15th February 2025

Management of personality disorders

Management plans should be agreed with the patient, be tailored to the individual and set clear expectations. There has been a movement away from prolonged inpatient stays or those involving psychiatric ICUs.

Psychotherapy

Psychotherapy is the first-line treatment for personality disorders. In particular, dialectical behaviour therapy (DBT) is recommended by NICE for women with borderline personality disorder who self-harm. DBT is a long-term intervention lasting 1-2 years. Brief psychological interventions (<3 months) should be avoided.

Pharmacological management

NICE recommends that drug treatment should not be used for borderline personality disorder or its symptoms (e.g. emotional instability, repeated self-harm), although drug treatment can be utilised in treating comorbid conditions. For concurrent depression, a combination of antidepressant medication (first line usually an SSRI) and a psychological treatment can be considered, depending on the patient’s preference (NICE notes that the evidence base is limited).

Where medications are used, NICE recommend the following:

• Consider side effects, addiction risk and safety in overdose.
• Avoid polypharmacy where possible.
• Antipsychotics should not be used as medium- or long-term treatment. 
• Short-term sedatives may be used in crisis but for no longer than one week.

References

• Casey P and Kelly B. Personality Disorders. In Fish’s Clinical Psychopathology: Signs and Symptoms in Psychiatry. 4th ed. Cambridge: Cambridge University Press; 2020. Pp. 109-123
• ICD-11. Personality Disorders. Online [cited 17 December 2023]. Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f37291724
• Management of Personality Disorder. In: Oxford Handbook of Psychiatry. 4th ed. Ed. Semple D and Smyth R. Oxford: Oxford University Press; 2019. Pp. 517-540
• Mind. Personality Disorder: Why is it Controversial? [Internet] [cited 21 January 2024]. Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/why-is-it-controversial
• National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management [Internet]. NICE. 28 January 2009 [cited 16 January 2024]. Available from: https://www.nice.org.uk/guidance/cg78
• National Institute for Health and Care Excellence. Depression in adults: treatment and management [Internet]. NICE. 29 June 2022 [cited 21 January 2024]. Available from: https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#depression-in-people-with-a-diagnosis-of-personality-disorder
• Personality Disorders. In DSM-5. Washington, DC: American Psychiatric Publishing; 2013. Pp. 645-684]
• ICD-11. Personality Disorders. Online [cited 17 December 202]. Available at: https://icd.who.int/browse11/l-m/en#/http%253a%252f%252fid.who.int%252ficd%252fentity%252f37291724