Considering Medication for Borderline Personality Disorder? Read This

Hear what a psychiatrist and team of psychiatric nurse practitioners have to say about the role of medication in borderline personality disorder (BPD) treatment.

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Without treatment, borderline personality disorder (BPD) can make life really hard. If you have BPD, you might have super overwhelming, intense emotions that you can’t control, extreme fears of being abandoned by loved ones, and chaotic interpersonal relationships. BPD symptoms can significantly impact your quality of life, relationships, and day-to-day functioning.

Thankfully, it doesn’t always have to be this way. Medication, when coupled with talk therapy, can make huge improvements in your mental health and your life. Read on to learn about the use of medication in BPD and the importance of therapy in conjunction with pharmaceutical interventions.

Understanding the role of medication in people with borderline personality disorder 

“Emotional instability is a key piece of borderline personality disorder,” says Claire Streeter, PMHNP, ARNP, a Psychiatric Mental Health Nurse Practitioner with Charlie Health. “That instability often expands to interpersonal relationships and self-image as well.” If you have BPD, you can take multiple approaches to relieving these, at times, paralyzing symptoms.

But believe it or not, medications are not the first-line treatment approach for people with BPD. “It’s always therapy first,” says Rebecca Holland, PMHNP-BC, a Psychiatric Mental Health Nurse Practitioner with Charlie Health. “Then, when we know for sure they’re engaging in therapy, I like to see what shakes out, whether that’s anxiety symptoms or depression symptoms or something else. From there, a treatment plan involving medications might come into play.”

Additionally, the majority of people with BPD have co-occurring conditions, and medications can help treat those, reducing the overall symptom burden. It’s estimated that about 84.5% of people with BPD have at least one other mental health disorder.

Commonly co-occurring conditions are:

• An anxiety disorder
• A mood disorder (such as depression or bipolar disorder) 
• A substance use disorder
• Post-traumatic stress disorder (PTSD)
• An eating disorder
• Attention-deficit/hyperactivity disorder (ADHD)
• Another personality disorder

What medications can help treat borderline personality disorder?

“There’s no FDA-approved medicine for borderline personality disorder –– but there are medicines we can use to treat symptoms,” Streeter says, pointing to antidepressants, mood stabilizers, and antipsychotics. 

As Streeter mentioned, though, none of these medications are FDA-approved for BPD itself, only for co-occurring conditions. If any of these medications are used for BPD without a co-occurring condition, this is considered an “off-label use” (because the FDA did not officially approve the medication for BPD alone due to a lack of high-quality drug trial data showing it was helpful in that disorder). 

Also, medications are not without risks and should always be used with caution under the care of a medical provider with experience using them. Specifically, mood stabilizers and antipsychotics have more side effects than antidepressants and thus should be used only in cases where the potential benefits of them clearly outweigh the risks. Here’s a rundown of three different types of medications a provider might incorporate into treatment, considering your BPD symptoms and symptoms of co-occurring conditions. 

Antidepressants

Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are commonly used since they can cover an “umbrella of symptoms,” Holland says. SSRIs can help with panic, anxiety, and depressive symptoms. Antidepressants like SSRIs are not directly targeting or treating core BPD symptoms. Rather, they are prescribed to relieve symptoms associated with mood disturbances and anxiety. Second-line antidepressants would be serotonin and norepinephrine reuptake inhibitors (SNRIs), which work similarly to SSRIs. 

Mood stabilizers

Since people with BPD struggle with mood swings and emotional dysregulation, mood stabilizers can sometimes help regulate this. Mood stabilizers essentially help level out the highs and lows. They may help with impulsivity, too, if it happens during high highs or low lows. Not to mention, if someone with BPD also has bipolar disorder, mood stabilizers can play a big part in reducing the frequency and severity of depressive episodes and manic episodes. 

Antipsychotics

Although this class of drugs was originally developed to treat psychosis (when someone is losing touch with reality), they’re now used to help treat symptoms of other mental health conditions, including BPD.

Psychosis isn’t a main trademark symptom of BPD, but some BPD patients may experience hallucinations or delusions. In these cases, antipsychotics can sometimes be helpful. Research also shows that antipsychotics can help address BPD symptoms like aggression, impulsivity, and anxiety. 

Are there any specific medications that are more effective for certain symptoms of borderline personality disorder?

There is no one-size-fits-all approach to BPD medication. As we mentioned, there isn’t a single FDA-approved drug to “treat” BPD –– rather, various medications (when used along with therapy) offer additional support for certain BPD symptoms or symptoms of disorders a person has in addition to BPD.

Everyone responds to medications differently, but generally speaking, here’s what’s standard:

• Antidepressants are often the first-line medication for addressing panic, anxiety, and depressive symptoms.
• Mood stabilizers are often the first-line medication for addressing severe affective instability, mood swings, and impulsivity, most commonly when these symptoms are caused by bipolar disorder.
• Antipsychotics are often the first-line medication for addressing psychotic symptoms, impulsive aggression, and mood instability.

Ultimately, a mental health professional will decide what medication or combination of medications is best for your unique symptoms. Every individual is different and responds to medications differently. None of these medications work immediately.  It’s important to be patient since it can take several weeks for medications to kick in and deliver the best results fully. 

What are the side effects of medications for borderline personality disorder?

If you’re considering medication, it’s important to understand the risks of side effects. Some people may not experience any bothersome side effects, while others might experience them more intensely. In most cases, side effects will dissipate once the body adjusts to taking the medication daily, which can take up to a few weeks. If your side effects are intolerable, let your provider know right away. Here are examples of common side effects you might experience from each type of medication.

Antidepressant side effects

• Constipation or diarrhea
• Feeling nervous or restless
• Nausea and vomiting
• Sexual dysfunction 
• Dizziness or headaches
• Dry mouth
• Excess sweating
• Fatigue
• Insomnia

Mood stabilizer side effects

• Confusion
• Fatigue
• Headache
• Low libido
• Nausea or vomiting
• Tremors
• Weight gain

Antipsychotic side effects

• Constipation
• Dizziness
• Drowsiness
• Restlessness 
• Dry mouth
• Tremors
• Extra or unwanted movements
• Weight gain

How borderline personality disorder is treated with therapy

Therapy is the main treatment for BPD, and medications serve as add-on support, Streeter says. Therapy can be truly life-changing for BPD patients.  While medication can take the edge off certain symptoms, it isn’t enough. Therapy is crucial for providing individuals with the psychoeducation, support, and skills necessary for long-term recovery. Types of therapy for borderline personality disorder include:

Dialectical behavior therapy (DBT)

DBT was designed specifically for the treatment of BPD, and it is an effective therapy modality, Streeter says. It’s extremely useful for people who have trouble regulating their intense emotions, struggle with interpersonal relationships, and suffer from suicidal ideation or self-harm. 

A dialectical behavior therapy program consists of individual therapy with a dedicated therapist, skills training, and supported groups. This combination takes a holistic approach to treating BPD symptoms and teaches you how to manage your emotions and have healthier interpersonal relationships. Skills you’ll focus on include distress tolerance, mindfulness, emotional regulation, and interpersonal effectiveness. 

Mentalization-based therapy

Mentalization is essentially the ability to comprehend your own mental state and other people’s mental states and intentions. Many people with BPD struggle with mentalization, and that’s where this unique therapy modality comes in.

MBT teaches you how to identify and understand your own emotions as well as the emotions of people around you. When you get better at understanding what other people might be thinking and feeling, you can react in healthier, less impulsive ways. 

Schema-focused therapy

This therapy helps you dive deep into your life, particularly your childhood experiences. From there, you can identify needs that weren’t met in childhood or any other specific struggles that might still affect you to this day. Looking back on all of this, your therapist will help you identify “schemas” –– unhelpful assumptions or outlooks on life that negatively affect your mental health and relationships.  You’ll develop healthier thought patterns and strategies for navigating any challenge that life throws at you. 

Systems training for emotional predictability and problem-solving (STEPPS)

Designed specifically for folks with BPD, STEPPS acts as a supplementary treatment alongside other therapies and pharmacological treatment. In 20 weekly sessions, participants learn skills surrounding enhancing emotional regulation and managing behaviors. Additionally, loved ones are encouraged to join in on these meetings and participate so they can gain insights into BPD and provide more compassionate support to their affected loved ones.

Transference-focused psychotherapy (TFP)

TFP offers a distinctive approach centered around the patient-therapist relationship. This is based on the principle that sometimes, the emotions and behaviors exhibited by individuals with personality disorders towards their therapist mirror their interactions outside the therapeutic setting. The roots of these interactions and emotions may extend far back to childhood experiences. By diving deep into these dynamics, TFP helps people with BPD gain a better understanding of their behaviors and relationships –– ultimately enhancing self-awareness and leaving them feeling more empowered. 

Borderline personality treatment at Charlie Health

Do you or a loved one have borderline personality disorder (BPD)? If so, Charlie Health may be able to help you. Our virtual intensive outpatient program (IOP) provides personalized mental health treatment for teens, young adults, and families dealing with serious mental health struggles, including BPD and co-occurring conditions. Plus, we offer medication management for those who need it. With this kind of holistic treatment, managing your mental health is possible. Fill out the form below or give us a call to start healing today.