Borderline personality disorder expert John Gunderson, M.D., says that psychiatrists should expect more from and provide more to their patients when it comes to social and functional rehabilitiation.
Symptoms of borderline personality disorder (BPD) often remit over a 10-year period, but patients continue to experience severe and persistent impairment in social functioning.
That was the finding from a follow-up of patients with BPD in the Collaborative Longitudinal Personality Disorders Study, a report of which appears in the August Archives of General Psychiatry. The analysis found that the 10-year course of BPD is characterized by high rates of remission, low rates of relapse, but severe impairment in social functioning (see Key Findings From BPD Study).
The report extends and confirms previous reports about the long-term course of BPD, which have suggested that therapies for the disorder tend to work well for the most acute symptoms—such as self-harm and emotional dysregulation—but do little to address impairments in social functioning.
“What this shows is that over time, patients are more quietly dysfunctional than they were likely to have been when originally treated,” lead author John Gunderson, M.D., told Psychiatric News. “A minority of patients go on to a reasonably good functional level with a job and a family life, and then another minority remain both functionally and symptomatically ill. But the largest group of patients are not symptomatic but don’t have friends or stable relationships.”
Gunderson is a professor of psychiatry at Harvard Medical School and director of psychosocial and personality research at McLean Hospital in Belmont, Mass.
In the study, 75 patients with BPD, 312 with cluster C personality disorder, and 95 with major depressive disorder (MDD) but no personality disorder were followed for a decade. Subjects were drawn from 19 clinical settings (hospital and outpatient) in four northeastern U.S. cities.
The Diagnostic Interview for DSM-IV Personality Disorders and its follow-along version were used to diagnose personality disorders and assess changes in the symptoms over time. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Longitudinal Interval Follow-Up Evaluation were used to diagnose MDD and assess changes in MDD and in social function.
Eighty-five percent of patients with BPD remitted, but remission was slower than for patients with MDD and minimally slower than for those with other personality disorders.
The other notable finding from the study is that once they are in remission, patients rarely relapse: 12 percent of patients with BPD relapsed, a rate less frequent than that for patients with MDD and with other personality disorders.
However, social-functioning scores showed severe impairment with only modest (although statistically significant) improvement; patients with BPD remained persistently more dysfunctional than those in the other two groups.
Gunderson said that the “most obvious reason” for the discrepancy between symptomatic and functional improvement is that treatments for BPD, as for many psychiatric and other medical disorders, are best for addressing acute symptoms, but do not typically address long-term functional and social deficits.
“Another fundamental answer is that even when the symptoms remit, the underlying basis of the disorder—whether it is psychological or genetic—remains,” he said. Those with the disorder aren’t well “just because they aren’t shouting and cutting themselves and being admitted into the hospital. There are fundamental handicaps that these patients have in terms of genetic predispositions.”
And there is a social learning aspect to the long-term course of BPD. “By the time a patient has BPD, he or she may never have gone through a job interview,” he said. “We don’t know how much of their dysfunction is genetic and how much is impaired social learning, but they are both important.”
Gunderson added that at McLean Hospital, social rehabilitation has been made a focus of BPD treatment. “Most of our patients eventually go to school or work, and we expect them to,” he said.
He added that office-based psychiatrists who work with BPD patients over the long term know “that we in the psychiatric community can and should expect more and give more to our patients in terms of social rehabilitation.”
“Ten-Year Course of Borderline Personality Disorder: Psychopathology and Function From the Collaborative Longitudinal Personality Disorders Study” is posted at <http://archpsyc.ama-assn.org/cgi/content/abstract/68/8/827>.
