General psychiatric management integrates key aspects from these treatments and is seen as more accessible and less resource-intensive.<ref name="Gund2011" /> Studies suggest DBT and MBT may be particularly effective, with ongoing research into developing abbreviated forms of these therapies to enhance accessibility and reduce both financial and resource burdens on patients and providers.<ref name="DBT_vs_therapyByExperts">{{cite journal|vauthors=Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N|title=Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder|journal=Archives of General Psychiatry|volume=63|issue=7|pages=757–766|date=July 2006|pmid=16818865|doi=10.1001/archpsyc.63.7.757|doi-access=free}}</ref><ref name="DBT_and_Mentalization">{{cite journal|vauthors=Paris J|title=Effectiveness of different psychotherapy approaches in the treatment of borderline personality disorder|journal=Current Psychiatry Reports|volume=12|issue=1|pages=56–60|date=February 2010|pmid=20425311|doi=10.1007/s11920-009-0083-0|s2cid=19038884}}</ref><ref name="BPD_therapies" />

[[Schema therapy]] considers [[List of maladaptive schemas|early maladaptive schemas]], conceptualized as organized patterns that recur throughout life in response to memories, emotions, bodily sensations, and cognitions associated with unmet childhood needs.<ref>{{Cite book|last1=Young|first1=Jeffrey E|title=Schema Therapy: A Practitioner's Guide|last2=Klosko|first2=Janet S|last3=Weishaar|first3=Marjorie E|publisher=[[Guilford Press]]|year=2003|isbn=9781593853723|location=New York|pages=306–372|chapter=Schema Therapy for Borderline Personality Disorder}}</ref>

Additionally, [[mindfulness meditation]] has been associated with positive structural changes in the brain and improvements in BPD symptoms, with some participants in mindfulness-based interventions no longer meeting the diagnostic criteria for BPD after treatment.<ref name="Mindfulness_neuroscience">{{cite journal|vauthors=Tang YY, Posner MI|title=Special issue on mindfulness neuroscience|journal=Social Cognitive and Affective Neuroscience|volume=8|issue=1|pages=1–3|date=January 2013|pmid=22956677|pmc=3541496|doi=10.1093/scan/nss104}}</ref><ref name="Mindfulness_mechanisms">{{cite journal|vauthors=Posner MI, Tang YY, Lynch G|title=Mechanisms of white matter change induced by meditation training|journal=Frontiers in Psychology|volume=5|issue=1220|page=1220|year=2014|pmid=25386155|pmc=4209813|doi=10.3389/fpsyg.2014.01220|doi-access=free}}</ref><ref name="Mindfulness_therapies">{{cite journal|vauthors=Chafos VH, Economou P|date=October 2014|title=Beyond borderline personality disorder: the mindful brain|journal=Social Work|volume=59|issue=4|pages=297–302|doi=10.1093/sw/swu030|pmid=25365830|s2cid=14256504}}</ref><ref name="Mindfulness_BPD">{{cite journal|vauthors=Sachse S, Keville S, Feigenbaum J|date=June 2011|title=A feasibility study of mindfulness-based cognitive therapy for individuals with borderline personality disorder|journal=Psychology and Psychotherapy|volume=84|issue=2|pages=184–200|doi=10.1348/147608310X516387|pmid=22903856}}</ref>

===Medications===
A 2010 [[Cochrane (organisation)|Cochrane]] review found that no medications were effective for the core symptoms of BPD, such as chronic feelings of emptiness, identity disturbances, and fears of abandonment. Some medications might impact isolated symptoms of BPD or those of comorbid conditions.<ref name="Stoffers">{{cite journal|vauthors=Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K|title=Pharmacological interventions for borderline personality disorder|journal=The Cochrane Database of Systematic Reviews|issue=6|page=CD005653|date=June 2010|pmid=20556762|pmc=4169794|doi=10.1002/14651858.CD005653.pub2}}</ref> A 2017 systematic review<ref name="Drugs2017rev"/> and a 2020 Cochrane review<ref name="pmid20044651">{{cite journal|vauthors=Lieb K, Völlm B, Rücker G, Timmer A, Stoffers JM|title=Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials|journal=Br J Psychiatry|volume=196|issue=1|pages=4–12|date=January 2010|pmid=20044651|doi=10.1192/bjp.bp.108.062984}}</ref> confirmed these findings.<ref name="Drugs2017rev">{{cite journal|vauthors=Hancock-Johnson E, Griffiths C, Picchioni M|title=A Focused Systematic Review of Pharmacological Treatment for Borderline Personality Disorder|journal=CNS Drugs|volume=31|issue=5|pages=345–356|date=May 2017|pmid=28353141|doi=10.1007/s40263-017-0425-0|s2cid=207486732}}</ref><ref name="pmid20044651"/> This 2020 Cochrane review found that while some medications, like mood stabilizers and second-generation antipsychotics, showed some benefits, [[SSRI]]s and [[SNRI]]s lacked high-level evidence of effectiveness.<ref name="pmid20044651"/> The review concluded that stabilizers and second-generation antipsychotics may effectively treat some symptoms and associated psychopathology of BPD, but these drugs are not effective for the overall severity of BPD; as such, pharmacotherapy should target specific symptoms.<ref name="pmid20044651"/>

Specific medications have shown varied effectiveness on BPD symptoms: [[haloperidol]] and [[flupenthixol]] for anger and suicidal behavior reduction; [[aripiprazole]] for decreased impulsivity and interpersonal problems;<ref name=Stoffers/> and [[olanzapine]] and quetiapine for reducing affective instability, anger, and anxiety, though olanzapine showed less benefit for suicidal ideation than a placebo.<ref name="Stoffers" /><ref name="Drugs2017rev" /> Mood stabilizers like [[valproate]] and [[topiramate]] showed some improvements in depression, impulsivity, and anger, but the effect of [[carbamazepine]] was not significant. Of the [[antidepressant]]s, [[amitriptyline]] may reduce depression, but [[mianserin]], [[fluoxetine]], [[fluvoxamine]], and [[phenelzine]] sulfate showed no effect. [[Omega-3 fatty acid]] may ameliorate suicidality and improve depression. {{as of|2017}}, trials with these medications had not been replicated and the effect of long-term use had not been assessed.<ref name="Stoffers" /><ref name="Drugs2017rev" /> [[Lamotrigine]]<ref name="stofferswinterling20" /> and other medications like IV ketamine<ref>{{cite journal|vauthors=Purohith AN, Chatorikar SA, Nagaraj AK, Soman S|date=December 2021|title=Ketamine for non-suicidal self-harm in borderline personality disorder with co-morbid recurrent depression: A case report|journal=Journal of Affective Disorders Reports|volume=6|pages=100280|doi=10.1016/j.jadr.2021.100280|issn=2666-9153|doi-access=free}}</ref><ref>{{cite journal|vauthors=Chen KS, Dwivedi Y, Shelton RC|date=October 2022|title=The effect of IV ketamine in patients with major depressive disorder and elevated features of borderline personality disorder|journal=Journal of Affective Disorders|volume=315|pages=13–16|doi=10.1016/j.jad.2022.07.054|pmid=35905793|s2cid=251117957|doi-access=free}}</ref> for unresponsive depression require further research for their effects on BPD.

[[Quetiapine]] showed some benefits for BPD severity, psychosocial impairment, aggression, and manic symptoms at doses of 150{{nbsp}}mg/day to 300{{nbsp}}mg/day,<ref name="stofferswinterling20"/> but the evidence is mixed.<ref name="pmid20044651"/>

Despite the lack of solid evidence, [[SSRI]]s and [[SNRI]]s are prescribed off-label for BPD<ref name="stofferswinterling20">{{cite journal|vauthors=Stoffers-Winterling J, Storebø OJ, Lieb K|year=2020|title=Pharmacotherapy for Borderline Personality Disorder: an Update of Published, Unpublished and Ongoing Studies|url=https://link.springer.com/content/pdf/10.1007/s11920-020-01164-1.pdf|journal=Current Psychiatry Reports|volume=22|issue=37|page=37|doi=10.1007/s11920-020-01164-1|pmc=7275094|pmid=32504127|doi-access=free|access-date=30 May 2021|archive-date=4 May 2022|archive-url=https://web.archive.org/web/20220504162542/https://link.springer.com/content/pdf/10.1007/s11920-020-01164-1.pdf|url-status=live}}</ref><ref name="pmid37256484">{{cite journal|date=31 May 2023|doi=10.1016/S0140-6736(21)00476-1|title=Pharmacological Management of Borderline Personality Disorder and Common Comorbidities|pmid=37256484|journal=CNS Drugs|vauthors=Pascual JC, Arias L, Soler J|volume=37|issue=6|pages=489–497|pmc=10276775}}</ref> and are typically considered adjunctive to psychotherapy.<ref name="pmid37256484"/>

Given the weak evidence and potential for serious side effects, the UK [[National Institute for Health and Clinical Excellence]] (NICE) recommends against using drugs specifically for BPD or its associated behaviors and symptoms. Medications may be considered for treating comorbid conditions within a broader treatment plan.<ref>{{cite web|url=http://www.nice.org.uk/nicemedia/live/12125/42900/42900.pdf|publisher=UK National Institute for Health and Clinical Excellence (NICE)|title=2009 clinical guideline for the treatment and management of BPD|access-date=6 September 2011|url-status=dead|archive-url=https://web.archive.org/web/20120618094650/http://www.nice.org.uk/nicemedia/live/12125/42900/42900.pdf|archive-date=18 June 2012}}</ref> Reviews suggest minimizing the use of medications for BPD to very low doses and short durations, emphasizing the need for careful evaluation and management of drug treatment in BPD.<ref>{{cite journal|vauthors=Crawford MJ, Sanatinia R, Barrett B, Cunningham G, Dale O, Ganguli P, Lawrence-Smith G, Leeson V, Lemonsky F, Lykomitrou G, Montgomery AA, Morriss R, Munjiza J, Paton C, Skorodzien I, Singh V, Tan W, Tyrer P, Reilly JG|title=The Clinical Effectiveness and Cost-Effectiveness of Lamotrigine in Borderline Personality Disorder: A Randomized Placebo-Controlled Trial|journal=The American Journal of Psychiatry|volume=175|issue=8|pages=756–764|date=August 2018|pmid=29621901|doi=10.1176/appi.ajp.2018.17091006|s2cid=4588378|doi-access=free|hdl=10044/1/57265|hdl-access=free}}</ref><ref>{{cite journal|vauthors=Cattarinussi G, Delvecchio G, Prunas C, Moltrasio C, Brambilla P|title=Effects of pharmacological treatments on emotional tasks in borderline personality disorder: A review of functional magnetic resonance imaging studies|journal=Journal of Affective Disorders|volume=288|pages=50–57|date=June 2021|pmid=33839558|doi=10.1016/j.jad.2021.03.088|s2cid=233211413}}</ref>

===Health care services===
The disparity between those benefiting from treatment and those receiving it, known as the "treatment gap," arises from several factors. These include reluctance to seek treatment, healthcare providers' underdiagnosis, and limited availability and accessibility to advanced treatments.<ref name="BPD Article">{{cite news|vauthors=Johnson RS|title=Treatment of Borderline Personality Disorder|url=http://bpdfamily.com/content/treatment-borderline-personality-disorder|publisher=[[BPDFamily.com]]|date=26 July 2014|access-date=5 August 2014|url-status=live|archive-url=https://web.archive.org/web/20140714183908/http://bpdfamily.com/content/treatment-borderline-personality-disorder|archive-date=14 July 2014}}</ref> Furthermore, establishing clear pathways to services and medical care remains a challenge, complicating access to treatment for individuals with BPD. Despite efforts, many healthcare providers lack the training or resources to address severe BPD effectively, an issue acknowledged by both affected individuals and medical professionals.<ref>{{cite journal|vauthors=Friesen L, Gaine G, Klaver E, Burback L, Agyapong V|title=Key stakeholders' experiences and expectations of the care system for individuals affected by borderline personality disorder: An interpretative phenomenological analysis towards co-production of care|journal=PLOS ONE|volume=17|issue=9|pages=e0274197|date=2022-09-22|pmid=36137103|pmc=9499299|doi=10.1371/journal.pone.0274197|bibcode=2022PLoSO..1774197F|doi-access=free}}</ref>

In the context of psychiatric hospitalizations, individuals with BPD constitute approximately 20% of admissions.<ref>{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J|title=Treatment histories of borderline inpatients|journal=Comprehensive Psychiatry|volume=42|issue=2|pages=144–150|year=2001|pmid=11244151|doi=10.1053/comp.2001.19749}}</ref> While many engage in outpatient treatment consistently over several years, reliance on more restrictive and expensive treatment options, such as inpatient admission, tends to decrease over time.<ref>{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Hennen J, Silk KR|title=Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years|journal=The Journal of Clinical Psychiatry|volume=65|issue=1|pages=28–36|date=January 2004|pmid=14744165|doi=10.4088/JCP.v65n0105}}</ref>

Service experiences vary among individuals with BPD.<ref>{{cite journal|vauthors=Fallon P|title=Travelling through the system: the lived experience of people with borderline personality disorder in contact with psychiatric services|journal=Journal of Psychiatric and Mental Health Nursing|volume=10|issue=4|pages=393–401|date=August 2003|pmid=12887630|doi=10.1046/j.1365-2850.2003.00617.x}}</ref> Assessing suicide risk poses a challenge for clinicians, with patients underestimating the lethality of self-harm behaviors. The suicide risk among people with BPD is significantly higher than that of the general population, characterized by a history of multiple suicide attempts during crises.<ref>{{cite journal|vauthors=Links PS, Bergmans Y, Warwar SH|date=1 July 2004|url=http://www.psychiatrictimes.com/articles/assessing-suicide-risk-patients-borderline-personality-disorder|title=Assessing Suicide Risk in Patients With Borderline Personality Disorder|journal=Psychiatric Times|series=Psychiatric Times Vol 21 No 8|volume=21|issue=8|url-status=live|archive-url=https://web.archive.org/web/20130821210809/http://www.psychiatrictimes.com/articles/assessing-suicide-risk-patients-borderline-personality-disorder|archive-date=21 August 2013}}</ref> About half of all individuals who commit suicide are diagnosed with a personality disorder, with BPD being the most common association.<ref>{{cite journal|vauthors=Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M|title=Borderline personality disorder|journal=Lancet|volume=364|issue=9432|pages=453–461|year=2004|pmid=15288745|doi=10.1016/S0140-6736(04)16770-6|s2cid=54280127}}</ref>