Could psychedelic-assisted therapy be effective in treating borderline personality disorder?
Written by Matilda Toseland
Borderline personality disorder (BPD) is an incredibly contentious diagnosis and the debate around it within healthcare is rife. Research investigating the prevalence, diagnosis and potential causes of this disorder is often polemic in nature and even in the age of “it’s okay to not be okay”, stigma around the diagnosis remains constant. BPD is characterized by emotion dysregulation, impulsivity, extreme rejection sensitivity, unstable self-concept, and volatile behaviour. (Gunderson et al., 2018). While often considered a ‘female disorder’ with women being diagnosed up to 75% more often than men, it is difficult to tell whether this is a function of sampling or diagnostic bias; or whether this difference reflects biological or sociocultural differences between men and women. (Skodol & Bender, 2003)
As with many mental health disorders, there is strong evidence to suggest childhood trauma is a causative factor, especially if viewed in the context of a multifactorial etiological model (Ball & Links, 2009). In fact, a link between childhood sexual abuse and BPD in women has been well established (Temes et al., 2020).
Whilst specific evidence-based therapeutic interventions such as dialectical behavioural therapy (DBT), mentalisation-based therapy (MBT) and transference-focused psychotherapy (TFP) exist, their effectiveness is sadly limited. (Zeifman and Wagner, 2020) Although evidence suggests that all these treatments are more effective than treatment as usual at reducing BPD symptoms (Stoffers et al., 2012), it appears the effect size for these treatments are only small to moderate at best. (Cristea et al., 2017) Moreover, there is little to no evidence suggesting any current pharmacological interventions are effective for BPD. (Zeifman & Wagner, 2020) Given the lack of current effective treatment options and the level of disruption BPD symptoms can have on one’s life, there is a clear need for exploring novel interventions and ideas for people with BPD.
A fast-expanding body of research investigating clinical applications of psychedelic research is encouraging. Studies have found that psychedelics combined with psychedelic-assisted therapy (PAT) cause a reduction in symptoms of major depressive disorder, PTSD, substance abuse disorders and OCD (Sessa et al., 2019). These disorders are often found comorbidly with BPD with many overlapping symptoms, hence providing grounds to suggest TAP could also be effective in treating BPD. Moreover, unprocessed trauma underlies many mental health conditions and it is by catalysing the processing of this trauma that it is hypothesised that psychedelics are able to have therapeutic effects as it has been shown to help patients reprocess trauma in a way that allows it to no longer trigger mental illness (Inserra et al., 2018). As BPD is so heavily linked with trauma, it seems logical to suggest psychedelics could be helpful in overcoming and managing this disorder too.
As of right now, there have been no investigations looking directly into treating BPD (as a disorder) with psychedelic-assisted therapy. However, there is evidence suggesting psychedelics may positively impact the symptoms commonly associated with BPD. These symptoms include emotion dysregulation, behavioural dysregulation, and disturbances in self-identity and social functioning (Ziefman & Wagner, 2020). Moreover, although no studies have looked directly at treating BPD with PAT, there have been approximately 10 studies which included participants with BPD. Promisingly, these studies found similar positive effects of PAT in the participants with BPD as those without (Zeifman & Wagner, 2020).
The emotional dysregulation people with BPD internally face leads to the dysregulated behaviours often associated with the disorder. These behaviours include aggression, substance abuse, suicidal behaviours, and impulsivity. (APA, 2013) Evidence suggests that psychedelics can aid with both emotional and behavioural dysregulation. Domínguez-Clavé et al. (2019) found administering ayahuasca significantly lowered emotional dysregulation 24 hours after administration. Despite this being a community sample, a sub-group of the sample was further analysed for having high levels of BPD traits. This sub-group also showed improved emotional dysregulation, specifically reduced emotional interference and lack of control. Additionally, Thiessen et al. (2018) found that lifetime psychedelic use is associated with lower levels of emotion dysregulation within community samples.
Emotional and behavioural dysregulation
Emotional dysregulation, a cluster of symptoms associated with emotional sensitivity, increased negative affect and a lack of emotion regulation strategies, is often considered the core underpinning of BPD aetiology (Zeifman & Wagner, 2020). It is hypothesized to arise from increased activity in limbic regions of the brain, associated with emotion generation and detection, coupled with reduced prefrontal activity, which is associated with top-down control. (Schulze, Schmahl & Niedtfeld, 2016) The resultant effect of coupling a more intense emotional response and a lower ability to control this is emotion dysregulation. The emotional dysregulation people with BPD internally face leads to the dysregulated behaviours often associated with the disorder. These behaviours include aggression, substance abuse, suicidal behaviours, and impulsivity. (APA, 2013)
In terms of behavioural regulation research is also positive, Bogenschutz et al. (2018) found patients reported increased behavioural control after psilocybin-assisted psychotherapy. Additionally, 3-9 monthly biweekly ritual ayahuasca use significantly decreased self-reported impulsivity (Fernández et al., 2014) and psychedelic use was also associated with a decrease in aggression. (Zeifman & Wagner, 2020) Moreover, psychedelics have also been found to reduce substance abuse (Krebs and Johansen, (2012) with LSD treatment significantly improving alcohol abuse among those with alcohol dependence. Finally, psychedelics have also been associated with a reduction in suicidal behaviours, (Zeifman & Wagner, 2020) even in studies which include individuals with BPD. (Grunebaum et al., 2017; Murrough et al., 2015) Thus, there is evidence to show PAT can help with all four key behavioural deficits manifestations seen in BPD: aggression, substance abuse, impulsivity and suicidality.
Mindfulness
Mindfulness and other related skills including mentalization, acceptance and decentring (observing one’s thoughts and emotions) are crucial for emotion regulation. People with BPD show lower levels of both mindfulness and acceptance, and it has been suggested this contributes to the emotion and subsequent behaviour dysregulation seen in BPD. (Zeifman & Wagner, 2020). Studies have shown that PAT, specifically ayahuasca ceremonies, lead to increased mindfulness-related skills such as acceptance and decentring. (Domíngues-Clavé et al., 2019; Soler et al., 2018)
Self-identity
Another core feature of BPD is an unstable self-identity. (APA, 2013) Although there hasn’t been a study yet to determine the effects of PAT on the stability of self-concept, there is evidence to show psychedelic use is linked with increased self-compassion and self-acceptance. (Zeifman & Wagner, 2020).
Social functioning
Because of the emotional dysregulation and subsequent behavioural dysregulation issues, BPD can be a very isolating disorder and social functioning can be very hard for people living with it. Research has shown that psychedelics can have a positive impact on social functioning, including within the BPD population: Krupitsky & Grinenko (1996) found that ketamine-assisted therapy led to improved interpersonal sensitivity and improvements in social functioning. Moreover, after both psilocybin and MDMA-assisted therapy, individuals reported improved relationships. (Zeifman & Wagner, 2020)
Psychedelics have been shown to improve many of the core deficits seen in BPD, however, many people have reservations about administering this kind of therapy to the BPD population. In fact, many retreat centres, treatment centres and PAT studies explicitly exclude participants with BPD or BPD symptomology. The main concerns around administering PAT to individuals with BPD seem to be safety concerns, but in the approximately 10 PAT studies which included participants with BPD, no serious adverse effects were reported. (Zeifman & Wagner, 2020)
As BPD is heavily associated with substance abuse there have been reservations about giving people with BPD a substance as a form of therapy. However, serotonergic psychedelics such as LSD and ayahuasca generally have very low dependence potential, thus this should not really be an issue. (Hamill, Hallak, Dursun & Baker, 2019). Still, the need to remain free of other substances to use them could be a challenge.
One of the major concerns may come from another large reservation many people have about treating BPD with TAP comes from the link between BPD and suicidality, as psychedelics can be somewhat unpredictable and the effects can be quite distressing if one has a ‘bad trip’. Giving them to a population already at risk of suicide is thus understandably a big concern. Zeifman & Wagner (2020) suggest that in line with common practice in other clinical trials, initial studies looking at the safety and tolerability of PAT should exclude participants with recent serious suicidal or self-harm behaviours. Moreover, treatment guidelines (Johnson et al., 2008) for PAT should be followed carefully. These include: administering psychedelics within a controlled setting; in the presence of a therapist who can provide support and sedatives if necessary; and that preparation and integration sessions prior to and following the psychedelic administration should be provided.
Additionally, anecdotally, to be able to have a ‘good trip’ one must be able to regulate one’s own emotions, in order to not ‘freak out’ at the effects of the psychedelics. As people with BPD struggle with this, again it makes sense to be tentative about administering PAT to this population. However, if administered according to protocol, with a trusted supervisor available to help calm down the participant and administer sedatives if needed, this should not be too much of a safety concern.
Zeifman & Wagner (2020) suggest due to the complex nature of BPD, PAT should be incorporated with existing models of therapy for disorders such as DBT. Danforth et al. (2018) showed that MDMA-assisted psychotherapy with an adapted DBT had promising results for treating autistic adults with social anxiety disorder, showing that this type of therapy could work in combination with psychedelics.
In conclusion, although no studies have yet looked at directly treating BPD with PAT, there is a vast body of evidence to suggest PAT has positive outcomes on many of the deficits associated with BPD. Moreover, although there are concerns about administering psychedelics to this population, if the proper safety protocol is followed, these should not be too much of an issue and could be an opportunity to provide therapy to a currently unmet need. In my opinion, when considering the potential reward for alleviating such a distressing disorder in comparison to the risk of the psychedelic, it is well worth the risk.
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