What medication is best for BPD?

Medications Used to Treat Borderline Personality Disorder

While there is no known medication that can target Borderline Personality Disorder (BPD) on its own, prescription medications can address many of the common symptoms of BPD.

Medications typically used in the treatment of BPD include antidepressants, mood stabilizers, anti-anxiety drugs, and antipsychotics. A combination of therapy and medication can improve your quality of life if you are living with BPD. Two of the therapies used in the treatment of BPD include Dialectical Behavior Therapy (DBT) and Mentalization-based Therapy (MBT).

Antidepressants Used for the Treatment of BPD Symptoms

A variety of antidepressants have been studied for use in treating the low moods, sadness, and depression that can occur with BPD, including the following:

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Citalopram (Celexa)
• Escitalopram (Lexapro)

Mood Stabilizers Used for the Treatment of BPD Symptoms

Medications with mood-stabilizing properties, such as lithium and some anticonvulsant (anti-seizure) medications, can help address the impulsive behavior and rapid emotional changes associated with BPD.

Mood stabilizers used to treat the symptoms of BPD may include:

• Divalproex sodium (Depakote)
• Lithium carbonate (Lithobid)
• Lamotrigine (Lamictal)

Anti-anxiety Medications Used for the Treatment of BPD Symptoms

Anti-anxiety (anxiolytic) medications can help with the intense anxiety some people with BPD may experience. However, there isn’t much research that supports the use of anti-anxiety drugs to treat BPD. Some research actually indicates that one class of anti-anxiety drug — benzodiazepines (e.g., Ativan, Klonopin) — may actually worsen BPD symptoms for some people.

Examples of anti-anxiety medications used to treat the symptoms of BPD include:

• Alprazolam (Xanax)
• Diazepam (Valium)
• Buspirone (Buspar)

Antipsychotic Medications Used for the Treatment of BPD Symptoms

Antipsychotic medications can help address occasional breaks from reality as well as the paranoia, anger, or hostility that people with BPD may experience.

Some antipsychotics used to treat BPD include:

• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
• Aripiprazole (Abilify)
• Haloperidol (Haldol)
• Paliperidone (Invega)

Borderline Personality Disorder Treatment

Taking medications may benefit people with BPD by alleviating the irritability, anger, aggressiveness, and emotional instability they experience.

However, there is also the possibility that medications can cause problems of their own. For instance, people with BPD who are taking multiple medications to treat their various symptoms may suffer more side effects as a result.

Since 70 percent of people with BPD will attempt suicide, medication should always be taken under the supervision of a medical professional to lower the risk of overdose.

Appropriate medications are best used in conjunction with talk therapy for the most effective BPD treatment. Dialectical Behavior Therapy (DBT), which helps people regain emotional stability and improve impulse control, is one of the most effective psychotherapy modalities used in the treatment of BPD.

Treatment — Borderline personality disorder

Treatment for BPD may involve individual or group psychotherapy, carried out by professionals within a community mental health team (CMHT).

The goal of a CMHT is to provide day-to-day support and treatment, while ensuring you have as much independence as possible.

A CMHT can be made up of:

• social workers
• community mental health nurses (who have specialist training in mental health conditions)
• pharmacists
• counsellors and psychotherapists
• psychologists and psychiatrists (the psychiatrist is usually the senior clinician in the team)
• occupational therapists

Care programme approach (CPA)

If your symptoms are moderate to severe, you’ll probably be entered into a treatment process known as a care programme approach (CPA).

CPA is essentially a way of ensuring that you receive the right treatment for your needs. There are 4 stages:

• an assessment of your health and social needs
• a care plan – created to meet your health and social needs
• the appointment of a care co-ordinator (keyworker) – usually a social worker or nurse and your first point of contact with other members of the CMHT
• reviews – where your treatment is regularly reviewed and any necessary changes to the care plan can be agreed

Psychotherapy

Treatment for BPD usually involves some type of psychological therapy, also known as psychotherapy. There are lots of different types of psychotherapy, but they all involve taking time to help you get a better understanding of how you think and feel.

As well as listening and discussing important issues with you, the psychotherapist can suggest ways to resolve problems and, if necessary, help you change your attitudes and behaviour. Therapy for BPD aims to help people get a better sense of control over their thoughts and feelings.

Psychotherapy for BPD should only be delivered by a trained professional. They’ll usually be a psychiatrist, psychologist or other trained mental health professional. Do not be afraid to ask about their experience.

The type of psychotherapy you choose may be based on a combination of personal preference and the availability of specific treatments in your local area. Treatment for BPD may last a year or longer, depending on your needs and how you live your life.

Dialectical behaviour therapy (DBT)

Dialectical behaviour therapy (DBT) is a type of therapy specifically designed to treat people with BPD.

DBT is based on the idea that 2 important factors contribute towards BPD:

• you are particularly emotionally vulnerable – for example, low levels of stress make you feel extremely anxious
• you grew up in an environment where your emotions were dismissed by those around you – for example, a parent may have told you that you had no right to feel sad or you were just «being silly» if you complained of feelings of anxiety or stress

These 2 factors may cause you to fall into a negative cycle – you experience intense and upsetting emotions, yet feel guilty and worthless for having these emotions. Because of your upbringing, you think having these emotions makes you a bad person. These thoughts then lead to further upsetting emotions.

The goal of DBT is to break this cycle by introducing 2 important concepts:

• validation: accepting your emotions are valid, real and acceptable
• dialectics: a school of philosophy that says most things in life are rarely «black or white» and that it’s important to be open to ideas and opinions that contradict your own

The DBT therapist will use both concepts to try to bring about positive changes in your behaviour.

For example, the therapist could accept (validate) that feelings of intense sadness cause you to self-harm, and that behaving in such a way does not make you a terrible and worthless person.

However, the therapist would then attempt to challenge the assumption that self-harming is the only way to cope with feelings of sadness.

The ultimate goal of DBT is to help you «break free» of seeing the world, your relationships and your life in a very narrow, rigid way that leads you to engage in harmful and self-destructive behaviour.

DBT usually involves weekly individual and group sessions, and you’ll be given an out-of-hours contact number to call if your symptoms get worse.

DBT is based on teamwork. You’ll be expected to work with your therapist and the other people in your group sessions. In turn, the therapists work together as a team.

DBT has proved particularly effective in treating women with BPD who have a history of self-harming and suicidal behaviour. It’s been recommended by the National Institute for Health and Care Excellence (NICE) as the first treatment for these women to try.

Mentalisation-based therapy (MBT)

Another type of long-term psychotherapy that can be used to treat BPD is mentalisation-based therapy (MBT).

MBT is based on the concept that people with BPD have a poor capacity to mentalise.

Mentalisation is the ability to think about thinking. This means examining your own thoughts and beliefs, and assessing whether they’re useful, realistic and based on reality.

For example, many people with BPD will have a sudden urge to self-harm and then fulfil that urge without questioning it. They lack the ability to «step back» from that urge and say to themselves: «That’s not a healthy way of thinking and I’m only thinking this way because I’m upset.»

Another important part of mentalisation is to recognise that other people have their own thoughts, emotions, beliefs, wishes and needs, and your interpretation of other people’s mental states may not necessarily be correct. In addition, you need to be aware of the potential impact your actions will have on other people’s mental states.

The goal of MBT is to improve your ability to recognise your own and others’ mental states, learn to «step back» from your thoughts about yourself and others and examine them to see if they’re valid.

Initially, MBT may be delivered in a hospital, where you would stay as an inpatient. The treatment usually consists of daily individual sessions with a therapist and group sessions with other people with BPD.

A course of MBT usually lasts around 18 months. Some hospitals and specialist centres encourage you to remain as an inpatient during this time. Other hospitals and centres may recommend that you leave the hospital after a certain period of time but remain being treated as an outpatient, where you visit the hospital regularly.

Therapeutic communities (TCs)

Therapeutic communities (TCs) are structured environments where people with a range of complex psychological conditions and needs come together to interact and take part in therapy.

TCs are designed to help people with long-standing emotional problems and a history of self-harming by teaching them skills needed to interact socially with others.

Most TCs are residential, such as in large houses, where you stay for around 1 to 4 days a week.

As well as taking part in individual and group therapy, you would be expected to do other activities designed to improve your social skills and self-confidence, such as:

• household chores
• meal preparation
• games, sports and other recreational activities
• regular community meetings – where people discuss any issues that have arisen in the community

TCs are run on a democratic basis. This means that each resident and staff member has a vote on how the TC should be run, including whether a person is suitable for admission to that community.

Even if your care team thinks you may benefit from spending time in a TC, it does not automatically mean the TC will allow you to join.

Many TCs set guidelines on what is considered acceptable behaviour within the community, such as not drinking alcohol, no violence to other residents or staff, and no attempts at self-harming. Those who break these guidelines are usually told to leave the TC.

While some people with BPD have reported that the time spent in a TC helped their symptoms, there’s not yet enough evidence to tell whether TCs would help everyone with BPD.

Also, because of the often strict rules on behaviour, a TC would probably not be suitable if a person were having significant difficulties controlling their behaviour.

Arts therapies

Arts or creative therapies may be offered individually or with a group as part of a treatment programme for people with BPD.

Therapies may include:

• art therapy
• dance movement therapy
• drama therapy
• music therapy

Arts therapies aim to help people who are finding it hard to express their thoughts and feelings verbally. The therapy focuses on creating something as a way of expressing your feelings.

The courses are run by trained therapists, who can help you to think about what you’ve created and whether it relates to your thoughts and experiences.

A course of arts therapy usually involves weekly sessions, which last up to 2 hours.

Treating a crisis

You’ll probably be given several telephone numbers to use if you think you may be experiencing a crisis (when symptoms are particularly severe and you have an increased risk of self-harm).

One of these numbers is likely to be your community mental health nurse. Other numbers may include an out-of-hours number for social workers and your local crisis resolution team (CRT).

Crisis resolution teams support people with serious mental health conditions who are currently experiencing an acute and severe psychiatric crisis, which would require hospitalisation without the team’s involvement. An example of a severe psychiatric crisis would be a suicide attempt.

People with BPD often find that simply talking to somebody who understands their condition can help bring them out of a crisis.

In a small number of cases, you may be given a short course of medicine, such as a tranquilliser, to calm your mood. This medicine is usually prescribed for 7 days.

If your symptoms are particularly severe and it’s thought you pose a significant risk to your own health, you may be admitted to hospital – very occasionally via detention under the Mental Health Act, if you’re unable to make appropriate decisions about your safety.

This will be for as short a time as possible and you should be able to return home once your symptoms improve. Doctors do their best to avoid detaining anyone unless it’s absolutely essential.

Medicine

Experts are divided over whether medicine is helpful. No medicine is currently licensed to treat BPD.

While medicine isn’t recommended by National Institute for Health and Care Excellence (NICE) guidelines, there’s evidence that it may be helpful for certain problems in some people.

Medicines are often used if you have another associated mental health condition, such as:

Mood stabilisers or antipsychotics are sometimes prescribed to help mood swings, alleviate psychotic symptoms or reduce impulsive behaviour.

More in Borderline personality disorder

Page last reviewed: 4 November 2022
Next review due: 4 November 2025

Support links

• Home
• Health A to Z
• Live Well
• Mental health
• Care and support
• Pregnancy
• NHS services
• Coronavirus (COVID-19)

• NHS App
• Find my NHS number
• Your health records
• About the NHS
• Healthcare abroad

• Contact us
• Other NHS websites
• Profile editor login

• About us
• Accessibility statement
• Our policies
• Cookies

Prescribing and borderline personality disorder

Accurate diagnosis is fundamental to effective management of borderline personality disorder, but many patients remain undetected.

The first-line management for borderline personality disorder is psychosocial treatment, not drugs. There are major prescribing hazards including polypharmacy, overdose and misuse.

Drug treatment might be warranted for patients who have a co-occurring mental disorder such as major depression.

If a drug is prescribed for borderline personality disorder, it should only be as an adjunct to psychosocial treatment. There should be clear and collaborative goals that are regularly reviewed with the patient.

Use single drugs prescribed in limited quantities for a limited time. Stop drugs that are ineffective.

Introduction

Borderline personality disorder is a severe mental disorder that has its onset during adolescence and emerging adulthood. 1 It affects up to 3% of the population 2, 3 and occurs almost equally among males and females. 4

The disorder has a fourfold higher prevalence among primary care patients than among the general population. 5 It affects around one-quarter of primary care patients with depression 6 and one in five psychiatric outpatients. 7, 8 In these settings females outnumber males by a ratio of up to 4:1.

Borderline personality disorder is a leading contributor to the burden of disease in our community. It is associated with adverse long-term outcomes that include severe and persistent functional disability, 9 high family and carer burden, 10 physical ill health, 11 and premature mortality, 12 including a suicide rate of 8%. 13 People with the disorder use mental health services continuously for long periods of time. 14 After schizophrenia, borderline personality disorder is the most costly psychiatric disorder to treat in Australia on a per case basis. 15

Psychosocial treatment is the primary therapy but access to this is poor. Despite the effectiveness of treatment, persisting psychopathology (e.g. borderline personality disorder features, depressive and anxiety symptoms) and functional impairment remain clinically problematic.

While it is easier to provide prescriptions than psychosocial treatments, evidence does not support the use of drugs as first-line or sole treatment. 16 Nevertheless, psychotropic drug use is common and needs careful management and review.

Clinical presentation

Borderline personality disorder is characterised by a pervasive pattern of instability in emotional regulation, interpersonal relationships and self-image, along with marked impulsivity. 17 Clinically, this often manifests as recurrent self-harm and suicide attempts. The person frequently describes a chaotic lifestyle and relationships, reckless behaviours likely to harm the individual (e.g. impulsive substance use, unsafe sex), chronic dysphoria and anxiety, severe mood instability and reactive aggression.

People with borderline personality disorder typically present to health services during times of crisis, following self-harm, because of the consequences of impulsive and self-damaging behaviour, or because of poor physical, sexual and reproductive health. Interpersonal problems are at the very heart of borderline personality disorder and these are usually magnified during crises. For example an individual might have unrealistically high expectations or demands of care from health practitioners and when these are not met, he or she might respond aggressively. It is important to remember that clinicians are likely to see patients at their lowest ebb, but this is when they are in greatest need of timely and coherent assistance.

Assessment

The DSM-5 criteria for borderline personality disorder are listed in Box 1. 18 Although the DSM-5 requires any five of these nine criteria in order to make a diagnosis, even low levels of borderline pathology (e.g. one criterion) are associated with substantial increases in psychosocial impairment. 19

Box 1 Diagnostic criteria for borderline personality disorder 18

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-mutilating behaviour covered in criterion 5)
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating – do not include suicidal or self-mutilating behaviour covered in criterion 5)
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Despite the evidence of the reliability and validity of the diagnosis, and the treatability of the condition, 20 many people with borderline personality disorder remain undiagnosed in clinical practice. This places them at risk of being given treatments that are ineffective or even harmful. 21 The central task for diagnosing personality disorder is to separate ‘state’ (transient aberrations in mental state) from ‘trait’ (long-standing patterns of thinking, feeling, behaving, perceiving and relating). Many mental state disorders can present with features that are similar to borderline personality disorder. For example, affective dysregulation is characteristic of both bipolar disorder and borderline personality disorder. Also, the current definition of depression incorporates non-specific forms of dysphoria that overlap with borderline personality disorder. What distinguishes borderline personality from these other disorders is that the features are present most of the time and comprise part of the patient’s ‘usual self’. These patients will tell you that this is how they ‘usually are’. Although various tools are available to aid the diagnosis of borderline personality disorder, clinical application of the DSM-5 criteria is sufficient in a busy clinical practice. Each of the nine criteria should be enquired about and considered in turn.

A common cause of misdiagnosis of borderline personality disorder is to rely on ‘gut feeling’ when a patient presents as interpersonally abrasive, sullen or hostile, particularly if the individual also engages in self-harm. Such diagnoses are often unreliable because they do not assess each of the DSM-5 borderline personality disorder criteria and do not take into account other reasons for such presentations, such as temporary aberrations in mental state, depression or other disorders.

Another cause of diagnostic confusion is the high rate of comorbid conditions. Comorbidity with other personality disorders and with mental state disorders is the norm. At times, these other disorders (e.g. mood, anxiety, eating and substance use disorders) can overwhelm the clinical picture, but this does not indicate that the underlying personality pathology is unimportant or should be a secondary concern. 21 Rather, there is evidence to suggest that personality disorder might be a key vulnerability factor for recurrent mental state disorders. 22, 23 Patients with borderline personality disorder who have these co-occurring conditions should be treated for these conditions in accordance with best practice. However, there should not be a disproportionate emphasis given to the immediate relief of mental state pathology at the expense of managing the borderline personality disorder.

Treatment

Since the 1990s there has been growing optimism and enthusiasm for the treatment of borderline personality disorder. There is now a variety of effective evidence-based psychosocial treatments (Box 2). Referral for one of these first-line treatments is recommended. 16, 24 No single treatment is recommended over another and they have common core features (Box 2). 25 Treatment guidelines include one published by the Australian National Health and Medical Research Council (NHMRC). 16

Box 2 Psychosocial treatments and their common characteristics

Treatments

Dialectical behaviour therapy

Cognitive behavioural therapy

Cognitive analytic therapy

Systems training for emotional predictability and problem solving

Dynamic deconstructive psychotherapy

Common characteristics 25

Approaches to prototypic borderline personality disorder problems are structured (manual-directed)

Patients are encouraged to adopt self-control (i.e. sense of agency)

Therapists help patients to connect feelings to events and actions

Therapists are active, responsive and validating

Therapists discuss cases, including personal reactions, with others

Despite advances in psychosocial treatment for borderline personality disorder, improvements remain suboptimal. 24, 25 Access to treatment is limited, and dropout rates are high (15–77%). 26 The NHMRC guidelines provide advice that can be implemented when referral to specialist services for borderline personality disorder is unavailable.

Evidence for drug therapy

Pharmacotherapy has been investigated as a stand-alone or adjunctive treatment option for borderline personality disorder. There are many high-quality reviews 16,27, 28 including a Cochrane review. 27, 29 The Cochrane group found 33 randomised controlled trials in adults with borderline personality disorder, 27, 29 but commented that the overall evidence base for prescribing is unsatisfactory. The literature is hampered by small trials (less than 50 patients) of numerous drugs, short treatment periods (mean duration of 12 weeks), diverse outcome measures, infrequent replication of findings, and lack of independence from the pharmaceutical industry. 30, 31 In addition, controversy has surrounded the methods of one research group and the integrity of the findings. 29

The available evidence 16,27- 29 does not support a prominent role for selective serotonin reuptake inhibitors in the treatment of borderline personality disorder, despite their widespread use. Other drugs require further investigation. Mood stabilisers (topiramate, sodium valproate, lamotrigine) have shown some effect in reducing affective dysregulation and impulsive aggression. Antipsychotics such as aripiprazole, olanzapine and quetiapine have shown some effect in reducing cognitive–perceptual symptoms and affective dysregulation. Omega-3 polyunsaturated fatty acids might reduce the overall severity of borderline personality disorder. 27

Although the evidence for drug therapy is less conclusive than for the psychosocial interventions, US data indicate that prescribing rates for borderline personality disorder are paradoxically high. Drugs are prescribed for 78% of patients for more than 75% of the time over a six–year period and polypharmacy occurs in 37% of patients, 32 perhaps reflecting clinical needs and pressures. To date, there has been no study of Australian prescribing practices, but clinical experience suggests that the situation might be similar.

Guidelines

In light of the clinical needs and pressures, and the harm associated with prescribing for these patients, the NHMRC 16 and UK National Institute for Health and Care Excellence (NICE) 28 have considered the controlled trial evidence. In general, both groups recommend against prescribing psychotropic drugs for treating borderline personality disorder. Importantly, the NHMRC guideline recognises that the absence of evidence can lead to heterogeneity of practice. It therefore provides some guidance for those who wish to try empirical treatment (Box 3).

Box 3 Key recommendations for treating borderline personality disorder 16

• People with borderline personality disorder should be provided with structured psychological therapies that are specifically designed for borderline personality disorder, and conducted by one or more adequately trained and supervised health professionals.
• Drugs should not be used as primary therapy for borderline personality disorder, because they have only modest and inconsistent effects, and do not change the nature and course of the disorder.
• The time-limited use of drugs can be considered as an adjunct to psychological therapy, to manage specific symptoms.
• Caution should be used if prescribing drugs that may be lethal in overdose, because of high suicide risk with prescribed drugs in people with borderline personality disorder.
• Caution should be used if prescribing medicines associated with substance dependence.
• Before starting time-limited pharmacotherapy for people with borderline personality disorder:
  • ensure that a drug is not used in place of other more appropriate interventions
  • take account of the psychological meaning of prescribing (both for the individual and for the prescriber) and the impact that prescribing decisions may have on the therapeutic relationship and the overall borderline personality disorder management plan, including long-term treatment strategies
  • use a single drug and avoid polypharmacy if possible
  • ensure that there is consensus among prescribers about the drug used, and collaboration with other health professionals involved in the person’s care, and that the main prescriber is identified
  • establish likely risks of prescribing, including interactions with alcohol and other substances.