Current Treatment Options in Psychiatry

, Volume 5, Issue 1, pp 141–161 | Cite as

Combination Treatments in Borderline Personality Disorder: Bridging the Gap Between Clinical Practice and Empirical Data

  • Lea K. Marin
  • K. Nidhi Kapil-Pair
  • Rachel E. Harris
  • Marianne Goodman
Personality Disorders (M Goodman, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Personality Disorders

Opinion statement

Purpose of Review This paper presents an empirical basis for combination treatments in borderline personality disorder (PD), including medication combinations, psychotherapy combinations, and psychotherapy with medication. The goals are to synthesize empirical data evaluating combination treatments and to demonstrate gaps between research and clinical practice.

Recent Findings The limited research supporting combination treatments displayed mixed results. There is minimal support for the frequent clinical practice of polypharmacy, with some evidence for the use of atypical antipsychotics with antidepressants. The scant research in combination psychotherapies supported its use primarily in individuals with comorbid psychiatric disorders (e.g., borderline PD and PTSD). Similarly, medication combined with psychotherapy had the greatest utility in individuals with comorbid psychiatric diagnoses.

Summary Further research is needed before firm conclusions can be drawn on the use of combination treatments in borderline PD. The few studies that exist had mixed results, were often based on small sample sizes, and had abbreviated treatment courses. Nonetheless, there does appear to be a potential utility in the use of combination treatments for this complex neuropsychiatric disorder with significant morbidity and mortality, a wide range of symptoms, and frequent comorbid diagnoses.


Borderline personality disorder Combination treatments Combination medications Combination psychotherapy Medication with psychotherapy Polypharmacy 


Compliance with ethical standards

Conflict of interest

Lea K. Marin declares that she has no conflict of interest. Rachel E. Harris declares that she has no conflict of interest. Kalpana N. Kapil-Pair declares that she has no conflict of interest. Marianne Goodman serves as a consultant for Boehringer Ingleheim Pharmaceuticals.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    APA. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013.Google Scholar
  2. 2.
    Levy KN, Yeomans FE, Denning F, et al. UK national institute for clinical excellence guidelines for the treatment of borderline personality disorder. Personal Ment Health. 2009;4:54–8.CrossRefGoogle Scholar
  3. 3.
    Oldham J, Gabbard G, Goin M, et al. (2001) Practice guideline for the treatment of patients with borderline personality disorder. APA practice guidelines for the treatment of psychiatric disorders: comprehensive guidelines and guideline watches. doi:
  4. 4.
    • Bridler R, Häberle A, Müller ST, et al. Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: a comparison with other psychiatric disorders. Eur Neuropsychopharmacol. 2015;25(6):763–72. This study identifies prescribing data to show widespread use of polypharmacy in borderline PD treatment.
  5. 5.
    Turhan S, Taylor M. The outcomes of home treatment for borderline personality disorder. BJPsych Bull. 2016;40(6):306–9. Scholar
  6. 6.
    Zanarini MC, Frankenburg FR, Hennen J, et al. Mental health service utilization by borderline personality disorder patients and axis II comparison subjects followed prospectively for 6 years. J Clin Psychiatry. 2004;65(1):28–36.CrossRefPubMedGoogle Scholar
  7. 7.
    Stoffers JM, Völlm BA, Rücker G, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012;8:CD005652.Google Scholar
  8. 8.
    Bellino S, Paradiso E, Bogetto F. Efficacy and tolerability of aripiprazole augmentation in sertraline-resistant patients with borderline personality disorder. Psychiatry Res. 2008;161(2):206–12. Scholar
  9. 9.
    Bellino S, Bozzatello P, Rocca G, et al. Efficacy of omega-3 fatty acids in the treatment of borderline personality disorder: a study of the association with valproic acid. J Psychopharmacol. 2014;28(2):125–32. Scholar
  10. 10.
    Podobnik J, Foller Podobnik I, Grgic N, et al. The effect of add-on treatment with quetiapine on measures of depression, aggression, irritability and suicidal tendencies in children and adolescents. Psychopharmacology. 2012;220(3):639–41. Scholar
  11. 11.
    Bellino S, Zizza M, Rinaldi C, et al. Combined treatment of major depression in patients with borderline personality disorder: a comparison with pharmacotherapy. Can J Psychiatr. 2006;51(7):453–60.CrossRefGoogle Scholar
  12. 12.
    Bellino S, Zizza M, Rinaldi C, et al. Combined therapy of major depression with concomitant borderline personality disorder: comparison of interpersonal and cognitive psychotherapy. Can J Psychiatr. 2007;52(11):718–25.CrossRefGoogle Scholar
  13. 13.
    Bellino S, Rinaldi C, Bogetto F. Adaptation of interpersonal psychotherapy to borderline personality disorder: a comparison of combined therapy and single pharmacotherapy. Can J Psychiatr. 2010;55(2):74–81.CrossRefGoogle Scholar
  14. 14.
    • Bellino S, Bozzatello P, Bogetto F. Combined treatment of borderline personality disorder with interpersonal psychotherapy and pharmacotherapy: predictors of response. Psychiatry Res. 2015;226(1):284–8. This research provides evidence that certain clinical predictors of combined treatment response could potentially impact severity of borderline PD symptoms.
  15. 15.
    Bozzatello P, Bellino S. Combined therapy with interpersonal psychotherapy adapted for borderline personality disorder: a two-years follow-up. Psychiatry Res. 2016;240:151–6. Scholar
  16. 16.
    Linehan MM, Mcdavid JD, Brown MZ, et al. Olanzapine plus dialectical behavior therapy for women with high irritability who meet criteria for borderline personality disorder. J Clin Psychiatry. 2008;69:999–1005.CrossRefPubMedGoogle Scholar
  17. 17.
    Moen R, Freitag M, Miller M, et al. Efficacy of extended-release divalproex combined with “condensed” dialectical behavior therapy for individuals with borderline personality disorder. Ann Clin Psychiatry. 2012;24(4):255–60.PubMedGoogle Scholar
  18. 18.
    Prada P, Nicastro R, Zimmermann J, et al. Addition of methylphenidate to intensive dialectical behaviour therapy for patients suffering from comorbid borderline personality disorder and ADHD: a naturalistic study. Atten Defic Hyperact Disord. 2015;7(3):199–209. Scholar
  19. 19.
    Simpson EB, Yen S, Costello E, et al. Combined dialectical behavior therapy and fluoxetine in the treatment of borderline personality disorder. J Clin Psychiatry. 2004;65(3):379–85.CrossRefPubMedGoogle Scholar
  20. 20.
    Soler J, Pascual JC, Campins J, et al. Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for borderline personality disorder. Am J Psychiatry. 2005;162(6):1221–4. Erratum in: Am J Psychiatry. 2008 Jun;165(6):777CrossRefPubMedGoogle Scholar
  21. 21.
    Swartz HA, Pilkonis PA, Frank E, et al. Acute treatment outcomes in patients with bipolar I disorder and co-morbid borderline personality disorder receiving medication and psychotherapy. Bipolar Disord. 2005;7(2):192–7.CrossRefPubMedGoogle Scholar
  22. 22.
    • Antonsen BT, Kvarstein EH, Urnes Ø, Hummelen B, et al. Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study. Psychother Res. 2017;27(1):51–63. This study provides a discussion of how combined psychotherapies may lead to diagnostic remission, greater symptom reduction, and improvement in the identity integration and self-control domains for patients with borderline PD>. Google Scholar
  23. 23.
    Edel MA, Raaff V, Dimaggio G, et al. Exploring the effectiveness of combined mentalization-based group therapy and dialectical behaviour therapy for inpatients with borderline personality disorder—a pilot study. Br J Clin Psychol. 2017;56(1):1–15. Scholar
  24. 24.
    • Harned MS, Korslund KE, Linehan MM. A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav Res Ther. 2014;55:7–17. This study discussed how combined DBT-PE achieved diagnostic remission, symptom reduction, and improvements in the emotional and cognitive constructs.
  25. 25.
    Marcinko D, Bilic V. Family therapy as addition to individual therapy and psychopharmacotherapy in late adolescent female patients suffering from borderline personality disorder with comorbidity and positive suicidal history. Psychiatr Danaub. 2010;22(2):257–60.Google Scholar
  26. 26.
    • Stoffers JM, Lieb K. Pharmacotherapy for borderline personality disorder--current evidence and recent trends. Curr Psychiatry Rep. 2015;17:534. Authors provide an overview of the most current treatments and identify trends in ongoing trials.
  27. 27.
    Zanarini MC, Frankenburg FR, Parachini EA. A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry. 2004,Jul;65(7):903–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Rivera M, Darke JL. Integrating empirically supported therapies for treating personality disorders: a synthesis of psychodynamic and cognitive-behavioral group treatments. Int J Group Psychother. 2012;62(4):500–29. Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Lea K. Marin
    • 1
    • 2
  • K. Nidhi Kapil-Pair
    • 1
    • 3
  • Rachel E. Harris
    • 3
  • Marianne Goodman
    • 1
    • 3
  1. 1.Department of PsychiatryIcahn School of Medicine at Mount SinaiNew YorkUSA
  2. 2.The Mental Health Patient Care CenterJames J. Peters Veterans Affairs Medical CenterBronxUSA
  3. 3.Mental Illness, Research, Education, and Clinical Center (MIRECC)James J. Peters Veterans Affairs Medical CenterBronxUSA

Personalised recommendations