Systematic Review of the Effectiveness and Experiences of Treatment for Men With Borderline Personality Disorder

Abstract

In clinical settings, among individuals diagnosed with borderline personality disorder (BPD), typically 75% are female and 25% male, although this discrepancy is not reported in the community. In the literature, little is known of the effectiveness and experiences of treatment of men with BPD. We aimed to review the effectiveness and experiences of treatment for men with BPD and outline future research priorities to promote better recovery. We searched Ovid MEDLINE and PsycINFO for eligible studies from inception until July 29, 2022. Peer-reviewed primary research articles on treatment effectiveness or experience for men with BPD were included. Data from eligible studies were synthesized in a narrative review. The protocol of our review was pre-registered on PROSPERO (CRD42022351908). Seventeen studies met the inclusion criteria, and men with BPD from eight countries were represented. Psychological therapies included Dialectical Behavioral Therapy, Systems Training for Emotional Predictability and Problem Solving, Mentalization Based Therapy, and psychoanalytic therapy. Pharmacologic treatment included topiramate, divalproex Extended-Release, and high-dose baclofen. Five studies investigated the service utilization of men with BPD. Compared to women, men were less likely to access treatment for BPD or find treatment helpful. Our findings demonstrated the potential efficacy of psychotherapy and pharmacologic interventions in reducing anger, aggression, and rule-breaking behavior, with limited evidence for reduction in suicide-related outcomes. Our findings are limited by inadequate power and heterogeneity of the included studies. Further research with larger sample sizes and qualitative studies is needed to better understand the treatment experience for men with BPD.

Background

Borderline personality disorder (BPD) is characterized by emotional dysregulation, identity instability, and dysfunctional behaviors, which contribute to marked impairment in personal, social, and occupational functioning (Links et al., 2023). BPD is a disabling condition affecting approximately 2% of the general population, 10% of psychiatric outpatients, and 20% of psychiatric inpatients (Lieb et al., 2004). Individuals with BPD are significant users of health services (Zanarini et al., 2004) with a lifetime risk of suicide ranging between 3% and 10% (Paris & Zweig-Frank, 2001).

While individuals diagnosed with BPD are typically 75% female and 25% male in the clinical setting, this difference in gender distribution is not reported in community samples (Bayes & Parker, 2017). Phenomenologically, men with BPD exhibit externalizing behaviors, including substance abuse, violent self-harm, and aggression. Women with BPD demonstrate internalizing behaviors that manifest in affective instability, comorbid anxiety, and eating disorders (Bayes & Parker, 2017; Qian et al., 2022). Men with BPD are more likely to be diagnosed with BPD in a drug rehabilitation clinic and less likely to receive psychotherapy or treatment for anxious or depressive symptoms compared with their female counterparts (Qian et al., 2022).

There is growing evidence that psychotherapy is effective for many patients with BPD, with at least six individual BPD psychotherapies demonstrating benefits, including Dialectical Behavioral Therapy, Transference-Focused Therapy, Schema Therapy, Mentalization Based Therapy, Good Psychiatric Management, and Cognitive Behavior Therapy for Personality Disorders (Choi-Kain et al., 2016; Cristea et al., 2017; Davidson et al., 2010; Leichsenring et al., 2024). Although BPD-specific psychotherapies have been recommended as first-line interventions for these patients, the appropriateness of this recommendation for men with BPD appears less established. A meta-analysis of randomized controlled trials (RCT) of psychotherapy versus controlled conditions in adults with BPD, which included 33 studies involving 2,256 participants, included 12 women-only studies and no analysis by gender was possible across the included studies (Cristea et al., 2017).

Little is known about men with BPD regarding their experience of treatment and their perceptions of what promotes their recovery. Katsakou and Pistrang (2018) reviewed qualitative studies of clients’ experience of treatment for BPD and their perceptions of recovery, but the 14 studies included only 38 men out of a total of 245 participants (15.5% of the sample) and discussion of experience by gender was not feasible.

The aims of the current systematic review were threefold. First, to focus exclusively on studies on the effectiveness and experience of treatment (and of recovery) for men with BPD. Second, to explore the gaps in the evidence on effective interventions, experiences, and needs for recovery for men with BPD. Finally, we aim to outline the future research priorities to better treat men with BPD and to promote their recovery.

Method

Protocol and Search Strategy

We conducted a systematic review of the treatment effectiveness and lived experiences of recovery of men with BPD following a pre-registered PROSPERO protocol (CRD42022351908). We searched Ovid MEDLINE and PsycINFO for eligible studies from inception until July 29, 2022, in collaboration with a librarian. The search strategy consisted of both subject headings and keywords involving BPD, male gender, treatment outcome, and treatment experience. Gray literature and other sources of data were not included in our search. The full search strategy is accessible in Supplemental Appendix A. We completed an updated search of the literature using the same search strategy and databases on November 16, 2023.

Eligibility Criteria

Peer-reviewed primary research articles focusing on treatment effectiveness or treatment experience for men with BPD were included. Treatment included psychological therapies or pharmacologic treatment for men with BPD. Eligible studies included participant samples that were majority adult male participants with BPD. Alternatively, studies that indicated in the abstract or study aims that they conducted a gender analysis of outcomes for participants with BPD were included. We included studies conducted in all treatment settings, including outpatient, inpatient, and high-security settings. There were no exclusion criteria for comorbid psychiatric conditions. Both qualitative and quantitative study designs were included to capture themes of treatment experience for men with BPD. Studies that included participants with BPD symptoms but not meeting diagnostic criteria for BPD and articles not written in English were excluded.

Screening and Data Extraction

Abstracts and full-text studies from the initial search were screened by two independent reviewers (YC and PL) on Covidence (2023) and conflicts were resolved through discussion between the two study members. We extracted inclusion criteria, exclusion criteria, study setting, sample characteristics, details of the intervention, dropout rates, and primary and secondary outcomes of eligible studies. Data from eligible studies were synthesized in a narrative review, with an overview of treatment efficacy in men with BPD, service utilization, and treatment experience of men with BPD. A thematic analysis was not performed as only one qualitative study met the inclusion criteria. Due to the heterogeneity of the study designs and outcomes, a meta-analysis was not conducted. Abstracts and full-text studies from the updated search were screened by three independent reviewers (YC, AK, and DB) on Covidence (2023), and conflicts were resolved through discussion with the entire research team (YC, AK, DB, and PL).

Quality Assessment

Quality assessment was completed using the appraisal criteria developed by Hawker et al. (2002) for both qualitative and quantitative studies (Hawker et al., 2002). This quality assessment tool included nine criteria that can be rated “good,” “fair,” “poor,” or “very poor.” Two reviewers independently assessed a subsample of the studies (YC and PL) and a kappa statistic was calculated to determine interrater agreement. Based on the weighted kappa (0.631), there was substantial agreement between the two reviewers.

Results

The initial search identified 1,305 unique studies, and 36 studies were selected for full-text screening. Two articles were unretrievable, and 17 articles were excluded for a total of 17 included studies (Figure 1). Most studies were excluded at the abstract screening stage as they did not focus on treatment effectiveness or experiences of males with BPD or did not include a study sample that consisted of a majority of male participants. From the updated search, 1,508 studies were identified, of which 1,469 were duplicate studies from the initial search (Figure 2). Of the 39 abstracts, 37 were excluded and 2 were screened at the full-text stage. Neither of the two studies met full inclusion criteria after full-text screening.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram for the Initial Search (Page et al., 2021)

Figure 2.

PRISMA Flow Diagram for the Updated Search (Page et al., 2021)

Study Characteristics

Five RCT’s (Bateman et al., 2016; Bianchini et al., 2019; Bogenschutz & Nurnberg, 2004; Nickel & Loew, 2008; Nickel et al., 2005), five prospective cohort studies (Löffler-Stastka et al., 2006; Pascual et al., 2007; Rolland et al., 2015; Tull & Gratz, 2012; Wetterborg et al., 2020), two retrospective cohort studies (Dehlbom et al., 2022; Meyers et al., 2014), one open-label trial (Simeon et al., 2007), two cross-sectional studies (Goodman et al., 2010; Lawn & McMahon, 2015), one program evaluation (Black et al., 2018), and one qualitative study (Russell & Siesmaa, 2017) were included in our review (Tables 1–3). Most participants were diagnosed with comorbid substance use disorders (SUD) in seven studies, predominantly mood disorders in four studies, and Antisocial Personality Disorder (ASPD) in three studies. Study settings were heterogeneous, with most studies performed in outpatient or community settings (Bateman et al., 2016; Bogenschutz & Nurnberg, 2004; Meyers et al., 2014; Nickel et al., 2005, Nickel & Loew, 2008; Rolland et al., 2015; Simeon et al., 2007), inpatient wards (Löffler-Stastka et al., 2006), community forensic services (Russell & Siesmaa, 2017), psychiatric emergency services (Pascual et al., 2007), inpatient forensic units (Bianchini et al., 2019), correctional settings (Black et al., 2018), and residential substance abuse treatment facility (Tull & Gratz, 2012).

Table 1.

Study Characteristics—Psychological Therapy Interventions

Study and Country	Study Design	Sample Characteristics	Main comorbid psychiatric conditions	Setting	Intervention	Results
Bianchini et al., 2019 Italy	Pilot RCT	SS: 21 Age: 41.79* 100% male	86% SUD	Inpatient forensic psychiatry	DBT, 12 months	• Significant improvement in emotional regulation • Significant improvement in motor impulsiveness • No significant difference in alexithymia
Meyers et al., 2014 United States	Retrospective cohort	SS: 41 Age: 47.1* 54% male	100% Depression or dysthymia, 81% PTSD, 71% SUD	Outpatient clinic	DBT, 6 months	• Significant decrease in the use of mental health services in the year following treatment • Direct costs of healthcare significantly reduced in the year following treatment • Hospital admissions (34.1% vs. 17.1%) and length of stay (average of 5.2 days vs. 1.6 days) significantly declined after treatment, whereas use of primary care and emergency services were slightly lower
Wetterborg et al., 2020 Sweden	Prospective cohort	SS: 30 Age: 35.3* 100% male	75% ASPD 82.1% Anxiety disorder	Outpatient forensic psychiatry and probation services	DBT, 12 months	• Self-harm significantly decreased post-treatment (RR = 0.30), whereas number of suicide attempts did not significantly decrease • Violence (RR = 0.39) and property offending (RR = 0.17) significantly declined • Significant decrease in self-reported and relative-reported aggression (d = 0.91, d = 0.79 respectively) • BPD symptoms (d = 1.26) and depressive symptoms (d = 0.84) significantly improved • No significant change in anxiety or drug use
Russell & Siesmaa, 2017 England	Qualitative study	SS: 6 Age: 47* 100% male	100% ASPD	Outpatient forensic program	DBT, 12–29 months	• Importance of motivation, reflection, and drive for change in engaging in DBT • Sense of shared learning, support, and belonging and trust in the therapist • Feelings of achievement and confidence in applying knowledge and skills from DBT
Black et al., 2018 United States	Sub-analysis of program evaluation	SS: 77 Age: *N/A 18.2% male	N/A	Prison or community corrections program	STEPPS, 20 weeks	• Similar improvements in BPD symptoms, suicidal behavior, disciplinary infractions for both genders • Greater positive (d = 0.39 vs. –0.40) and negative affectivity (d = 0.81 vs. 0.33) improvement in women compared to men • STEPPS satisfaction lower in men than women • Completion rate significantly higher in women compared to men (59% vs. 29%)
Löffler-Stastka et al., 2006 Austria	Pilot prospective cohort	SS: 20 Age: 38.9* (males) 50% male	All patients had a history of addictive behavior	Inpatient psychiatry	Psychoanalytic therapy, group occupational therapy, music therapy, skills training, 6 weeks	• Males were less likely to continue therapy compared to women • Men had higher levels of self-reported aggressiveness, self-efficacy after treatment • Men’s self-assessed exploitability significantly decreased after treatment
Bateman et al., 2016 England	RCT	SS: 40 Age: 31.50* (MBT group) 75% male	100% ASPD	Outpatient Clinic	MBT, 18 months	• Anger and paranoia significantly reduced • Suicide attempts, self-harm attempts, and hospital admissions significantly reduced • Self-rated hostility decreased in both groups • Anxiety and depression significantly improved

SS = sample size, * = mean, BPD = borderline personality disorder, RCT = randomized control trial, ASPD = antisocial personality disorder, STEPPS = Systems Training for Emotional Predictability and Problem Solving, MBT = mentalization based therapy, DBT = dialectical behavioral therapy, PTSD = post-traumatic stress disorder, SUD = substance use disorder, RR = rate ratio, d = effect size.

Table 2.

Study Characteristics—Pharmacologic Interventions

Study and Country	Study Design	Sample Characteristics	Main comorbid psychiatric conditions	Setting	Intervention	Results
Bogenschutz & Nurnberg, 2004 United States	RCT	SS: 40 Age: 32.6* 37.5% male	N/A	Community and outpatient clinics	Olanzapine (range 2.5 – 20mg/day), 12 weeks	• Endpoint dose*: olanzapine 6.9 ± 3.2 mg daily • Significantly improved CGI-BPD scores in the olanzapine group (d = 0.77) compared with the placebo group from 4 weeks onward, with the greatest improvement in inappropriate anger • Significant weight gain in the olanzapine group • No significant relationship between gender and outcome
Nickel et al., 2005 Netherlands	RCT	SS: 42 Age: 29.5* (topiramate) 100% male	Mood disorders 68.2% (treatment group)	Community and outpatient clinics	Topiramate 50mg daily (titrated to 250mg/day), 8 weeks	• Topiramate group showed significant improvement in all STAXI scales measuring anger (State Anger, Trait Anger, Anger Out, Anger Control) compared to placebo • Greater weight loss in the treatment group
Nickel & Loew, 2008 Netherlands	RCT	SS: 44 Age: N/A 100% male	N/A	Community and outpatient clinics	Topiramate (up to 250mg/daily), 18-month follow-up	• Topiramate group maintained significant improvement in all STAXI scales measuring anger compared to ex-placebo group • Greater weight loss in the treatment group • Overall, topiramate was well-tolerated
Rolland et al., 2015 England	Prospective cohort	SS: 23 (participants with BPD) Age: 45.3* 56.5% male	Alcohol Use Disorder	Outpatient setting	High dose baclofen, 1 year	• Baclofen dose*: 102.2 ± 42.7 mg daily • Significantly higher heavy drinking days in the BPD group • Significantly higher rate of serious adverse events in the BPD group compared with the control group (65.2% vs. 6.5%, respectively), most of which were hospitalization for intoxication or self-poisoning with baclofen, two events were suicide by hanging • Excessive sedation or insomnia is more frequently experienced by those with BPD • 12/23 men with BPD discontinued baclofen compared with 6/46 men without BPD
Simeon et al., 2007 United States	Open-label trial	SS: 20 Age: 37* 65% male	Mood disorders 50%	Outpatient setting	Divalproex ER 250mg daily (starting dose), titrated to highest tolerated dose, 12 weeks duration	• Significant global improvement and reduction in irritability and aggression • Nonsignificant improvement in affective intensity • No significant improvement in affective lability or dissociative symptoms

SS = sample size, * = mean, BPD = borderline personality disorder, RCT = randomized control trial, CGI = clinical global impression, STAXI = State-Trait Anger Expression Inventory.

Table 3.

Study Characteristics—Service Utilization

Study and Country	Study Design	Sample Characteristics	Setting	Results
Dehlbom et al., 2022 Sweden	Retrospective cohort (registry)	SS: 5,530 Age: 37.9* (men), 34.1* (women) 14.7% male	Outpatient psychiatry	• Men were diagnosed with BPD later in life compared with women (34.0 vs. 29.6 years) • Men with BPD were more likely to have comorbid ASPD, SUD, and nonaffective psychosis compared with women having BPD • Males were more likely to be diagnosed at a drug dependency clinic and less likely to visit outpatient psychiatry clinics • Men received fewer psychiatric medications (88.7% vs. 91.7%) or psychological therapies (78.1% vs. 81.1%) compared with women
Goodman et al., 2010 United States	Cross-sectional study (internet survey)	SS: 495 Age: 22.8* (men), 23.8* (women) 17.4% male	Community setting	• No significant gender difference in the age of BPD diagnosis • Male probands with BPD had higher lifetime diagnoses of conduct disorder, substance use, ADHD, psychotic spectrum disorders • Males with BPD received more alcohol and drug rehabilitation treatment recommendations than women with BPD • Females with BPD more likely to undergo outpatient psychotherapy (OR = 2.303) and receive pharmacological treatment (OR = 2.255), particularly antidepressant medications, compared to men with BPD
Lawn & McMahon, 2015 Australia	Cross-sectional study (internet survey)	SS: 153 Age: *N/A 12.2% male	Community setting	• Males with BPD were less likely to be provided an explanation of their BPD diagnosis compared with females with BPD • Males were less likely to receive psychotherapy (63.5% vs. 87%) and find it helpful (25% vs. 71%) compared with women • Males were less likely to find hospital admission helpful (12.5% vs. 50.5%) compared with women • Males were more likely to perceive benefits from primary care services compared with services from psychiatrists and mental health workers • Males reported longer service response times for crises than females
Pascual et al., 2007 Spain	Prospective Cohort	SS: 1,032 visits Age: 31.3* (patients with BPD) 37% of the visits were by males	Psychiatric Emergency services	• Significant predictors for benzodiazepine prescriptions included male gender, greater self-care ability with fewer medical and drug problems • Significant predictors for antipsychotic prescriptions included male gender, psychosis, and greater risk of harm to others
Tull & Gratz, 2012 United States	Prospective Cohort	SS: 159 Age: 36* 100% male	Residential substance abuse treatment facility	• Patients with BPD were significantly more likely to drop out of treatment than those without BPD (38.2% vs. 16%), specifically center-initiated treatment dropout (26.5% vs. 6.4%)

SS = sample size, * = mean, BPD = borderline personality disorder, RCT = randomized control trial, ASPD = antisocial personality disorder, SUD = substance use disorder, ADHD = attention deficit hyperactivity disorder, OR = odds ratio.

Seven studies investigated psychological therapies including dialectical behavioral therapy (DBT; Bianchini et al., 2019; Meyers et al., 2014; Russell & Siesmaa, 2017; Wetterborg et al., 2020), Systems Training for Emotional Predictability and Problem Solving (STEPPS) (Black et al., 2018), mentalization based therapy (MBT; Bateman et al., 2016), psychoanalytic therapy (Löffler-Stastka et al., 2006), and occupational therapy (Löffler-Stastka et al., 2006).

Five studies examined pharmacologic approaches, such as the use of topiramate (Nickel & Loew, 2008; Nickel et al., 2005), olanzapine (Bogenschutz & Nurnberg, 2004), divalproex ER (Simeon et al., 2007), and high-dose baclofen (Rolland et al., 2015).

Five studies reported on the service utilization of men with BPD (Dehlbom et al., 2022; Goodman et al., 2010; Lawn & McMahon, 2015; Pascual et al., 2007; Tull & Gratz, 2012). The most frequently investigated outcomes were anger, aggression, and property offending in six of the included studies. By comparison, only three studies investigated suicide-related outcomes. A variety of other psychosocial outcomes were assessed, including intervention satisfaction, dropout rates from therapies, emotional regulation, and service utilization.

Quality Assessment

Quality assessment ratings are outlined in Supplemental Appendix B. Overall, quality of the studies varied considerably, and most studies were rated poor due to small sample sizes (Bianchini et al., 2019; Bogenschutz & Nurnberg, 2004; Lawn & McMahon, 2015; Löffler-Stastka et al., 2006; Meyers et al., 2014; Rolland et al., 2015; Russell & Siesmaa, 2017; Simeon et al., 2007; Tull & Gratz, 2012; Wetterborg et al., 2020). In addition, some studies that included both genders did not conduct gender analysis (Bateman et al., 2016; Rolland et al., 2015), whereas other studies that performed gender analysis did not include enough males to have adequate power (Black et al., 2018). A few studies utilized convenience sampling (Goodman et al., 2010; Lawn & McMahon, 2015) and included self-reported diagnoses of BPD. Proxy reporting by parents or relative informants could have further introduced bias in some studies (Goodman et al., 2010; Wetterborg et al., 2020).

Generalizability was rated poor for eleven studies due to heterogeneous study settings and varied psychiatric comorbidities. For instance, Tull and Gratz (2012) conducted in a residential substance abuse treatment facility, whereas Meyers et al. (2014) investigated the usage of Veterans Affairs services. Study inclusion and exclusion criteria differed greatly among the included studies. Certain studies had high prevalence of comorbid diagnoses such as MDD, SUD, and ASPD (Bateman et al., 2016; Bianchini et al., 2019; Meyers et al., 2014; Rolland et al., 2015; Russell & Siesmaa, 2017; Tull & Gratz, 2012; Wetterborg et al., 2020), while others listed one or more of these diagnoses as exclusion criteria (Löffler-Stastka et al., 2006; Nickel et al., 2005). Other exclusion criteria specific to certain studies included actively suicidal patients (Bogenschutz & Nurnberg, 2004) and violent offenders requiring seclusion (Black et al., 2018) which limits generalizability.

Psychological Therapy Interventions

Psychological therapies have been shown to be effective in improving emotional regulation, impulsivity, aggression, and self-harm behavior with limited evidence for reducing suicidal attempts in men with BPD (Bateman et al., 2016; Bianchini et al., 2019; Black et al., 2018; Wetterborg et al., 2020). Some studies cited higher dropout rates and lower satisfaction with psychological therapies in men with BPD compared with women (Black et al., 2018; Löffler-Stastka et al., 2006). However, these findings should be interpreted with caution due to limited sample sizes and inadequate power of the following studies.

Dialectical Behavioral Therapy

Four studies assessed the effectiveness and experiences of DBT for individuals with BPD (Table 1). Included in this study were one pilot RCT (Bianchini et al., 2019), two observational studies (Meyers et al., 2014; Wetterborg et al., 2020), and one qualitative study (Russell & Siesmaa, 2017). DBT was shown to be effective for emotional regulation and reduction in motor impulsiveness (Bianchini et al., 2019), reduction in property offending, violent offending, self-reported aggression, borderline symptoms and depressive symptoms (Wetterborg et al., 2020). In addition, DBT was reported to decrease utilization of mental health services, admission rates, and length of stay (Meyers et al., 2014). However, no significant improvements were detected for alexithymia (Bianchini et al., 2019), number of suicide attempts, and anxiety after DBT (Wetterborg et al., 2020).

The aforementioned quantitative studies investigating DBT in men are limited by various factors. The pilot RCT is limited by its pilot nature and sample size (Bianchini et al., 2019). The observational studies were also subject to limitations including inadequate sample size, a high dropout rate (30%; Wetterborg et al., 2020), lack of a control group, a high percentage of female participants (46%), and a lack of gender analysis (Meyers et al., 2014).

In a qualitative study, six men with BPD and ASPD in an outpatient forensic service were invited to discuss their experiences of an adapted forensic DBT program (Russell & Siesmaa, 2017). Overall, participants emphasized the importance of group support and dynamics along with trust in the therapist, rather than referencing specific therapeutic content or skills. All participants reported positive experiences with the program. However, the modest sample size and forensic setting may limit the generalizability of the findings to all men with BPD.

Systems Training for Emotional Predictability and Problem Solving

Black and colleagues (2018) investigated subgroup differences in offenders who participated in STEPPS in Iowa’s prisons or community correctional settings. Men showed significantly higher dropout rates, with 29% of men completing the program (compared with 59% of women), and reporting significantly lower satisfaction with the STEPPS program. Yet, improvements in suicidal behavior and disciplinary infractions were observed for both genders, and no significant gender difference was identified. However, these findings may not be generalizable to violent offenders and those in maximum security settings as they were excluded from this study. In addition, of the 77 individuals registered for the program, only 14 were men, which limits the power to detect subgroup differences.

Mentalization Based Therapy

In Bateman et al. (2016), a subgroup analysis of an RCT assessed the effectiveness of MBT for treating aggression in patients with BPD and comorbid ASPD. Clinician-rated anger, self-rated paranoid ideation, and hostility significantly declined in the MBT group. Anxiety and depression, postulated as drivers of aggression, improved after MBT. The number of suicide attempts, self-harm behavior, and hospital admissions decreased after receiving MBT. However, the study is inadequately powered to detect significant differences between the groups due to the limited sample size. The authors noted the difficulty in effectively measuring the mentalizing ability in the participants.

Other

Löffler-Stastka and colleagues (2006) studied 20 inpatients undergoing a 6-week treatment involving psychoanalytic therapy, group occupational therapy, music therapy, and skills training. Male patients were less inclined than females to continue psychotherapy post-discharge, with only 2 of 10 males continuing psychotherapy compared with 7 of 10 females, and demonstrated higher hospital readmission rates. The authors suggested that gender stereotypes may have deterred men from seeking further psychotherapy as increases in self-efficacy were greater in men compared with women after psychotherapy. Study limitations include a small sample size and a short follow-up period. In addition, the exclusion of those with involuntary psychiatric hospitalizations or current substance abuse limits the study’s generalizability.

Pharmacological Interventions

The included studies find that pharmacotherapies may help males with BPD manage anger, aggression, and overall functioning in males, but small study sizes hinder definitive conclusions.

Topiramate

In an RCT by Nickel and colleagues (2005) (N = 44 males with BPD), individuals who received topiramate (titrated from 50 mg to 250 mg daily), demonstrated significant improvements in various anger assessments, maintained at the 18-month follow-up, compared with subjects in the ex-placebo group (Nickel & Loew, 2008). Topiramate was well-tolerated, with weight loss as the only significant side effect. However, the study’s generalizability was limited due to the exclusion of patients with concurrent major depressive disorder and substance abuse.

Olanzapine

An RCT by Bogenschutz and Nurnberg (2004) documented significant improvement in BPD symptoms, particularly inappropriate anger, without a clear gender impact on outcomes after a 12-week course of olanzapine 2.5 mg daily titrated to up to 20 mg daily. Of the 40 enrolled participants, 15 were male. Individuals with active suicidal ideation were excluded from the study.

Divalproex ER

Simeon et al. (2007) reported a 12-week open-label trial of Divalproex ER for 20 participants (13 males), where significant improvements were noted in global functioning and aggression among the 10 completers. No improvements in affective lability or dissociative symptoms were identified. Limitations of the study included a high attrition rate (50%), absence of a placebo-control, outpatient setting, and lack of gender analysis.

Baclofen

In a one-year prospective cohort study, Rolland et al. (2015) observed 69 individuals (56.5% male), with AUD, 23 of whom had BPD, receiving high-dose baclofen for over a year. Those with BPD experienced more heavy drinking days and serious adverse events, including hospitalizations and suicides, compared to those without BPD. Baclofen-related side effects like sedation or insomnia were also more common in the BPD group, possibly resulting in a higher discontinuation rate.

Service Utilization of Men With BPD

Five studies investigated gender differences in the service utilization of individuals with BPD (Dehlbom et al., 2022; Goodman et al., 2010; Lawn & McMahon, 2015; Pascual et al., 2007; Tull & Gratz, 2012) (Table 3). Overall, men with BPD were less represented than women in these studies, with the proportion of male participants ranging from 12% to 37%. Men were less likely to receive psychotherapy or psychiatric medication for BPD compared with women. Men were more likely to be diagnosed and treated for comorbid psychiatric conditions (e.g., ASPD, SUD) and may be less represented if they were within the criminal system (Dehlbom et al., 2022).

Dehlbom and colleagues (2022) conducted a registry-based study of Sweden’s health care system, which included forensic treatment and drug rehabilitation settings, to explore gender differences in the treatment of BPD. Of 5,530 individuals diagnosed with BPD in Stockholm Country, only 802 (14.7%) were males. Males were more likely to be diagnosed with BPD later in life and were less likely to receive psychological therapy compared with women having BPD. Even upon starting psychotherapy, men received less psychotherapy compared to women. Men were significantly less likely to receive pharmacologic treatments, such as antidepressants or sedatives, after their BPD diagnosis. Mental health visits were less likely to be coded for BPD diagnosis for men. Most men and women received their diagnosis in psychiatric clinics; however, more men were diagnosed with BPD in drug dependency clinics and were more likely to utilize services of drug dependency clinics and psychiatric services. Finally, men with BPD were more often diagnosed with ASPD, SUD, and non-affective psychosis compared with women.

Similar findings were observed in Goodman et al. (2010), where parents of offspring with BPD completed a survey of the patients’ treatment utilization. Males with BPD were more likely to undergo drug rehabilitation treatment and have a concurrent diagnosis of conduct disorder, SUD, ADHD, or psychotic spectrum disorders compared with females. Females with BPD were more likely to undergo psychotherapy and pharmacological treatment, particularly with antidepressants compared with males. In contrast to Dehlbom et al. (2022), the duration of treatment was similar between the genders, implying an initial barrier to commencing treatment in men with BPD. Unlike the findings of Dehlbom et al. (2022), there was no significant difference in the age of diagnosis between the genders. Given the self-report nature of the online survey, recall bias on previous treatment history may be a limitation. The represented parents were possibly a highly afflicted sample and the offspring with BPD may have required more intensive mental health care.

Lawn and McMahon (2015) conducted a survey to investigate service utilization by individuals with BPD in Australia. Men used less psychotherapy and were less likely to find it helpful compared with women. In addition, men were less likely to visit hospitals for BPD or find admissions helpful. Men were less likely to receive an explanation of BPD diagnosis than women with BPD. Response times for mental health crises were longer for men with BPD. Men with BPD sought care from general practitioners more than from psychiatrists or mental health professionals. However, the study was not adequately powered to detect significant gender differences; only 18 of the 147 participants were male.

Pascual and colleagues (2007) conducted a cohort study of psychiatric emergency visits in Spain. Of the 1,032 emergency visits by individuals with BPD, 37% of those visits were by males with BPD. Men with BPD were more likely to receive benzodiazepines and antipsychotics compared with women. Individuals who received benzodiazepine prescriptions were more likely to have lower symptom severity whereas those requiring antipsychotics were more likely to have psychosis, pose a greater risk of harm to others, and report greater drug use.

Finally, in a residential substance abuse facility, men with BPD were more likely to drop out of treatment compared with individuals without BPD (Tull & Gratz, 2012). Residents with BPD experienced greater rates of center-initiated dropout, likely due to infringing upon rules enforced by the facility.

Discussion

We conducted a systematic review to investigate treatment effectiveness and experiences of recovery for men with BPD. In addition, we sought to highlight knowledge gaps and areas for further research that can improve treatment for this population. However, study findings should be interpreted with caution given the poor quality ratings for most studies due to limited sample sizes. Our review identified 17 studies on treatment for men with BPD, including a wide range of psychotherapeutic and pharmacological interventions, and studies on treatment utilization by men with BPD. Both psychotherapy and pharmacologic treatment interventions were effective in improving anger, aggression, and rule-breaking behavior, with some limited evidence for a reduction in suicide-related outcomes.

Treatment Effectiveness, Experiences, and Service Utilization

DBT was the most frequently studied intervention in our review, with its effectiveness demonstrated in forensic settings and veteran services. DBT (Russell & Siesmaa, 2017; Wetterborg et al., 2020), targeted and improved various areas such as emotional regulation, impulsiveness, self-harm, and aggression in the included studies. Meyers and colleagues (2014) demonstrated sustained benefits of DBT in a cohort of veterans as hospital admissions were significantly reduced for a year following completion of the program. Russell and Siesmaa (2017) discussed the importance of group processes in DBT, as men with comorbid BPD and ASPD underscored the sense of belonging and trust with the therapist that contributed to their positive experiences. However, one study noted that the number of suicide attempts did not significantly change after DBT treatment in a sample of men with BPD and antisocial behavior (Wetterborg et al., 2020).

MBT, an intervention aimed at improving mentalization abilities, significantly improved anger, anxiety, depression, and suicidal behavior in males with BPD (Bateman et al., 2016). In addition, STEPPS, an adjunctive group psychological intervention that incorporates skills training, reduced suicidal behavior, disciplinary infractions, and anger in males with BPD (Black et al., 2018). Pharmacologic interventions for BPD included in our review also showed efficacy in reducing anger and aggression in men with BPD with less attention on suicide-related outcomes.

Service utilization by men with BPD demonstrated significant gender differences. On the whole, men received less psychotherapy or psychiatric medications compared with women (Dehlbom et al., 2022; Goodman et al., 2010; Lawn & McMahon, 2015). Men were also less satisfied with psychotherapy compared with women and were more likely to drop out of treatment compared to women (Black et al., 2018; Löffler-Stastka et al., 2006). Men were more likely to utilize drug rehabilitation services and have concurrent diagnoses of SUD, ASPD, and psychotic spectrum disorders (Dehlbom et al., 2022; Goodman et al., 2010). Men were also less likely to receive explanations of their BPD diagnosis compared with women (Lawn & McMahon, 2015).

Knowledge Gaps

To our knowledge, our systematic review is the first to solely investigate treatment effectiveness across a wide range of interventions for men with BPD. The findings of our review agree with a scoping review conducted by Qian et al. (2022) which reported that men with BPD were more likely to have an externalizing pattern as displayed through aggression or substance use. Similar to our study, Qian et al. (2022) demonstrated that men were more likely to be diagnosed with BPD in a drug rehabilitation clinic and find psychotherapy or hospital admissions less helpful than women, which may potentially be related to higher dropout rates. Further research is needed to assess whether higher dropout rates are a consequence of lower satisfaction levels and perceived helpfulness by men with BPD. Our findings that men with BPD were more likely to have comorbidities with SUD and ASPD than women have been replicated numerous times (Barrachina et al., 2011; Tadić et al., 2009; Zlotnick et al., 2002). Unfortunately, little is known regarding the appropriate treatment for co-occurring BPD and SUD, which can heighten the challenge of effectively treating BPD in men (Helle et al., 2019; Trull et al., 2018). As demonstrated in our review, Wetterborg and colleagues (2020) documented that a 12-month DBT program did not significantly reduce drug use in men with BPD and antisocial behavior. In Rolland et al. (2015), men with BPD and AUD who received pharmacotherapy with high-dose baclofen had a higher number of adverse events than men without BPD.

The effectiveness of psychological therapies, including DBT and MBT, has been well-established for BPD symptom severity and self-harm behavior (Storebø et al., 2020), however, most studies are not specific to men with BPD and have a significantly higher proportion of female subjects. Out of 75 trials in this Cochrane review, only two trials had exclusively male participants (Storebø et al., 2020). With respect to pharmacological therapies in our review, Nickel et al. (2005) and Simeon et al. (2007) demonstrated that mood stabilizers can effectively treat symptoms of anger and aggression in BPD. Yet, a large, randomized placebo-controlled trial by Crawford et al. (2018) revealed that lamotrigine was not superior to placebo in treating BPD symptoms. Of the 137 participants who received lamotrigine, only 34 (25%) were men (Crawford et al., 2018). In addition, a recent meta-analysis by Stoffers-Winterling and colleagues (2022) recorded minimal effectiveness in pharmacotherapy for treating BPD symptoms, suicidality, and improving psychosocial functioning. Again, out of 46 RCTs, only one trial included solely male participants with BPD (Stoffers-Winterling et al., 2022).

BPD is associated with a heightened risk of suicide, with a suggested lifetime suicide rate of 5.9% and a range between 3% to 10% (Links et al., 2021). The risk of suicide appears to be reduced by appropriate treatment and consistent follow-up, however, engaging patients with BPD, particularly men, in therapy remains a challenge (Links et al., 2021; Seidler et al., 2018). Outcomes of suicide and self-harm behaviors were not as prominent as outcomes of anger and aggression in our study. As a result, there is a gap in our knowledge about how best to intervene with men with BPD at risk for suicide. With regard to suicidality and self-harm behavior, Sansone and Sansone (2011) did not identify significant gender differences. However, Sher and colleagues (2019) noted that although the number of suicide attempts do not significantly differ between the genders, men tend to use more lethal means leading to higher suicide rates than women. Thus, suicide-related outcomes in men with BPD is an area that requires further prioritization and research given the high risk associated with suicide in this population.

Future Steps and Recommendations

Gender differences in clinical presentation and treatment utilization of patients with BPD may arise from societal expectations and stereotypes of gender-related behaviors. Outward anger and physical aggression are more socially accepted or even reinforced in men, whereas females are socialized to believe such behaviors are socially undesirable (Nehls, 1998; Sharp et al., 2014 Skodol & Bender, 2003). Differences in help-seeking behavior could explain lower utilization of psychotherapy and psychiatric services by men with BPD (Goodman et al., 2010). A cross-sectional study by Amerio et al. (2023) identified that females used certain coping strategies such as restraint and the use of instrumental social support more often than males. Within our review, men were consistently the minority as only 12% to 37% of the study samples were men in studies investigating service utilization. Perhaps due to societal pressures, men may face greater difficulty expressing vulnerability and emotions for fear of undermining masculinity (Goodman et al., 2010). Galdas et al. (2023) discuss a conceptual model—the “5C Framework”—involving careful consideration of masculinity and gender socialization in the design, marketing, setting, content, and delivery of men’s health programs. Key themes include using existing gender norms to engage men (e.g., program delivery in settings where men socialize, content appealing to masculine ideals of independence), while taking measures not to perpetuate harmful hypermasculinity. Of note, Galdas et al. (2023) reference the Canadian Veteran Transition program, which effectively engages men in group-based counseling (Kivari et al., 2018). Strategies employed by this program include avoiding labels (using terms like “picking up tools” instead of “therapy”), using a “soldiers helping soldiers” model, and having a focus on teamwork and physical activity (Kivari et al., 2018). Recognizing the role of masculinity and gender socialization in men’s health service utilization may therefore be a promising step forward in increasing the use of psychotherapy and psychiatric services in men with BPD (Galdas et al., 2023; Kivari et al., 2018; Seidler et al., 2022).

Similar methods of engaging men in mental health services are proposed by the literature. Like Alcoholics Anonymous, Goodman et al. (2010) and Kwon et al. (2023) recommended a collaborative model with a facilitator, rather than an expert-client model, with predominantly male participants (Goodman et al., 2010; Kwon et al., 2023). Seidler et al. (2018) argued that a collaborative style upholding men’s autonomy, coupled with an exploration of male clients’ internalized gender ideals and societal stigma by clinicians can help engage men in psychological therapy. Russell and Siesmaa (2017) also reinforced the importance of group processes, as participants reported positive experiences from a sense of belonging and trust with other men and facilitators in the group, rather than a reference to certain skills acquired from DBT. Women endorsed the importance of content and specific skills from DBT rather than group dynamics (Russell & Siesmaa, 2017). For men, group dynamics and the processes of therapy may be more important than skill development in psychotherapy. Further research needs to be conducted to delineate gender differences in treatment experiences and better adjust existing interventions for men with BPD.

Biases held by service providers may impact the assessment and treatment of men with BPD. Lawn and McMahon (2015) demonstrated delayed responses to mental health crises for men compared with women. In addition, Dehlbom and colleagues (2022) highlighted that men were diagnosed with BPD at a later age and were less likely to be referred for psychological therapies than women. Men were also less likely to have the BPD diagnosis explained (Lawn & McMahon, 2015). Men with BPD received fewer treatments for comorbid anxiety or depression and were prescribed antidepressants significantly less than women (Dehlbom et al., 2022; Goodman et al., 2010). Men were more likely to receive treatment in drug rehabilitation or forensic settings (Dehlbom et al., 2022; Goodman et al., 2010). Men with BPD were more likely to value their primary care physicians than their psychiatrists or mental health workers (Lawn & McMahon, 2015). These findings suggest the need for further training for health care providers to increase awareness and understanding of the experiences and needs of men with BPD. Similar programs are being piloted—Seidler et al. designed an online training program for health care practitioners aimed at engagement and appropriate response to male depression and suicidality (Seidler et al., 2022). The module includes education on masculinity and gender identity, their influence on clinical interactions, and methods clinicians can use to identify and respond to depression and suicidality in men (Seidler et al., 2022). The role and professional development of primary care physicians are pivotal as we continue to learn about effective interventions for men with BPD. Increased access to targeted interventions for BPD and psychological therapies for men with BPD need to be available in drug rehabilitation facilities and forensic settings.

Limitations

Our study has several limitations that arise from the nature of the included studies. First, our review highlighted the need for research with more rigorous sampling strategies as the majority of studies had limited sample sizes with inadequate power. As well, most studies relied solely on self-report questionnaires, or even relative-reported outcomes and diagnoses, which could introduce bias in the study. Only five RCTs were included, and comparator groups were not available for most of the studies. In addition, given the varied study contexts, we were unable to evaluate differences in externalizing behaviors of men with BPD in forensic versus community settings. Concurrent ASPD is frequently observed in forensic settings, which may further complicate the treatment pathway and response in this population. Future studies need to be conducted with this population, as comorbidity with ASPD can further elevate the risk of suicide and reoffending (Wetterborg et al., 2020). Overall, significant heterogeneity in study settings and characteristics, which also included variable measured outcomes and follow-up durations, hinder the ability to generalize the findings of this review. There were no studies from low or middle-income countries that met inclusion criteria and caution should be applied in transferring our study findings to these regions. Our study excluded male children and adolescents with BPD, who may have different clinical presentations and needs. Unfortunately, only one qualitative study met our inclusion criteria, and further qualitative exploration of men’s experiences of treatment with BPD is needed. Using a clinical-focused lens in selecting the literature is a limitation of our study, and including CINAHL or other social science databases may have yielded other studies of experiences of men identifying as having BPD.

Conclusion

In conclusion, our review highlighted a critical lack of literature on treatment effectiveness and experiences of recovery of men with BPD. Although many studies demonstrated potential efficacy of various psychotherapeutic and pharmacologic interventions for men with BPD, several studies were weakened by small sample sizes and poor overall quality. Future studies should prioritize larger sample sizes to ensure adequate power in detecting gender differences. There is a need for more qualitative research to explore men’s experiences of recovery and elucidate the reasons for higher dropout rates compared to women with BPD. Anger and aggression were prominent outcomes investigated, more so than suicide-related outcomes or other symptomatology of BPD. Men were less likely to receive psychotherapies, and certain medications, or feel satisfied with treatment compared with their female counterparts. There is a need for greater research investigating treatments for men with BPD, given the high burden and potentially devastating outcomes of this disorder, coupled with a deeper exploration of men’s unique perspectives of treatment and recovery.