The American Psychiatric Association (APA) recently released updated practice guidelines for the treatment of borderline personality disorder (BPD). BPD has a prevalence of 10%–18% among outpatients and up to 25% among inpatients, with a lower estimated prevalence in the general population (1.4%–2.7%). Individuals with BPD frequently experience co-occurring psychiatric conditions including MDD, bipolar disorder, PTSD, anxiety disorders, ADHD, SUDs, and eating disorders. The presence of these comorbidities is associated with increased symptom severity and a more challenging course of illness.

The updated guidelines address key misconceptions about BPD, with a focus on the outdated view that the condition is untreatable. While BPD symptoms can persist for years, many patients achieve significant improvement, particularly with targeted psychotherapy. However, core symptoms such as fear of abandonment, impulsivity, and emotional dysregulation often remain. Individuals with BPD also continue to face heightened risks of suicide, self-harm, and all-cause mortality even after significant improvement, reinforcing the need for ongoing clinical support. However, despite these lasting symptoms, patients can and do experience significant improvement of their BPD with proper treatment.

The APA strongly recommends psychotherapy as the primary treatment for BPD. Dialectical behavior therapy (DBT), mentalization-based therapy (MBT), transference-focused therapy (TFT), and general psychiatric management (GPM) have been shown to reduce core BPD symptoms and improve functioning. The APA recommends that medications be used cautiously and as adjuncts to psychotherapy rather than primary treatments. Medications should be prescribed with a clear target symptom in mind, such as impulsivity or mood instability, and should be regularly reviewed and tapered when appropriate. The guidelines discourage routine use of psychotropic medications for BPD alone, emphasizing that they should only be considered in the presence of co-occurring disorders or severe symptom exacerbation. Regardless of the methods used, patients should be engaged in a collaborative discussion about their diagnosis and treatment. Involvement of the patient helps improve their adherence and overall treatment outcomes.

Unfortunately, many patients with BPD report experiencing discrimination in healthcare settings. Education and training programs for healthcare practitioners reduce stigma and increase empathy. The guidelines encourage structured training in BPD management to help clinicians develop confidence in treating this complex condition.

Overall, the APA’s updated practice guideline reinforces the importance of structured, evidence-based treatment for BPD while calling for increased clinician education and awareness. With appropriate interventions, many individuals with BPD can achieve significant improvements in symptoms and functioning, challenging long-standing misconceptions about the disorder’s prognosis.

Reference:
Keepers GA et al. Am J Psychiatry 2024;181(11):1024-1028. Abstract.