Management of borderline personality disorder

Psychotherapy is the most important component in the treatment of borderline personality disorder, leading to large reductions in symptoms that persist over time. Over the past 2 decades, many forms of psychotherapy have been developed specifically to treat the disorder. The best studied are dialectical behaviour therapy, mentalization- based treatment, transference-focused psychotherapy, and systems training for emotional predictability and problem solving. In this article, we focus on dialectical behaviour therapy and mentalization-based treatment, two of the most popular and oldest specialized treatments of borderline personality disorder. Other forms of psychotherapy, including transferencefocused psychotherapy and systems training for emotional predictability and problem solving, can be helpful, and the evidence supporting their use is summarized in Appendix 1 (available at www.cmaj.ca /lookup /suppl /doi:10.1503 /cmaj .112055 /- /DC1). The role of pharmacotherapy in the treatment of borderline personality disorder is limited. The efficacy of different drugs has been studied, but the research methodology limits the applicability of results to clinical practice, for 5 main reasons. First, many of the pharmacotherapy trials were short, often lasting between 6 and 12 weeks. Because the condition is, by definition, a longstanding disorder, it is unclear whether changes that occurred during treatment persisted over time. Second, the sample sizes were small in most of the trials. This was compounded by high dropout rates. The third limitation is the choice of outcome measures. Many studies reported changes in self-reported ratings of depression, anxiety or general psychiatric symptoms, but these measures are not meant to assess changes in symptoms of borderline personality disorder. Changes attributed to the study medication could therefore have been due to treatment of comorbid disorders or subsyndromal pathology, even if treatment of comorbid depression is more difficult in these patients.40 The use of validated measures to assess the effect of treatment on specific symptoms of borderline personality disorder such as self-harm, suicidality or impulsivity would be helpful. The fourth limitation is the number of exclusion criteria. Most patients with borderline personality disorder frequently experience suicidality and often have multiple comorbidities. 41 Therefore, trials with long lists of exclusions that included suicidal ideation and depression have sa