Few clinicians look forward to treating patients with borderline personality disorder, in part because of the assumption that the symptoms and dysfunction associated with the syndrome are likely to prove intractable. A new study in the May issue of the American Journal of Psychiatry challenges those assumptions about the course and prognosis of the disease. Mary C. Zanarini, Ed.D., of McLean Hospital, Belmont, Mass., and her colleagues reported on the longitudinal course of personality disorder over 16 years of follow-up (2012;169:476-83).
The investigators followed 290 inpatients diagnosed with BPD according to DSM-III-R criteria and compared them with 72 inpatients diagnosed with other personality disorders. Subjects were reassessed every 2 years for symptoms of personality pathology as well as for indicators of social and occupational functioning. The authors assessed the study subjects for two end points: remission, defined as no longer meeting diagnostic criteria for BPD; and recovery, defined as meeting operationalized criteria in order to qualify for a Global Assessment of Functioning (GAF) score of 61 or higher. Criteria for this score included the remission of BPD symptoms, the presence of a supportive social or romantic relationship, and the capacity for full-time work as an employee, homemaker, or student.
The results showed that nearly all the subjects in the BPD sample (99%) experienced remission of BPD symptoms for at least a 2-year period. Nearly 80% of borderline patients had a remission of their symptoms lasting 8 years or more. And nearly 90% of all participants completed all interviews for the entire 16-year study.
From the perspective of symptomatology, the prognosis for these inpatients was relatively positive and less chronic and unremitting than many psychiatric clinicians would assume about BPD. Even more encouragingly, only 10% of those with remission of BPD symptoms lasting 8 years experienced a recurrence of BPD symptoms over the course of the study. Once BPD symptoms had remitted for an extended period, they tended to "stay gone."
However, the study’s findings were considerably less encouraging when viewed with the goal of achieving a full functional recovery. Slightly more than half of the BPD subjects attained a full functional recovery lasting 2 years, meaning that nearly half of the sample never reached the point of a functional recovery. What’s more, among those who did achieve recovery, nearly 50% did not sustain social and/or occupational engagement for more than 2 years. In the end, a significant proportion of subjects with BPD eventually came to require federal disability payments.
The key findings from this study are consistent with those of a 10-year follow-up of a different sample of patients with BPD, led by Dr. John G. Gunderson, also of McLean Hospital (Arch. Gen. Psych. 2011;68:827-37).
In that trial, known as the Collaborative Longitudinal Personality Disorders Study, 85% of patients with BPD exhibited a remission of symptoms; only 12% experienced a relapse of symptoms following remission; but, discouragingly, only 36% with BPD were employed full-time at the 10-year mark, and only 41% were found to be in a marital or cohabiting relationship at that point.
What are we to make of these converging findings? On the one hand, Dr. Zanarini’s study provides a sobering reminder that with BPD, as with patients with schizophrenia and with substance dependence, remission of psychiatric symptoms does not equal a return to optimal psychosocial functioning.
As Dr. Joel Paris of McGill University in Montreal points out, these and other longitudinal studies point to the need for a second phase of treatment that extends beyond symptom control to target social and occupational domains (Am. J. Psychiatry 2012;169;445-6).It may be prudent for personality researchers to consider adaptation and modification of the rehabilitation models developed for schizophrenia (Psychiatry 1993;56:238-49) and severe substance dependence (Psychol. Bull. 1995;117:416-33).
On the other hand, there appears to be a substantial case for clinical optimism. Clinicians should feel a measure of reassurance by the knowledge that the most intense period of symptomatology for most young BPD patients can be expected to remit by middle age. Although the course of symptoms, the scope of acting-out behaviors, and the lurking risk of self-harm may be quite intense and destructive, a mounting and increasingly persuasive body of evidence suggests that the affect storms of the illness will often prove to be time-limited.
As Dr. Gunderson wrote in this study, "What is evident appears clinically counterintuitive; patients with BPD improve symptomatically more often, more quickly, and more dramatically than expected and, once better, maintain improvements more enduring than for many other major psychiatric disorders."
Increasingly, affective disorders have been conceptualized as chronic conditions that may require treatment across the lifespan (Br. Med. J. 2001;322:419-21). Evidence from recent papers suggests that even the most feared and intense of the personality disorders may have a disease course considerably shorter than that of unipolar or bipolar depression. This makes clinical sense; few among us would be surprised when an elderly patient develops mood symptoms following years of euthymia, but many of us would be surprised if that elderly person developed a sudden resurgence of cutting, affect storms, and frantic efforts to avoid abandonment. What remains to be seen is whether the research findings about borderline personality disorder can be translated into meaningful advances in the science of treatment and psychosocial rehabilitation of these challenging and significantly impaired patients.