Borderline personality disorder (BPD) is a serious mental health condition characterized by difficulties regulating emotions, impulsive behavior, and unstable interpersonal relationships. Many people with BPD struggle to function without some form of treatment. However, medication is not always necessary for recovery. Some people with BPD can achieve remission through psychotherapy alone.
What is BPD?
Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, emotions, and behavior. People with BPD often have a poor sense of self, feel empty or unsure of their identity, and can have sudden shifts in feelings or opinions about people in their lives. They may make desperate attempts to avoid real or imagined abandonment. Common BPD symptoms include:
- Intense but unstable relationships
- Impulsiveness and risky behavior
- Unstable self-image
- Extreme emotional reactions
- Chronic feelings of emptiness
- Explosive anger
- Paranoia and dissociation
These symptoms typically start in early adulthood and occur across many different situations. To receive a BPD diagnosis, someone must exhibit at least 5 of the 9 symptoms listed in the DSM-5 psychiatric manual. Around 1.6% of adults in the United States have BPD. Women are more frequently diagnosed than men.
Treatment options for BPD
Treatment for borderline personality disorder aims to reduce symptoms, improve functioning, and help people develop more stability in relationships and self-image. The main treatment options include:
Psychotherapy
Talk therapy or psychotherapy is considered the core treatment for BPD. It provides people with coping skills, helps identify triggers, and improves relationships. The most researched therapies for BPD are dialectical behavior therapy (DBT) and mentalization-based therapy. DBT focuses on distress tolerance, emotion regulation, and interpersonal effectiveness. Mentalization-based therapy aims to improve people’s ability to recognize and understand their own mental states and thought processes.
Medications
No medications are FDA-approved specifically for treating BPD. However, doctors may prescribe medications to target specific symptoms such as depression, impulsivity, or anger. Common medications used include antidepressants, anti-anxiety drugs, and mood stabilizers. These drugs can help many people manage BPD more effectively when combined with psychotherapy.
Hospitalization
In crisis situations where there is an imminent risk of self-harm or suicide, a brief psychiatric hospitalization may be necessary to keep someone safe. Hospitalization can also help stabilize people during acute BPD flare-ups so they can better utilize outpatient treatments.
Support groups
Joining a support group provides connection with others who understand the BPD experience. Support groups help reduce feelings of isolation and provide peer support for implementing new skills. Many people find support groups a valuable complement to formal therapy.
Is medication required for BPD treatment?
Medication is not strictly required for treating borderline personality disorder. The mainstay of treatment is psychotherapy, which directly teaches skills for managing BPD symptoms more effectively. However, many people find medications helpful as an additional tool to relieve some of the most distressing symptoms.
The choice about whether to use medication is a complex decision that must balance potential benefits and risks. Factors to consider include symptom severity, level of functioning, treatment history, and personal preferences. Some people wish to avoid psychiatric medications if possible, especially given the stigma surrounding BPD and other mental health conditions. Ultimately, the best treatment plan depends on each individual’s unique needs.
Psychotherapy alone can enable recovery
Numerous studies have shown psychotherapy alone can lead to significant improvement in managing borderline personality disorder. The largest clinical trials have focused on DBT with consistent findings:
| Study | Participants | Treatment | Results |
|---|---|---|---|
| Linehan et al, 1991 | 24 women with BPD | 1 year DBT vs. treatment as usual | DBT superior in reducing suicide attempts, self-harm, and psychiatric hospitalizations |
| Linehan et al, 2006 | 101 women with BPD | 1 year DBT vs. community treatment | DBT more effective for reducing suicide attempts and self-injury |
| McMain et al, 2009 | 180 BPD patients | 1 year DBT vs. general psychiatric management | Equivalent improvement across most outcomes |
These studies demonstrate DBT’s ability to enable recovery without any co-treatment with medications. Patients experienced significant improvement through skills training alone. Other psychotherapies like mentalization-based treatment and schema therapy have also shown success as stand-alone treatments. Sustainable recovery is possible with consistent engagement in psychotherapy.
Medications can provide added benefits
While psychotherapy serves as the foundation of treatment, medications can provide additional benefits for some BPD patients. Anti-anxiety and antidepressant medications may help reduce instability and emotional sensitivity. Mood stabilizers can decrease impulsivity and anger outbursts. By managing these symptoms, medications allow people to focus more during psychotherapy sessions.
However, medication effects vary widely among individuals due to differences in biology and body chemistry. Some people experience major improvement with medications, while others derive little benefit. Many psychiatrists use a process of trial and error to find the correct medication regimen that works for each patient. The right medications combined with psychotherapy tends to have the best results.
What helps recovery besides formal treatment?
Formal psychotherapy and medication management are the core treatments for BPD. However, many complementary strategies and lifestyle changes can also facilitate the recovery process:
Self-help resources
Workbooks, online tools, and support groups provide added guidance outside of therapy appointments. These resources help people implement new skills consistently across all life situations. Peer support is especially valuable for handling setbacks and reinforcing progress.
Stress management
Learning stress management skills is vital for regulating emotions and reducing BPD flare-ups. Techniques like mindfulness meditation, yoga, exercise, and breathing exercises help stabilize mood. Setting healthy work-life boundaries and getting adequate sleep also limit stress.
Healthy relationships
Cultivating stable, caring relationships provides a secure attachment that many people with BPD lack. Connection with family, friends, mentors, and partners serves as a protective factor against worsening symptoms. However, it’s important to proceed cautiously and avoid intense relationships that could destabilize progress.
Meaning and purpose
Part of recovery is constructing a life of meaning independent of BPD. Exploring enjoyable hobbies, volunteering, engaging with faith/spirituality, pursuing career aspirations, and contributing to community all help develop a stronger sense of identity and purpose. This provides additional motivation for sticking with treatment.
Habit formation
Consciously practicing and embedding new skills into daily habits helps sustain recovery in the long-term. For example, using diaries or apps to track mood and behaviors makes it easier to spot problematic patterns early. Preparing coping strategies in advance reduces reliance on defense mechanisms.
Concerns about recovering without medication
Despite evidence showing psychotherapy alone can enable BPD recovery, there are some concerns regarding eschewing medication:
Risk of relapse
Medications may help consolidate gains made during intensive psychotherapy by preventing full relapse afterward. Stopping medication use increases the likelihood of recurrence of more severe BPD symptoms. However, structured follow-up psychotherapy can also help sustain remission.
Adherence issues
High drop-out rates plague psychotherapy for BPD. People may stop attending sessions due to discomfort with the therapeutic process or believing they are “cured.” Lack of symptoms when taking medications could ironically reinforce discontinuation. Careful monitoring is required.
Loss of crisis stabilization
Medications can provide rapid stabilization during emotional crises that disrupt functioning and pose threats of self-harm. Without this quick relief, destructive behaviors may be harder to avoid. Developing effective coping skills requires time.
Co-occurring conditions
Many people with BPD also suffer from co-occurring diagnoses like major depressive disorder and post-traumatic stress disorder. These issues may require medication even if BPD symptoms improve with therapy alone. Treating the full range of mental health problems maximizes well-being.
Tips for seeking treatment without medication
Here are some tips for seeking BPD treatment without using psychiatric medications:
– Clearly communicate your preferences to treatment providers and inquire about medication-free options. However, also listen openly to professional recommendations.
– Commit fully to psychotherapy homework and integrate learnings into daily life. This requires much time and energy without medication assistance.
– Utilize adjunctive supports like self-help tools, peer support groups, stress reduction activities, and journaling.
– Monitor mood and behaviors closely. Quantify symptoms to detect early warning signs of worsening. Have a crisis response plan in place.
– Consider occupational therapy or vocational rehabilitation to help function at work or school without medication.
– Establish accountability checks from trusted friends/family. Give them permission to express concerns about significant regressions.
– Have a psychiatrist available to consult even if not actively prescribing. Keep the door open to reconsidering medication if needed.
Conclusion
Sustainable recovery from borderline personality disorder is possible without medication, especially with consistent engagement in evidence-based psychotherapy. Skills training alone can decrease BPD symptoms dramatically and improve functioning. However, psychiatric medications often provide additional advantages for managing acute symptoms and stabilizing some of the most severe cases.
Each person needs to thoughtfully weigh the risks and potential benefits of including medications as part of their BPD treatment plan. Developing a strong collaborative relationship with a psychotherapist is the most critical factor, as their guidance will be essential for navigating the complexities around medication decisions and holistic management of BPD. With commitment to the recovery process, healing and meaningful life are attainable even in this serious mental health condition.