Many people who have been diagnosed with borderline personality disorder (BPD) are told that their chronic disorder is not treatable. However, BPD can have a good prognosis if properly treated.
“It’s time to reject the notion that people with personality disorders are beyond help,” says Peter Aldhous.
Personality disorders cause difficulties with social interactions that can be debilitating for those with the disorder as well as their loved ones. Time magazine summed up the reputation of BPD as “the disorder that doctors fear most.”
BPD is characterized by emotional instability, distress and neurosis. Individuals with this disorder tend to experience difficulty in forming stable relationships. A paranoid fear of being abandoned haunts these patients, and this fear frequently becomes a self-fulfilling prophecy. Angry outbursts are common. People with BPD tend to view people in black and white, idealizing someone one day and devaluing them the next.
In the past few years, major research has been conducted on the prognosis of BPD, namely two long-term studies called the Collaborative Longitudinal Personality Disorders Study (CLPS) and the McLean Study of Adult Development (MSAD). These studies examined the course of BPD in populations of individuals seeking treatment for the disorder.
One major finding was that the remission rate went from 30 to 50 percent by the second year follow-up, up to 80 percent by the tenth year. What this means is that remission of symptoms might be more frequent than what researchers and clinicians previously believed.
Another important finding was that many variables influence the symptomatic outcome of this disorder. Variables such as adverse childhood experiences, family history of psychiatric disorders, older age and extent of earlier psychiatric treatment all affect the patient outcome. Sometimes individuals with BPD require hospitalization due to suicide attempts or self-injurious behavior. In addition the presence of comorbid issues such as post-traumatic stress disorder and substance use disorders also influence the course of the disorder. Anxious personality disorder traits and certain temperament variables also affect symptom outcome.
Individuals with BPD often experience difficulty trusting healthcare workers and clinicians. Because of this they may misinterpret interactions with others. Often healthcare workers do not understand that this aspect is innate to the pathology and will take these actions personally. Adding to this is the fact that psychiatrists have believed for years that this disorder is a lifelong affliction.
Specialized psychotherapy can significantly improve the lives of individuals with this debilitating disorder. Remission from BPD includes psychopathology, personality and socio-demographic variables.
It is important to note that the majority of studies on BPD prognosis have been conducted in North America. Consequently, little is known about the course of BPD in different countries and cultures. Because social factors shape how personality disorders are expressed, further research needs to be conducted cross-culturally. One study found that over-involvement in family relationships predicts a poor outcome of borderline personality disorder in both Japanese and Canadian patients.
Structured psychotherapies have been found to be more effective in many studies than control conditions, and structured psychological interventions have been recommended by many clinicians as the best treatment for BPD. Commonly, a combination of medications, psychotherapy and support groups are used. Psychotherapy with one or two weekly visits with a clinician whom the patient trusts is essential. Dialectical behavior, psychodynamic, cognitive-behavioral and supportive psychotherapeutic approaches are frequently used in the treatment of this disorder.
The psychoanalytic approach is effective because it focuses on resolving incorrect representations of interpersonal relationships. With the proper support system these internalized views can be corrected. The goal of therapy should be an adjustment over time to the reality-oriented approach.
Dialectical behavior therapy and cognitive-behavioral therapy in group format are structured akin to classes. The group leader provides practice exercises that the patients can work on between sessions and dialectical behavioral therapy has a manual that is used weekly.
Dialectical behavior therapy was modified from the standard cognitive-behavioral model for BPD and is one of the only approaches backed by data. This successful therapy was developed by Marsha Linehan at the University of Washington in Seattle. It draws from the Buddhist idea of “mindfulness,” a calm awareness of the present moment, as a method of achieving behavioral change. It can be used in hospitals and outpatient programs as well as other settings.
Four patient skills are enhanced through dialectical behavior therapy. Mindfulness, the first skill, calls for an increased attention to one’s experiences. Interpersonal effectiveness teaches the patient to focus on assertiveness. Emotional regulation and distress tolerance are the last two vital skills taught to patients.
A number of clinical trials have been conducted on dialectical behavior therapy, and the results have verified that this therapy aids patients better than standard talk therapies. A reduction in self-injury, anger, suicide attempts and substance abuse have been evidenced with the use of dialectical behavior therapy.
Mentalization-based treatment was developed at University College London. This therapy focuses on helping patients with BPD to understand the mental states of others more clearly. It also aids in the patient’s understanding of their own mental states. While mentalization-based treatment has not been studied as extensively as dialectical behavior therapy, it appears to lower the rate of suicide attempts as well as the use of psychiatric mental health services. It may also increase a patient’s ability to maintain a steady job.
Interpersonal or psychodynamic group therapies may be uncomfortable for those with BPD because they necessitate the expression of intense personal feelings. However, these groups can provide the chance to learn from people with similar life experiences. It is important to note that group sessions should be used in conjunction with other forms of treatment.
Medications have been proven effective in stabilizing impulsivity and emotionality for people with BPD. They are also helpful for reasoning and thinking abilities. Neuroleptics and atypical antipsychotic agents improve disordered thinking and behavioral issues of people with mental disorders. Commonly these medications are used to treat schizophrenia and bipolar disorder, but in smaller doses they work well for calming emotional reactivity and impulsivity. They also elevate mood, depression, anger and anxiety.
Atypical antipsychotic agents and neuroleptics were first used for the treatment of psychotic disorders. One side effect that can occur is tardive dyskinesia, an involuntary movement disorder that is typically associated with larger doses of the medication. Atypical antipsychotics may cause side effects such as insomnia, drowsiness, weight gain, breast engorgement or discomfort, or general restlessness. It is important to speak with a psychiatrist regarding the proper medications and their side effects.