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Borderline personality disorder (BPD) is the only disorder to date for which the American Psychiatric Association's (APA) treatment guidelines specify psychotherapy as the treatment of choice.1 Over the past decades, many evidence-based therapies have been developed to address BPD: psychotherapies based on cognitive-behavioral models (dialectical behavior therapy and schema-focused therapy) and on psychodynamic models (mentalization- based therapy, transference-focused psychotherapy, and dynamic deconstructive psychotherapy).2-6
Although cognitive-behavioral therapies (CBTs) and psychodynamic therapies represent different viewpoints, both models share certain basic tenets in the treatment of patients with BPD.7 In this article, we review the treatments with a strong evidence base and discuss some the therapies that offer promise but do not yet have a rigorous evidence base.
Cognitive-behavioral therapies
Dialectical behavior therapy and schema-focused therapy are two evidence-based therapies founded on modified CBT principles. To date, no standard CBT treatment has shown efficacy in a randomized controlled trial (RCT), although these modified approaches share many core features of a CBT approach, including teaching patients how to recognize, manage, or modify painful mental states.
CBT-based treatments address deficits in skills needed to tolerate intense affects and distortions in thinking and, in the case of schema-focused therapy, provide a reparative emotional experience. These therapies seek to identify dysfunctional beliefs in patients with BPD; these beliefs include seeing themselves as a combination of undesirable, needy, helpless, bad, unlovable, and deserving of punishment, and seeing others as neglectful, untrustworthy, rejecting, or harmful. Addressing these beliefs and skills deficits functions to decrease helplessness and increase a sense of self-efficacy and mastery.
Dialectical behavior therapy. This model views emotional dysregulation as at the core of BPD, which is seen as developing from the combination of a genetic tendency to intense emotional reactions and an early environment that does not validate the individual's emotional experience. The term "dialectic" refers to the combining of and alternating between the therapist's acceptance of the patient as is (the context of emotional validation) and active encouragement toward behavioral change. Dialectical behavior therapy provides 1 hour of individual therapy and 1.5 hours of skills training groups per week.
The focus is on a therapeutic alliance in which skills (motivation and capability enhancement on the part of both patient and therapist) are taught and reinforced, and undesirable behaviors are...