Long-Term Prognosis of Borderline Personality Disorder

Corrine R. Stoewsand, Ph.D.

Borderline Personality Disorder (BPD) was once used as a pejorative label by clinicians for patients who were untreatable. It was considered a chronic lifelong disorder and many clinicians wanted to avoid working with such difficult patients.


Thanks to advances in research and treatment of BPD, remission and recovery from this illness are to be expected. To be clear, the term “diagnostic remission” refers to the condition in which a person with BPD no longer meets more than two of the nine diagnostic criteria. (According to the Diagnostic and Statistical Manual of Mental Disorders, one has to meet at least five of the nine criteria in order to be diagnosed with BPD.) The term “recovery” is based upon an assessment of social and vocational functioning (doing well at work or in school and having meaningful interpersonal relationships.)

 

“Remission” – a person does not meet more than two of the

nine criteria for BPD for at least two months

“Recovery” – a person functions well in school or work and has

meaningful interpersonal relationships for at least two years

 

Two separate research studies begun in the 1990s both followed the long-term course of borderline personality disorder. The MacLean Study of Adult Development of 290 persons with BPD was the first study and began in 1992, led by Mary Zanarini. The second study, known as the Collaborative Longitudinal Personality Disorders Study was launched in 1996, led by John Gunderson, and followed the progress of 175 persons diagnosed with BPD.


Both studies included people who were in some type of treatment at the beginning. The first study began with inpatients at MacClean hospital. The Collaborative study included psychiatric inpatients and outpatients from 12 different institutions. Both studies included persons with other types of personality disorders as comparisons. Both studies measured the social and vocational functioning and the physical health of participants every two years by research staff who had no access to previously collected information ("blind evaluators").


The Collaborative study published its findings after 10 years and the MacClean study continued to publish research after 20 years. A summary of remission and recovery in each of the studies showed similar results, in spite of some differences in defining and measuring these two factors.


The MacClean study defined good recovery is defined as “Some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.” Excellent recovery is defined as If symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning.”


PERCENTAGE OF PERSONS WITH BPD IN DIAGNOSTIC REMISSION AND RECOVERY

after 4, 10, and 20 years from start of study:

MacClean Study


After 4 years:

55% Diagnostic Remission

25% Good Recovery

5% Excellent Recovery


After 10 years:

91% Diagnostic Remission

50% Good Recovery

25% Excellent Recovery


After 20 years:

99% Diagnostic Remission

60% Good Recovery

50% Excellent Recovery

Collaborative Study


After 4 years:

50% Diagnostic Remission (sustained for prior 12 months)

60% Diagnostic Remission (sustained for prior 2 months)

25% Good Recovery

5% Excellent Recovery


After 10 years:

91% Diagnostic Remission sustained for prior 2 months

85% Diagnostic Remission sustained for prior 12 months


45% Good Recovery

25% Excellent Recovery

Several factors were associated with a faster onset of remission, including:

· Lack of co-morbid, axis-1 disorders

· No history of childhood sexual abuse,

· No history of family substance abuse,

· High baseline functioning (demonstrated at school or in the workplace), and

· Age less than 25 years.


Unfortunately, diagnostic remission was associated with impoverished social relationships, which suggests that patients may appear to remit because they avoid interpersonal relationships, rather than gradually developing better interpersonal skills.


It is noteworthy that acute symptoms (eg, self-mutilation) remit more rapidly and recur more rarely than temperamental symptoms (eg, chronic depressed affect). Never achieving recovery from BPD is associated with vocational impairment and physical illness.


Mary Zanarini, the principal author of the MacClean study has suggested that treatment modules aimed at vocational functioning, temperamental symptoms, "grit" (perseverance), and resilience (trying again after failure) might allow persons with BPD to overcome temperamental difficulties such as becoming easily overwhelmed or overly discouraged as well as relieve some of the shame and suffering of these persons.


In summary, BPD can be treated and people can recover. These studies follow the naturalistic course of the diagnosis, independent of treatment over the course of time. Of course, there is still room for more improvement of outcomes, but today there is real hope for persons diagnosed with BPD.

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