Borderline personality disorder (BPD) is a serious and complex psychiatric illness impacting 1-2% of the general population.
Despite available treatments, many patients continue to struggle with suicidal behavior, emotional dysregulation, and impaired interpersonal functioning.
Researchers are now considering the potential of MDMA-assisted psychotherapy (MDMA-AP) as a complementary treatment approach for BPD.
Key Facts:
- BPD involves difficulties with emotion regulation, impulse control, self-image, and interpersonal relationships. Symptoms often emerge during adolescence.
- Current treatments like dialectical behavior therapy (DBT) and mentalization-based therapy (MBT) can reduce self-harm and suicidal behaviors but have limited effects on core BPD symptoms like emotional dysregulation and unstable relationships.
- MDMA-AP involves 1-3 doses of MDMA paired with psychotherapy sessions. It has shown promising results for post-traumatic stress disorder (PTSD) and may also benefit BPD given the overlap between the two disorders.
- Potential mechanisms include reduced avoidance of difficult emotions/memories and increased therapeutic rapport and disclosure. MDMA-AP may help “re-open” a critical period for emotional learning.
- Clinical trials are needed to evaluate the safety and efficacy of MDMA-AP for BPD, with careful suicide risk management protocols.
Source: Focus (Am Psychiatr Publ). 2022
The Challenges of Treating BPD
BPD is characterized by difficulties with emotion regulation, impulse control, unstable relationships, and distorted self-image.
Patients often engage in self-harm behaviors like cutting due to overwhelming emotions.
They may also make repeated suicide attempts.
BPD typically emerges during adolescence and is thought to arise from a combination of genetic factors and traumatic childhood experiences like abuse or neglect.
Theories suggest early attachment disruptions lead to core BPD issues with emotional/interpersonal regulation.
First-line treatments for BPD include DBT and MBT.
These therapies can help reduce suicidal behavior and self-harm within the first 6-12 months.
However, they seem to have more limited effects on core BPD symptoms:
- Emotional dysregulation and painful emotions persist, even when self-harm remits.
- Interpersonal symptoms like fears of abandonment appear especially resistant to change.
- Improvements in areas like relationships and identity are small compared to regular therapy.
- Nearly 50% of patients drop out prematurely.
The chronic nature of emotional and interpersonal BPD symptoms contributes to an ongoing risk of suicide attempts, especially in response to interpersonal stressors like rejection.
More effective treatments are needed targeting these core mechanisms.
The Case for Exploring MDMA-Assisted Psychotherapy
MDMA is a psychoactive substance that produces feelings of euphoria, emotional openness, and connection to others.
When administered in a controlled setting alongside psychotherapy, it is known as MDMA-AP.
MDMA-AP has shown promising results for PTSD treatment.
Given the extensive overlap between PTSD and BPD, it may also benefit BPD:
- High rates of comorbidity between BPD and PTSD (up to 80%). Comorbid cases have more severe symptoms.
- Shared childhood trauma risk factors and neurobiological abnormalities (HPA axis dysfunction, frontolimbic processing biases).
- Similar core symptoms like emotional dysregulation, interpersonal difficulties, and dissociation.
- Dimensional models group BPD and PTSD within a domain of “internalizing distress.”
Though risky behaviors like substance abuse are more common in BPD versus PTSD, MDMA does not appear to be habit-forming when used sparingly in a controlled setting.
In phase 2 and 3 trials for PTSD, MDMA-AP led to self-reported improvements in empathy, emotion regulation, relationships, and self-awareness – issues also relevant to BPD.
How Could MDMA-Assisted Therapy Help BPD?
MDMA-AP may enable patients to revisit and process traumatic memories with less emotional avoidance.
Key mechanisms could include:
Reduced emotional reactivity – MDMA acutely dampens fear/anxiety responses in the amygdala. This may help patients stay emotionally engaged without becoming overwhelmed.
Increased self-disclosure – MDMA reduces distrust and enhances feelings of connection. This may strengthen the therapeutic alliance and disclosure of distressing material.
Re-opening a critical developmental period – Animal research suggests MDMA can briefly restore neural plasticity levels seen during childhood. This plasticity may support re-learning of emotional regulation skills.
Through these mechanisms, MDMA-AP may “unlock” traumatic memories and maladaptive attachment patterns formed in childhood, allowing them to be processed and healed within the therapeutic space.
Designing Clinical Trials of MDMA Psychotherapy for BPD
While promising, clinical trials are needed to rigorously test MDMA-AP for BPD.
These should evaluate:
- Safety – Suicide risk management protocols are crucial. Skills for coping with dissociation/self-harm should be taught before dosing sessions.
- Efficacy – Randomized placebo-controlled trials are needed to account for placebo effects. Primary outcomes should include emotional dysregulation, social functioning, and suicide attempts.
- Protocols – Optimal MDMA dosage, schedule, and integrative therapy approaches must be explored. Non-directive and trauma-focused therapy models could be compared.
- Accessibility – Studies must ensure diversity in gender identity, race, and socioeconomic status. This includes therapist diversity, cost offsets, and inclusive recruiting.
- Ethics – Boundaries around physical touch, session endings, and post-study contact should be addressed given attachment issues in BPD.
Research of MDMA in Borderline Personality Disorder Needed
BPD is a disabling condition affecting many young people.
While current treatments help, they leave room for improvement in core areas like emotional and interpersonal functioning.
The research on MDMA-AP for PTSD provides a strong rationale for exploring its potential in BPD.
With careful risk management and rigorous study design, clinical trials could uncover an important new treatment option for this vulnerable population.
References
- Study: MDMA-assisted psychotherapy for borderline personality disorder
- Authors: Jenna M. Traynor PhD et al. (2022)
