Borderline personality disorder (BPD) is a complex psychiatric condition characterized by difficulty regulating emotions, impulsivity, unstable relationships, and a distorted sense of self. BPD was officially recognized as a distinct disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. However, the symptoms and behaviors associated with BPD have been described in medical literature for over a century.
The way BPD has been conceptualized and treated has evolved significantly over time. In the early 20th century, psychoanalysts viewed BPD as a milder version of schizophrenia. Patients were often labeled as “latent schizophrenics” and treated with traditional psychoanalysis. As research on BPD progressed, more targeted psychosocial treatments emerged in the 1960s-1980s. Since the 1990s, dialectical behavior therapy (DBT) has become the gold standard treatment for BPD.
This article will provide an overview of how BPD was understood and managed throughout history, focusing on key developments in psychoanalysis, psychosocial interventions, medication, and the rise of DBT.
Psychoanalysis and “Latent Schizophrenia” (Early 1900s-1960s)
One of the earliest descriptions of BPD symptoms came from Emil Kraepelin, a German psychiatrist who classified mental disorders in the late 1800s. Kraepelin used the term “latent schizophrenia” to describe patients who showed odd behaviors, rapidly shifting moods, and instability in relationships and self-image. This set the stage for viewing BPD as a mild variant of schizophrenia.
In the first half of the 20th century, psychoanalysis became the dominant treatment for mental health conditions. Sigmund Freud did not specifically describe BPD, but his daughter Anna Freud recognized borderline symptoms in her clinical work. She viewed BPD as originating from early childhood trauma and ineffective defense mechanisms.
Other influential psychoanalysts like Otto Kernberg continued viewing BPD as a level of organization between neurosis (anxiety disorders) and psychosis. In the 1960s-1970s, Kernberg developed Transference-Focused Psychotherapy (TFP) for BPD patients based on psychoanalytic principles. TFP aims to work through identity diffusion and stabilize a sense of self in long-term therapy.
Overall in this era, psychoanalysts saw BPD symptoms as rooted in ego weakness, primitive defenses, and an inability to integrate good and bad representations of self and others. Treatment involved extensive analysis to uncover the unconscious roots of pathology.
Psychoanalysis Treatment Approach
– View of BPD as “mild schizophrenia” or “pseudoneurotic schizophrenia”
– Link to childhood trauma and defective ego defenses
– Treatment with classic psychoanalysis to uncover unconscious conflicts
– Development of Transference-Focused Psychotherapy (TFP)
Early Psychosocial Interventions (1960s-1980s)
As the psychoanalytic view dominated in the mid-20th century, some clinicians began questioning if BPD was truly a variant of schizophrenia. Research showed BPD patients did not exhibit the same thought disorders, deterioration, or poor prognosis as those with schizophrenia.
Alternative perspectives on BPD began emerging in the 1960s-1970s. Clinicians like Peter Giovacchini viewed BPD as a distinct disorder that was more psychosocial than biological in origin. This prompted a shift toward more environmental and relationship-based interventions.
Some pioneering treatments from this era include:
– Dialectical Behavior Therapy (DBT) – Originally developed by Marsha Linehan in the late 1980s, DBT combines cognitive-behavioral techniques for emotion regulation with concepts of dialectics, mindfulness, and acceptance from Eastern philosophy. DBT marks a shift toward balancing change and acceptance strategies in BPD treatment.
– Mentalization-Based Therapy (MBT) – Developed by Peter Fonagy and Anthony Bateman, MBT aims to strengthen the capacity to mentalize, or understand your own and others’ inner experiences. The inability to mentalize is viewed as a core deficit in BPD.
– Schema Therapy – Jeffery Young blended cognitive-behavioral therapy with techniques to modify maladaptive schemas, or deeply entrenched patterns people follow in relationships. Schema therapy addresses schema modes that frequently alternate in BPD.
– Systems Training for Emotional Predictability and Problem Solving (STEPPS) – Blaine Fowers and other University of Miami psychologists created this group intervention integrating systems, social skills, and cognitive-behavioral training. STEPPS is still used today.
Early Psychosocial Treatments
| DBT | Balances change & acceptance strategies |
| MBT | Strengthens capacity to mentalize inner experiences |
| Schema Therapy | Modifies maladaptive schemas & modes |
| STEPPS | Group intervention with systems, social, & CBT components |
Rise of Dialectical Behavior Therapy (1990s-Present)
Since its development in the late 1980s, DBT has become the most well-researched and widely implemented treatment for BPD. Multiple studies show DBT effectively reduces self-harm, suicide attempts, hospitalizations, anger, mood swings, and improves social adjustment.
DBT consists of four components administered by a team of providers:
– Weekly individual psychotherapy
– Group skills training
– Phone coaching for crisis management
– Consultation team for therapists
DBT focuses on core mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance skills. Therapists balance validation with change-based strategies. DBT requires a significant weekly time commitment from patients and extensive training for providers.
Many clinicians now consider DBT the gold standard psychosocial treatment for BPD. However, some criticisms include DBT’s demanding format requiring highly trained therapists, lack of focus on trauma, and need to integrate DBT skills into everyday life during and after treatment. Researchers continue working to address these limitations.
Key Components of DBT
| Individual therapy | Group skills training |
| Phone coaching | Consultation team for therapists |
| Core mindfulness, emotion regulation, interpersonal & distress tolerance skills | |
Role of Medications in Treating BPD
Unlike many mental illnesses, BPD is not considered biologically or chemically based. No medications directly treat BPD or target underlying causes. However, certain drugs may help manage specific symptoms when combined with psychotherapy.
Antidepressants like SSRIs can treat co-occurring depression but have limited effects on core BPD issues like anger, impulsivity, or chronic emptiness.
Antipsychotics may help with brief psychotic-like symptoms or agitation. However, antipsychotics do not reduce self-harm and come with major side effects.
Mood stabilizers such as lithium have mixed evidence for reducing anger, irritability, and impulsive aggression in BPD. Anticonvulsants like valproate may also help with emotional instability.
Anti-anxiety drugs like benzodiazepines carry a high risk for dependency and abuse in BPD. They should be avoided long-term.
Overall, medications play a supportive but not curative role in BPD treatment. Most clinicians agree psychotherapy should be the primary treatment. Medication use must be carefully monitored by doctors.
Medications for Managing BPD Symptoms
| Antidepressants | Help co-occurring depression |
| Antipsychotics | Manage brief psychotic symptoms |
| Mood stabilizers | Reduce anger, irritability, aggression |
| Anti-anxiety drugs | Avoid long-term due to abuse potential |
Current Landscape and Future Directions
Our understanding and treatment of BPD continue to evolve. In addition to DBT, evidence-based therapies like MBT, STEPPS, and schema-focused approaches are used today. Newer interventions incorporate trauma, meditation, or mobile technology.
However, significant gaps remain in effectively treating and managing BPD long-term. Many patients struggle to sustain recovery after finishing therapy. Researchers are now studying ways to improve generalization and maintenance of skills, identify biomarkers and subtypes, destigmatize BPD, and reach underserved populations.
Future directions include:
– Early intervention in adolescents and young adults showing BPD traits
– Stage-based approaches tailored to shifting needs across the disorder course
– Trauma-informed care to process past abuses that often precede BPD
– Technology-enhanced delivery of therapy through mobile apps and online tools
– Holistic integration of psychotherapy, skills coaching, medications, and community support
While BPD remains challenging to treat, progress continues. As we better understand BPD’s complex roots and nuanced developmental course, clinicians can humanely support those struggling toward lasting wellness.
Conclusion
BPD is no longer the mysterious, untreatable condition it was once viewed as. Modern evidence-based psychosocial therapies like DBT offer hope for stabilization, healing, and an improved quality of life. At the same time, we still have far to go in delivering personalized, accessible care across all stages of the disorder. Ongoing advances in psychotherapy, medications, technology, early intervention, and destigmatization will continue transforming the landscape of BPD treatment in the years ahead.
