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Author Topic: POLL: Prediction of the 10-Year Course of BPD - Mary C. Zanarini, Ed.D.,  (Read 10740 times)
Skippy
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« on: May 29, 2006, 07:21:31 PM »

Am J Psychiatry 163:827-832, May 2006
doi: 10.1176/appi.ajp.163.5.827
© 2006 American Psychiatric Association

Prediction of the 10-Year Course of Borderline Personality Disorder
Mary C. Zanarini, Ed.D., Frances R. Frankenburg, M.D., John Hennen, Ph.D., D. Bradford Reich, M.D., and Kenneth R. Silk, M.D.

OBJECTIVE: The purpose of this study was to determine the most clinically relevant baseline predictors of time to remission for patients with borderline personality disorder.

METHOD: A total of 290 inpatients meeting criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R for borderline personality disorder were assessed during their index admission with a series of semistructured interviews and self-report measures. Diagnostic status was reassessed at five contiguous 2-year time periods. Discrete survival analytic methods, which controlled for baseline severity of borderline psychopathology and time, were used to estimate hazard ratios.

RESULTS: Eighty-eight percent of the patients with borderline personality disorder studied achieved remission. In terms of time to remission, 39.3% of the 242 patients who experienced a remission of their disorder first remitted by their 2-year follow-up, an additional 22.3% first remitted by their 4-year follow-up, an additional 21.9% by their 6-year follow-up, an additional 12.8% by their 8-year follow-up, and another 3.7% by their 10-year follow-up. Sixteen variables were found to be significant bivariate predictors of earlier time to remission. Seven of these remained significant in multivariate analyses: younger age, absence of childhood sexual abuse, no family history of substance use disorder, good vocational record, absence of an anxious cluster personality disorder, low neuroticism, and high agreeableness.

CONCLUSIONS: The results of this study suggest that prediction of time to remission from borderline personality disorder is multifactorial in nature, involving factors that are routinely assessed in clinical practice and factors, particularly aspects of temperament, that are not.


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« Reply #1 on: April 16, 2010, 10:27:02 AM »

Am J Psychiatry Published April 15, 2010
doi: 10.1176/appi.ajp.2009.09081130
© 2010 American Psychiatric Association

Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-year Prospective Follow-Up Study
Mary C. Zanarini, Ed.D., Frances R. Frankenburg, M.D., D. Bradford Reich, M.D., and Garrett Fitzmaurice, Sc.D.

Objective: The purposes of this study were to determine time to attainment of recovery from borderline personality disorder and to assess the stability of recovery.

Method: A total of 290 inpatients who met both DSM-III-R and Revised Diagnostic Interview for Borderlines criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. The same instruments were readministered every 2 years for 10 years.

Results: Over the study period, 50% of participants achieved recovery from borderline personality disorder, which was defined as remission of symptoms and having good social and vocational functioning during the previous 2 years. Overall, 93% of participants attained a remission of symptoms lasting at least 2 years, and 86% attained a sustained remission lasting at least 4 years. Of those who achieved recovery, 34% lost their recovery. Of those who achieved a 2-year remission of symptoms, 30% had a symptomatic recurrence, and of those who achieved a sustained remission, only 15% experienced a recurrence.

Conclusions: Taken together, the results of this study suggest that recovery from borderline personality disorder, with both symptomatic remission and good psychosocial functioning, seems difficult for many patients to attain. The results also suggest that once attained, such a recovery is relatively stable over time.
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« Reply #2 on: April 21, 2010, 07:06:29 AM »

Many Zanarini of McLean Hospital in Massachusetts [an expert researcher in the field] studied 290 hospitalized patients with BPD over 10 years. Half of the patients (50%) recovered from the disorder after 10 years of follow-up. Recovery was defined as at least two years without symptoms and both social and vocational functioning. Overall, 93% of patients achieved a remission of symptoms lasting at least two years and 86% for at least four years.

The LA Times says, “A new study offers hope that recovery, although challenging, can be long-lasting.” The LA Times article continues, “The research suggests that while it may be difficult to achieve recovery, once recovery has been attained it appears to last. While many treatments focus on symptoms, therapy should include work on improving relationships and functioning in the workplace, areas that vastly boost the odds of long-term recovery.”
See http://latimesblogs.latimes.com/booster_shots/2010/04/borderline-personality-disorder-recovery.html for the whole article.

A Medscape article had a different slant.

“Recovery from borderline personality disorder, which includes symptom remission and good psychosocial functioning, seems difficult for most patients to attain,” conclude study investigators in the April 15 online issue of the American Journal of Psychiatry.

However, "once attained, such a recovery is relatively stable over time," first study author Mary C. Zanarini, EdD, of McLean Hospital, Belmont, Massachusetts, and colleagues report.

These findings stem from a 10-year, prospective, follow-up study of 290 patients who met diagnostic criteria for borderline person0ality disorder. The patients were overwhelmingly female and white; the mean age was 27. These were lower-functioning, “conventional” BPs interested in working in treatment.

At the beginning of treatment, the mean Global Assessment of Functioning (used to rate the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living) was 38.9. This means the patients had major impairment in several areas, such as work or school, family relations, judgment, thinking, and mood.

Then, researchers interviewed the patients every two years for 10 years. The assessment included both semistructured interviews and self-report measures. Attrition was relatively low. Of the original 290 patients, 275 patients were reinterviewed at two years, 269 at four years, 264 at six years, 255 at eight years, and 249 at 10 years.

(This attrition rate is low. According to Joel Paris, M.D., because of their impulsivity, about two thirds of borderline patients drop out of treatment within a few months. See http://www.jwoodphd.com/borderline_personality_disorder.htm. My guess would be that these patients were either more highly motivated at the beginning, or participating in the study gave them higher motivation.)

The report states that at 10 years, 93% of patients had attained a symptomatic remission lasting at least two years, and 86% had sustained remission lasting at least four years. However, only 50% of patients experienced a recovery from the disorder (which the researchers defined as a two-year symptomatic remission and the attainment of good social and vocational functioning during the previous two years, as well as a Global Assessment of Functioning score of 61 or higher).

The investigators said that, "It is sobering that only half of our study sample achieved a fully functioning adult adaptation with only mild symptoms of borderline personality disorder.” Sadly, 34% of patients who recovered from borderline personality disorder lost their recovery. About 30% of those who achieved a two-year remission of symptoms experienced a recurrence of symptoms, as did 15% of those who had achieved a four-year sustained remission.

In part, the Medscape Psychiatry article http://www.medscape.com/viewarticle/720303 (but you must register) written by Megan Brooks reads:  

"This set of results is consistent with clinical experience," Dr. Zanarini and colleagues note in their report. The current study, they point out, is an extension of the National Institute of Mental Health (NIMH)–funded McLean Study of Adult Development, which found ‘steady, if modest, overall improvement over six years of prospective follow-up.’

“Another NIHM-funded study — the Collaborative Longitudinal Personality Disorders Study — found that borderline patients continued to function in the fair range of global functioning during two years of prospective follow-up.

“Joel Paris, MD, professor of psychiatry at McGill University, Montreal, Quebec, Canada, who was not involved in the study, told Medscape Psychiatry that the latest findings from the McLean study "are not unexpected; they do confirm what is already out there in the literature. On the other hand, this is a well-described sample, and it's the first time we've gotten this much detail.’

“Taken together, Dr. Paris said, the research suggests that patients with borderline personality disorder ‘do get better with time, but they don't get all better.’ The long-term observations in the McLean study, Dr. Zanarini's team notes, also suggest that remissions are ‘far more common than the good psychosocial functioning needed to achieve a good global outcome.’

"It would thus seem wise for those treating borderline patients to consider a rehabilitation model of treatment for these psychosocial deficits. Such a model would focus on helping patients become employed, make friends, take care of their physical health, and develop interests that would help fill their leisure time productively.’”
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Author, The Essential Family Guide to Borderline Personality Disorder, Stop Walking on Eggshells, and the SWOE Workbook. Coauthor, Splitting: Protecting Yourself While Divorcing Someone with Borderline or Narcissistic Personality Disorder.  www.BPDCentral.com
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« Reply #3 on: April 21, 2010, 07:48:14 AM »

Well, it's interesting to see Mary Zanarini's  distinction in the use of the terms recovery and remission.

Extended Recovery=remission of symptoms and having good social and vocational functioning during the previous 4 years.

Recovery=remission of symptoms and having good social and vocational functioning during the previous 2 years.

Remission=remission of symptoms
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« Reply #4 on: April 21, 2010, 10:05:16 AM »

Well, it's interesting to see Mary Zanarini's  distinction in the use of the terms recovery and remission.

Extended Recovery=remission of symptoms and having good social and vocational functioning during the previous 4 years.

Recovery=remission of symptoms and having good social and vocational functioning during the previous 2 years.

Remission=remission of symptoms


   Interesting..
So my H would be in "recovery" and odds are good he will stay there, headed to "extended recovery".

Any idea what treatments were used to get there?

I wonder what studies of older folks might look like? And men?  In my Hs case, he was always very high functioning, had no other mental illness issues or addictions and Ive felt that was always a big asset to his recovery.
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« Reply #5 on: April 21, 2010, 10:24:54 AM »

I had the same questions as Steph. I'm assuming these patients were under some type of treatment or they wouldn't be able to get the data on them for the study? Am curious as to whether they all were under treatment and what type of treatment was used.

Thanks Skip and Randi for posting the info. Interesting!
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« Reply #6 on: April 22, 2010, 04:16:47 PM »

Then, researchers interviewed the patients every two years for 10 years. The assessment included both semistructured interviews and self-report measures. Attrition was relatively low. Of the original 290 patients, 275 patients were reinterviewed at two years, 269 at four years, 264 at six years, 255 at eight years, and 249 at 10 years.

(This attrition rate is low. According to Joel Paris, M.D., because of their impulsivity, about two thirds of borderline patients drop out of treatment within a few months. See http://www.jwoodphd.com/borderline_personality_disorder.htm. My guess would be that these patients were either more highly motivated at the beginning, or participating in the study gave them higher motivation.)

http://www.borderlinepersonalitydisorder.com/audio-pres.shtml
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   Ten-year Course: Longitudinal Study
   Mary Zanarini, EdD

She specifically discusses this aspect in this conference presentation, this is roughly what I remember she said: The adherence to the study was exceptional and quite possibly higher than for normal or any other mental illness. Patients got even upset when they did not get their follow-up call in time and called in.

I think we must never underestimate the attachment of a BPD sufferer once it is formed. I remember also have heard that marriages tend to last longer with BPD than between healthy people. They may marry less often but once they do it endures - for better or worse...

While not all results where in at that time the conference was a lot of data was almost there and I suspect it is worth listening for anyone interested in this study and at little time.
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« Reply #7 on: May 01, 2010, 12:42:01 AM »

I'm not a professional in the field but I've been informally studying it (BPD) for five years and been married to one for twentyfour years. I've seen various others with differing manifestations of it all in the same family. My perspective is that the root cause is so deep that remission is not an appropriate term. Either it gets cured or it isn't. I liken it to a flaw in the basic operating system of the mind (faulty logic code installed during initial programming). Humans are extremely adaptable and can find creative workarounds and/or ways to mask it but the flaw will resurface unless it is truly overwritten. Behavior modification therapy may manage the expression of symptoms but a truly sound sense of self is the ultimate cure. The real problem is that there are a lot of well-built defence mechanisms to get past in order to reprogram code in the deepest level if the operating system.
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« Reply #8 on: May 01, 2010, 12:50:25 AM »

Oh, and I would like to add that I suspect hypnosis (an uncluttered encounter with self as I like to call it) may offer a route to this deepest level if the mind's operating system.
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« Reply #9 on: May 01, 2010, 10:55:29 AM »

These results are very encouraging and a relief.  My impression from past reading was that the prognosis is very dim in most cases.

On the personal side, this gives me a little more optimism that things could turn to the positive for stbxw and her sons.  Also a little relief that maybe my current battles, exposure of her, and discussions with her sons' father won't necessarily have only negative consequences for her.

From my own experience with FOO, I think vast improvement is possible, whether remission or recovery.
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« Reply #10 on: May 01, 2010, 01:30:26 PM »

Thank you for posting the information about the new study, Skip.  I've read lit reviews covering hundreds of studies and this is the first one I recall that dealt with social and vocational functioning, as opposed to merely failure to meet the criteria for the dx.
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« Reply #11 on: May 05, 2010, 06:10:58 AM »

But these are bpd's who are in treatment.. from my 20 odd year experience with my bpd mum, it's very difficult to get them to admit anything is wrong and the need for any treatment. What are the odds of someone in denial recovering just miraculously? Is it zero? And how do you get them into treatment?
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« Reply #12 on: May 08, 2010, 09:26:21 AM »

Hi everyone!
I'm new to this particular forum and still have to send my introduction but I have the same question as "Neverending" except it applies to my uBPDH of nearly 22 years.  Forever I've felt like there is no hope...and almost automatically find myself predicting the answer to this question.  The timing and this article gives me hope smiley   I'm returning to the on-line support group after a couple of years of going totally NC with my H after separating and also disengaging w/my BPDcentral group since 2007.  Clearly "I'm back" which means I'm seeking help again. 
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« Reply #13 on: June 04, 2010, 07:23:56 PM »

Quote
I liken it to a flaw in the basic operating system of the mind (faulty logic code installed during initial programming). Humans are extremely adaptable and can find creative workarounds and/or ways to mask it but the flaw will resurface unless it is truly overwritten.

Love this. Overwriting takes time and effort, but is possible. I'm watching it happen with my daughter, as she has gone through DBT and CBT and worked to get her meds on-line. Fascinating, and I wonder if I had been able to watch myself recover (in the 80s) would I have seen similar changes.

Quote
In my Hs case, he was always very high functioning, had no other mental illness issues or addictions and Ive felt that was always a big asset to his recovery.
 

I agree. The BPDs I know (including my BPD sister) who I'm pretty sure will never get real help share this- there are significant comorbidities, particularly addiction. I'm on the fence about high vs low functioning...could be associated, ironically enough, with a more intransigent denial.

vivgood
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NeilWiste
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« Reply #14 on: February 16, 2011, 07:39:52 AM »

intransigent denial ?

What exactly do you mean by that ?
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« Reply #15 on: February 16, 2011, 12:18:37 PM »

in·tran·si·gent also in·tran·si·geant (n-trns-jnt, -z-)
adj.
Refusing to moderate a position, especially an extreme position; uncompromising.
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« Reply #16 on: February 23, 2011, 06:58:02 PM »

thank you lbjnltx!

By which i mean that someone who is high functioning (working, able to socialize normally, unaddicted) may find it easier to believe that they are not affected by mental illness, whereas someone who is low functioning has "proof" of their dysfunction staring them in the face (homeless, jobless, etc). 


vivgood
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