Psychotherapy of borderline personality disorder: current trends and research issues

La psicoterapia del disturbo borderline di personalità: attuali orientamenti e linee di ricerca

S. Bellino, P. Bozzatello, A. Blandamura, F. Bogetto

Servizio per i Disturbi di Personalità, Struttura Complessa di Psichiatria 1 a Direzione Universitaria, Dipartimento di Neuroscienze, Università di Torino


Borderline personality disorder (BPD) is an Axis II mental disorder characterized by a pervasive pattern of instability in interpersonal relationships, affects, and identity, as well as severe impulsive behaviors.
According to literature data and treatment guidelines of the American Psychiatric Association, borderline personality disorder can be usefully treated with both pharmacotherapeutic and psychotherapeutic interventions. Clinical experience suggests that patients with BPD need extended psychotherapy (at least 1 year) to attain and maintain lasting improvement in psychiatric symptoms, interpersonal problems, and overall functioning. Main models of psychotherapy that have been tested for BPD treatment in trials of single or combined therapy are: psychodynamic psychotherapy, dialectical behavior therapy (DBT), schema focused therapy (SFT) and system training for emotional predictability and problem solving (STEPPS) interpersonal psychotherapy (IPT). The present review aims to report and comment results of clinical trials assessing the efficacy of the above listed models of psychotherapy in the treatment of borderline personality disorder.

Psychodynamic psychotherapy is a therapy that is focused on the transference relationship. The therapist provides interpretations of transference choosing the most suitable times in the therapeutic process. Authors proposed different approaches to psychodynamic therapy of borderline patients, preferring the use of supportive or explorative techniques. Psychodynamic psychotherapy is recommended for treatment of patients with BPD on the basis of the positive results of several randomized controlled trials. However, the use of this model of psychotherapy in clinical practice is limited, probably due to the high amount of resources required to both therapists and the patients.
Dialectical behavior therapy is a model proposed by Linehan and derived from cognitive-behavioral therapy. It was specifically designed to treat women who meet diagnostic criteria for BPD and engage in self-injurious behaviors. DBT can be currently considered the psychotherapy with the largest amount of controlled studies in BPD samples. It has been found to be efficacious in the treatment of high-risk behaviors and suicide attempts, but it is not so useful in reducing depressive symptoms and increasing patients’ degree of overall satisfaction. DBT has been also studied to treat BPD patients with substance abuse or eating disorders comorbidity. Interpersonal therapy was initially proposed to treat major depression, but has been more recently considered a good option to treat other psychiatric disorders, such as bipolar disorder, bulimia nervosa, and anxiety disorders. Markowitz (2006) proposed an adaptation of IPT to the peculiar clinical and relational features of patients with borderline personality disorder (IPTBPD). Interpersonal therapy appears a suitable approach to these patients, who show prominent relational problems and high comorbidity rates with major depression.

Growing clinical evidence supports combination of psychotherapy and pharmacotherapy in treatment of BPD, but only few controlled trials comparing efficacy of combined and single therapy have been completed. Borderline personality disorder is characterized by various psychopathological dimensions, that could be more responsive to specific models of psychotherapy, to different drug interventions or to combined or sequential therapy. Further investigations are required to collect data on this core issue of BPD treatment, identifying response predictors and designing more individualized treatment projects.

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